Literature Review























NATIONAL COUNCIL ON DISABILITY




A STUDY ON FINANCING OF ASSISTIVE TECHNOLOGY DEVICES AND 
ASSISTIVE TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES




                         Literature Review
Preliminary Findings
December 3, 1991





Contractor: United Cerebral Palsy Associations, Inc.
1522 K Street, N.W., Suite 1112
Washington, DC  20005



                         Table of Contents



                                                       Page

I.   Introduction                                      3

II.  Recent Public Policy Experience                   4

III. Approach to the Literature Review                 16

IV.  Findings                                          18

V.   Review of Literature on the Financing of 
     Assistive Technology and Related Services         24

VI.  Appendix                                          85
          
     .  Policy Letter:  Office of Special Education
     .  Policy Letter:  Rehabilitation Services Administration




                  National Council on Disability

                        Study on Financing
of Assistive Technology Devices and Assistive Technology Services for Individuals 
with Disabilities

                         Literature Review



I.   Introduction

The application of technologies to diminish the limitations and 
extend the capabilities of persons with disabilities is one of 
the prime social and economic goals of public policy.  (Gibbons, 
1982, Office of Technology Assessment).  In the past 25 years, 
Congress has established over 30 programs that affect Americans 
with disabilities.  There are over a dozen agencies on the 
federal level charged with the responsibility of managing these 
programs, interpreting Congressional mandates, and monitoring 
state implementation.  Although sometimes described as a 
patchwork quilt or "federal maze" (President Ronald Reagan, 
1983), which continues to grow more complex each year, there is 
agreement that federal laws and programs must be directed toward 
the national goal of "assuring equal opportunities and promoting 
independence for persons with disabilities," (National Council on 
Disability, 1986). 

Technology is a proven means to assure equal opportunities and 
promote independence.  The public record of House and Senate 
hearings that led to the passage of the Technology Related 
Assistance Act in 1988, (P.L. 100-407), documents professionals, 
parents, and consumers' viewpoints that for many individuals with 
disabilities, assistive technology devices and services enable 
them to:

     a.   have greater control of their lives;
     b.   participate in and contribute more fully to activities 
          in their home, school and work environments;
     c.   interact to a greater extent with non-disabled 
          individuals; and
     d.   otherwise benefit from opportunities that are taken for 
          granted by individuals who do not have disabilities.  
          (Section 2:  Findings 29 USC 2201)

If persons with disabilities had a sufficient income base, 
identified appropriate technology would be purchased without 
third party involvement.  However, the limited economic status 
and purchasing power of persons with disabilities requires a 
search for alternative solutions.  The development and use of 
technologies by persons with disabilities is critically impacted 
by the availability and allocation of public resources in support 
of public policy to promote equal opportunity and independence.  
An
effective funding system(s) that is incentive driven, outcome 
oriented and consumer responsive must be designed to respond to 
the concerns frequently expressed by potential technology users 
with disabilities.   "Technology could dramatically change my 
life...  Unfortunately, I can't afford it!"  The purpose of this 
study is to examine the effectiveness of current third party 
payor options in the public and private sectors on state and 
federal levels and propose the development of alternative 
strategies for acquiring or paying for assistive technology 
devices and services.

II.  Recent Public Policy Experience

During the past six years, Congress and federal agencies have 
moved dramatically forward with public policy that improves 
access to assistive technology (see Table 1).  An effective 
funding and financing strategy must be designed in light of 
seventeen  significant public policy developments that have 
occurred since 1986:


1.   Amendments to the Rehabilitation Act,  P.L. 99-506

     A.   In 1986, for the first time, a definition of 
          rehabilitation engineering was added to the Act to 
          "include a range of services and devices which can 
          supplement and enhance individual functions..."  The 
          Amendments require each state vocational rehabilitation 
          agency to describe in their three-year state plan how 
          rehabilitation technology services will be provided to 
          assist an increasing number of individuals with 
          disabilities.  The Amendments also require the 
          application of rehabilitation technology services when 
          making determinations of eligibility.  This is 
          particularly important for individuals who might 
          otherwise be found ineligible for vocational 
          rehabilitation services.  The Amendments further 
          include rehabilitation engineering technology as one of 
          only four services which must be provided by the state 
          rehabilitation system without consideration of 
          comparable services and benefits -- a clear indication 
          of Congressional recognition both of its importance and 
          of the need for public systems to provide funding 
          support to enable people who can benefit to be able to 
          access these important supports.   

     B.   An important new direction in public policy was 
          accomplished with the addition of Section 508 to the 
          Act, without imposing any significant new financial 
          burdens on government, business, or employees.  Federal 
          agencies must provide workers with and without 
          disabilities equivalent access to electronic office 
          equipment.  As a result of Section 508, the federal 
          government, with the General Services Administration 
          (GSA) taking the lead, has changed its rules for 
          purchasing/leasing information technology.  New 
          guidelines for functional performance can be 
          accomplished by manufacturers of computers "building in 
          alternative
          capabilities such as single keystroke commands or 
          providing hooks for the addition of adaptive peripheral 
          equipment such as a one-handed keyboard or a braille 
          printer."  (Resna TA Project, 1990)  As implementation 
          of Section 508 proceeds, it is expected that 
          accessibility-related equipment and support services 
          will become an integral aspect of federal agency 
          acquisition.  It is anticipated that these new 
          accessibility procurement guidelines by the federal 
          government, who is the single largest purchaser of 
          computers, will stimulate the accelerated development, 
          manufacturing and marketing of accessible or adaptable 
          office automation systems.

2.   Early Intervention for Infants, Toddlers and Families,
     P.L. 99-457

     In 1986, Congress enacted P.L. 99-457, within which was 
     included a new Part H amendment to the Individuals with 
     Disabilities Education Act (formerly Education for the 
     Handicapped Act).  This public policy declaration 
     dramatically advanced national efforts to provide 
     appropriate services to infants and toddlers with 
     disabilities and their families.  The statutory definition 
     of early intervention services states, in part, "...designed 
     to meet a handicapped infant's or toddler's developmental 
     needs in any one or more of the following areas:", which 
     include physical development, cognitive development language 
     and speech development, psychosocial development, or 
     self-help skills.  Amplification of Congressional intent 
     occurred in the Department of Education's final regulations 
     issued on June 22, 1989 at 34 CFR Part 303, which includes 
     the following:  

          'Occupational therapy' includes services to address the 
          functional needs of a child related to the performance 
          of self-help skills, adaptive behavior and play, and 
          sensory, motor, and postural development.  These 
          services are designed to improve the child's functional 
          ability to perform tasks in home, school, and community 
          settings, and include:  (i) identification, assessment, 
          and intervention; and (ii) adaptation of the 
          environment, and selection, design, and fabrication of 
          assistive and orthotic devices to facilitate 
          development and promote the acquisition of functional 
          skills.

     With this new legislation and regulations, a major leap in 
     assistive technology public policy occurred by creating an 
     entitlement to such services for infants, toddlers and their 
     families.  A five year planning process will in 1992 be 
     replaced by a new entitlement to services.

3.   Employment Opportunity for Disabled Americans Act  
     P.L. 99-463

     The greatest public expenditures on behalf of persons with 
     disabilities remain income maintenance programs.  The two 
     largest are Supplemental Security Income (SSI), and Social 
     Security Disability Insurance (SSDI).  In 1986, Congress 
     approved new legislation to make it easier for people with 
     disabilities to work and not lose their SSI benefits.  As 
     part of this public policy goal, Congress permanently 
     authorized the PASS program.  PASS is an acronym for Plan 
     for Achieving Self-Support.  An individual who is receiving 
     SSI, or who would qualify for SSI by setting aside income 
     from their paycheck, is eligible to develop a PASS.  Each 
     plan must be approved by the Social Security Administration, 
     and can be used to purchase work-related assistive 
     technology equipment or devices.  The plan must state a 
     clear and realistic vocational goal, and explain how the 
     sheltered income will be spent within a specific timetable.  
     This policy approach recognizes the importance of assistive 
     technology to achieve the goals of independence and 
     self-sufficiency, and gives special consideration from a  
     tax or income perspective of the extra costs associated with 
     acquisition.

4.   Developmental Disabilities Assistance and Bill of Rights Act 
     Amendments of 1987,  P.L. 100-146

     The Developmental Disabilities Assistance and Bill of Rights 
     Act reflects emerging "best-practice" supports and services 
     within a value-based context for individuals with 
     developmental disabilities and their families.  During the 
     1987 reauthorization process, Congress added assistive 
     technology as a priority for state planning and funding for 
     system development and system change.  Within the 1990 
     amendments to the Act (P.L. 101-576), Congress modified the 
     definition of assistive technology to conform to the 
     definition in the Tech Act (P.L. 100-407).  With this 
     legislation, public focus on the financing of assistive 
     technology was further advanced within a state system for 
     planning and systems advocacy.
5.   Older Americans Act of 1965, as amended (P.L. 100-175)

     In 1987, the Act was amended (P.L. 100-175) to include 
     several provision related to older persons with 
     developmental disabilities and/or mental health needs. Among 
     the provision are requirements that:
     o    planning linkages be established between HHS 
          Commissioners of Aging, Developmental Disabilities and 
          Alcohol, Drug Abuse and Mental Health;
     o    the Commissioner of Aging consult and cooperate with 
          the Commissioner of the Rehabilitation Services 
          Administration in planning Older Americans Act 
          programs; and 
     o    in evaluating OAA programs the Commissioner on Aging 
          consult with developmental disability organizations 
          whenever possible.
     
     Title III, Part B,  Grants for Supportive Services, 
     Nutrition and Other Activities, assists older individuals in 
     avoiding institutionalization and individuals in long-term 
     care institution who are able to return to their 
     communities, including client assessment through case 
     management, and integration and coordination of community 
     services.
               
          The term "client assessment through case management" 
          includes the provision of assistive technology.
          
          The term "assistive technology" is defined as 
          engineering methodologies, or scientific principles 
          appropriate to meet the needs of, and address the 
          barriers confronted by, older individuals with 
          functional limitations.

     Grants are awarded to States to develop and strengthen 
     services systems on aging.  State plans include several 
     assurances including assurances associated with access to 
     services (i.e. transportation, outreach, and information and 
     referral).
          
          The phrase, "information and referral" includes 
          information regarding to assistive technology.
     

6.   Medicaid Amendments of 1988 for Special Education Related 
     Services,  P.L. 100-360

     The Medicare Catastrophic Coverage Act (P.L. 100-360), 
     contains a significant technical amendment to Medicaid law, 
     which was not repealed with the Catastrophic Act.  This 
     legislation was intended to resolve a historical dispute in 
     which the Health Care Financing Administration had declared 
     that any service within a child's individualized education 
     program (IEP), was the financial responsibility of the 
     education agency and could not be billed to Medicaid.  The
     1988 amendment and accompanying report language explicitly 
     offered states the option of including special education and 
     related services under Part B of IDEA, and those services 
     included under Part H of IDEA as Medicaid reimbursable 
     services under the state's Medicaid plan.  With this policy, 
     Congress provided a major opportunity for states to access 
     federal Medicaid funds for a full range of individual 
     assistive technology services without adding additional 
     burdens to the local and state special education budgets.


7.   Technology-Related Assistance Act,  P.L. 100-407

     This federal mandate provides financial assistance to states 
     on a competitive grant basis, to plan and implement a 
     consumer responsive system of technology services for 
     individuals of all ages with disabilities.  Technology 
     services and devices are defined in a broad context to 
     stimulate creative problem solving, interagency coordination 
     and professional consumer collaboration.  In the first two 
     years of implementation of the Act, 23 states have competed 
     successfully for funding.  States have broad discretion to 
     target their funds to training, public awareness, service 
     demonstration, policy analysis, and systems change.  Unlike 
     already existing public programs, this federal initiative 
     represents the first time Congress targeted new public 
     resources exclusively to expand access to assistive 
     technology.  

8.   Telecommunications Accessibility Enhancement Act of 1988
     P.L. 100-542

     In 1988, Congress authorized P.L. 100-542,  The 
     Telecommunications Accessibility Enhancement Act of 1988.  
     The purposes of the Act are to implement an interim 
     telecommunications relay system to serve the needs of 
     individuals who are hearing-impaired and speech-impaired for 
     access to Federal departments and agencies; to equip all 
     Federal departments and agencies with TDDs or facilities to 
     accommodate portable TDDs; to provide for the assembly, 
     publication and maintenance of a TDD directory for Federal 
     departments and agencies; and for the publication of 
     governmental TDD access numbers in other existing 
     directories.

     The Act also required the FCC, in consultation with the 
     Architectural and Transportation Barriers Compliance Board 
     to establish and implement a telecommunications system for 
     individuals who are hearing impaired and speech impaired 
     within the Federal Government that serves as an interface 
     between the TDD user and Federal departments and agencies. 



9.   Medicaid Early and Periodic Screening, Diagnosis and 
     Treatment Amendments of 1989,  P.L. 101-238

     Included within the massive Omnibus Budget Reconciliation 
     Act of 1989 (OBRA '89, P.L. 101-238), Congress enacted major 
     changes within the Medicaid program required in all states, 
     called Early and Periodic Screening, Diagnosis, and 
     Treatment (EPSDT).  Although EPSDT has been one of nine 
     state Medicaid mandated services since its enactment in 
     1967, the states have had great discretion in interpretation 
     and implementation of this benefit.  As of April 1, 1990, 
     the EPSDT Medicaid benefit was "federalized" and mandates 
     that all children from birth to twenty-one years of age 
     receiving, or eligible to receive Medicaid are entitled to 
     the "medically necessary" diagnostic and treatment services 
     for any physical or mental problem identified during such 
     screening or assessment.  Such services would be 
     reimbursable under Medicaid if such "treatment" is coverable 
     under federal Medicaid law, even if these "treatments" are 
     not in the state's Medicaid plan; e.g. augmentative 
     communication devices, wheelchairs, hearing aids, optical 
     aids including glasses, etc. As a result of this Amendment, 
     a significant number of children with physical, sensory or 
     mental disabilities now have a right to assistive 
     technology.  Due to established practices within Medicaid, 
     many challenges remain in assuring this right in concert 
     with the second, and often overlooked, statutory purpose of 
     Medicaid:  "to furnish rehabilitation and other services to 
     help such families and individuals attain or retain 
     capability for independence or self-care," (P.L. 90-248, 42 
     USC 1396, Sec. 1901).

10.  Americans with Disabilities Act (ADA),  P.L. 101-336

     Signed into law by President Bush on July 26, 1990, the Act 
     will protect over 40 million Americans with disabilities 
     from discrimination in employment, public services, 
     transportation, public accommodations and 
     telecommunications.  Each Title of the Act specifically 
     references assistive technology equipment or devices as a 
     means to achieve access and equal opportunity.  In Titles I 
     and III, the purchase or modification of equipment and 
     devices is included within the definition of "reasonable 
     accommodation."  However, the removal of architectural, 
     physical, or communication barriers, through "reasonable 
     accommodation," is not an absolute civil right.  On a case 
     by case basis, access to employment opportunity or public 
     accommodations must be weighed against a defense of "undue 
     hardship," a still evolving standard to evaluate the degree 
     of difficulty and expense to a particular business.

     Title IV of the ADA expands access rights to the important 
     area of telecommunications.  Telephone services offered to 
     the public in every state must include interstate and 
     intrastate telecommunications relay services so that these 
     services provide individuals with speech and hearing 
     impairments access
     to communications equivalent to those provided to 
     individuals able to use voice telephone systems.

     In multiple approaches, ADA will begin to redefine the 
     inclusion of assistive technology within the core and 
     penumbra of civil rights to be enjoyed by citizens with 
     disabilities.  The current year, 1991, represents a critical 
     year of regulatory development that will begin to more 
     solidly define the limits of access to assistive technology 
     as part of "reasonable accommodation" in the workplace, 
     commercial buildings, and public arenas.

11.  ADA Tax Credit,  P.L. 101-508

     Under the Omnibus Budget Reconciliation Act of 1990, a new 
     tax credit was created for small businesses, to provide 
     additional incentives and assistance to meet the access 
     requirements under ADA.  The credit amount allowed a tax 
     year is 50 percent of expenditures, up to a maximum of 
     $10,250.  Acceptable expenses include removal of 
     architectural, communication, or transportation barriers.  
     Coverage does include the purchase or modification of 
     adaptive equipment or assistive devices as part of an effort 
     to improve access to persons with disabilities.  To qualify, 
     a business must have gross receipts of less than one million 
     dollars, or fewer than 30 full-time employees.

12.  Decoder Circuitry Act of 1990,  P.L. 101-431

     In yet another approach to expand public policy, new 
     requirements are mandated for the manufacturers of 
     television sets with screens 13 inches or larger, sold in 
     the United States after July 1, 1993.  Televisions will be 
     required to have built-in decoder circuitry to be compatible 
     with current closed captioning signals.  This new mandate 
     will assure that people with hearing impairments will be 
     able to see captions on programs that provide them by merely 
     flipping a switch on their television.  Mass production of 
     the built-in decoders will cost an estimated three to five 
     dollars per television.  The potential audience for 
     closed-captioned programming for individuals with 
     communication disabilities is estimated to be more than 24 
     million.

13.  Policy Letter:  Office of Special Education Programs

     On August 10, 1990, Office of Special Education Programs 
     Director, Dr. Judy Schrag issued a policy letter that 
     clarifies the rights of children with disabilities to access 
     assistive technology.  This policy letter states clearly and 
     unequivocally that assistive technology services and devices 
     may be considered special education, related services, or 
     supplementary aids and services to enable a student with a 
     disability to remain in the regular education classroom.  In 
     other words, as part of the requirements of a "free, 
     appropriate public
     education," (FAPE), assistive technology needs must be 
     considered when developing a child's individualized 
     education program (IEP).  Needed assistive technology 
     devices and services must be appropriately included as part 
     of the IEP.  In response to the requirements of the least 
     restrictive environment principle and as special education 
     or related services, children with disabilities have a right 
     to assistive technology.  These requirements were further 
     reinforced in the recent reauthorization of the Education of 
     the Handicapped Act.  On October 30th, 1990, President Bush 
     signed into law the Individuals with Disabilities Education 
     Act (IDEA), P.L. 101-476, which, for the first time, 
     includes definitions of assistive technology devices and 
     services identical to those included in the TECH Act, P.L. 
     100-407.  In report language, there is further emphasis on 
     the right to assistive technology as part of special 
     education and related services.

     The reauthorization language and the policy letter should 
     result in more consistent access to assistive technology by 
     school-age children with disabilities nationwide.

14.  Policy Memo:  Rehabilitation Services Administration

     On November 16th, 1990, Commissioner Nell Carney issued a 
     policy directive to all state vocational rehabilitation 
     agencies that sets important new guidelines concerning 
     implementation of the 1986 rehabilitation technology 
     amendments.  Each state must develop written policies to 
     address the need for assistive technology during the entire 
     rehabilitation process:  as part of determination of 
     eligibility, evaluation of rehabilitation potential, 
     extended evaluation, services provided under the individual 
     written rehabilitation plan (IWRP), annual reviews of 
     ineligibility, and post-employment services.  An assessment 
     of an individual with disabilities should consider how 
     assistive technology devices and services can:

          a.   increase or supplement function; and
          b.   modify environments to accommodate individual 
               abilities in the home and workplace.

     This added policy direction to implement the intent of 
     Congress should place new demands on a major public resource 
     program to allocate funds to increase access to technology.

Analysis of these public policy developments reflects numerous 
approaches which have been utilized to increase availability of 
and access to assistive technology.  These approaches include a 
range of activities designed to influence all aspects of policy 
development and implementation, (see Table 2).  While these 
policy approaches do not reflect all of the avenues available to 
direct the public policy arena towards increased
access to assistive technology, they certainly provide excellent 
examples of approaches which have been successfully utilized to 
date to begin movement in that direction.  In addition, they 
provide important information on approaches which should be 
considered when developing additional strategies for the 
acquisition and financing of assistive technology services and 
devices in the future.

                              Table 1

                 RECENT PUBLIC POLICY DEVELOPMENTS



1.





2.





3.




4.


5.




6.





7.



8.



9.



10.





11.



12.



13.



14.



15. 




16.




17.











Year

1986





1986





1986




1986


1987




1987





1988



1988



1988



1990





1990



1990



1990



1990



1990




1991




1991
   Action

Amendments to Rehabilitation Act: add definition, expand program 
requirements


Amendment to Rehabilitation Act, Section 508:  new guidelines for 
federal procurement of computers

Early Intervention:  new entitlement, expand program benefits


Social Security Amendments 

Amendments to Developmental Disabilities Act:  expand program 
requirements

Older Americans Act
Amendments: adds provision of assistive technology to Act; 
defines
assistive technology

Medicaid Amendments: clarify funding options and mandates

Tech Act: Create statewide systems of technology assistance

New Telecommunications
Access Law


ADA:  employment, transportation, public accommodations, 
telecommunications


ADA Tax Credit for Small Businesses


Decoder Circuitry Act:  design standard for televisions

Policy Memo
Special Education


Policy Memo
Rehabilitation


Amendment to IDEA adding definitions of assistive technology 
devices and services

Amendments to Part H of IDEA adding definitions of assistive 
technology services and devices

Policy Letter
Special Education







    Approach

Clarify and expand program benefit of major public program



Change procurement practices, impact manufacturers expectation of 
accessible design standards at lower cost

Establish new major public program



Tax sheltering of income to purchase technology

New priority within existing public program



Expands program benefit





Clarify and expand existing program benefit


New funding, new public program


New TDD access requirement within Federal agencies

New access requirements of private sector, access technology by 
expanding concept of civil rights


Tax incentives to expand access to assistive technology

Require new manufacturer standard for access


Clarify rights under existing major public program

Clarify rights under existing major public program

Clarify rights under existing public program



Clarify rights under existing public program



Clarity right to take technology home from school



                              Table 2

                         POLICY APPROACHES



1.   Redirect or increase resource allocation under existing 
     public programs.

2.   Modify entitlements under existing public programs.

3.   Clarify existing policy to mandate and monitor more 
     consistent practices.

4.   Modify discretionary priorities under existing public 
     programs.

5.   Establish new public programs.

6.   Establish new laws to expand definition of civil rights.

7.   Alter procurement practices of government.

8.   Alter existing or create new tax incentives.

9.   Allow tax sheltering of income.

10.  Require new design standards for manufacturers of equipment
     to displace need for specialized equipment purchases.


 


III. Approach to the Literature Review

In light of recent public policy developments, the purpose of the 
Literature Review was to review and analyze both published and 
unpublished literature related to issues and practices in the 
acquisition and financing of assistive technology services and 
devices.

The following activities were undertaken to accomplish the 
literature review:

.    Documents which were reviewed have been compiled in "core 
     area" annotated bibliographies, including:

     1.   Enders, A. & Hall, M. (1990).  Assistive Technology 
          Sourcebook.  Washington, D.C.:  RESNA Press.

     2.   Enders, A. (1989).  Funding for Assistive Technology 
          and Related Services: An Annotated Bibliography. 
          Washington, D.C.:  Electronics Industries Foundation.

     3.   Request Program (1990).  An Annotated Bibliography on 
          Funding for Technology.  Washington, D.C.: 
          Rehabilitation Engineering Center, National 
          Rehabilitation Hospital.

     4.   Center for Special Education Technology.  Selected 
          Readings:  Funding Technology Products and Services.  
          Reston, VA:  A Project of the Council of Exceptional 
          Children.

.    Over 15 national organizations and federal agencies who have 
     done exemplary work in the field of assistive technology 
     were contacted for information and materials available on 
     the financing of assistive technology.  These included:

          American Speech-Language-Hearing Association
          Paralyzed Veterans of America
          National Easter Seals Society
          National Association of Rehabilitation Facilities
          American Association of Occupational Therapists
          American Physical Therapists Association
          National Association of Equipment Suppliers
          Office of Technology Assessment, U.S Congress
          National Mobility Equipment Dealers Association
          Mobility Equipment Manufacturers Organization
          Health Industry Manufacturers Association
          Health Industry Distributors Association
          Council for Exceptional Children
          UCPA's S.M.A.R.T. Exchange
          Association for Retarded Citizens of the United States
          American Foundation for the Blind
          Alliance for Public Technologies
          World Institute on Disability
          Rehabilitation Engineering Society of North America 
          (RESNA)

.    A meeting was held with Karen Franklin (RESNA TA Project) to 
     discuss the Literature Review and review materials available 
     through RESNA.

.    A meeting was held with Ana Torres, Project Coordinator of 
     the George Washington University Regional Rehabilitation 
     Continuing Education Program.  RRCEP, in collaboration with 
     Electronic Industries Foundation, has initiated a national 
     project to develop, conduct and evaluate a national training 
     program related to the Financing of Assistive Technology.  
     The meeting was held to discuss issues related to the 
     Literature Review.

.    The National Rehabilitation Information Center (NARIC), a 
     rehabilitation information center and research library, was 
     contacted to conduct a literature search on the financing of 
     assistive technology, for review and possible inclusion in 
     the Literature Review.

.    Sixteen Rehabilitation Engineering Centers were contacted 
     regarding both published and unpublished materials that are 
     available or will soon be available on the financing of 
     assistive technology, for review and possible inclusion in 
     the Literature Review.

.    Key decisions specifically pertaining to lawsuits filed on 
     the financing of assistive technology were reviewed by Lewis 
     Golinker, Esq., of Legal Services of Central New York, Inc., 
     and a recognized  national expert on funding.

.    Numerous experts on the funding of assistive technology were 
     consulted.  These included:  (1) Alexandria Enders, 
     University of Montana Rural Institute on Disability, and 
     author of The Assistive Technology Sourcebook; (2) Anna 
     Hofmann, Phonic Ear Inc., Editor, "The Many Faces of 
     Funding;" (3) Steve White, American Speech-Language and 
     Hearing Association; (4) Jan Galvin, National Rehabilitation 
     Hospital; and (5) David Capozzi, Project ACTION, to discuss 
     issues related to the Literature Review. 

.    Each document was read and summarized using the following 
     framework:

     1.   Reference/Source
     2.   Topics Covered:
          .  Acquisition of Assistive Technology
          .  Payment of Assistive Technology
          .  Finance of Assistive Technology
          .  Barriers to Finance of Assistive Technology
          .  Facilitating Mechanisms for Finance of Assistive
               Technology
          .  Federal and State Laws 
          .  State Regulations
          .  State Procedures, Practices and Programs
          .  Policies and Practices of Private Entities
          .  Alternative Strategies to Financing
          .  Available Surveys, Studies and Commission Findings
          .  Loan System
          .  Cost Factors to Financing

     3.   Database on which the findings were based (for 
          experimental and cost studies)
     4.   Methodology employed (for experimental, survey, and 
          cost studies)
     5.   Key findings/solutions/results
     6.   Areas in need of further study (strengths and 
          weaknesses)
     7.   Targeted Audience

.    All Title I funded states and recently awarded Title II 
     funded projects were contacted, to secure "in progress," "in 
     press" and locally circulated documents for review and 
     inclusion in the literature review.

.    All material was organized into functional user categories 
     both for purposes of general use and for use of the 
     Literature Review by Project Staff in completing tasks.

IV.  Findings

1.   With the passage of the Technology-Related Assistance Act in 
     1988, children and adults with disabilities and their 
     families have an expanding set of expectations about 
     assistive technology devices and services, that is more 
     available, accessible, and responsive to consumer needs.

2.   Most individuals with disabilities and families with 
     children with disabilities cannot afford to purchase 
     assistive technology devices and services they need.  The 
     potential user is dependent on third party support, both 
     public and private.

3.   The challenge interested parties share is to clearly 
     identify the entry points for a particular funding source, 
     bridges to other funding options, and ways to avoid detours 
     and stop signs that delay or deny reimbursement for 
     assistive technology.

4.   The majority of literature reviewed supports the finding 
     that the most significant barriers to the availability of 
     assistive technology are the unpredictable and inadequate 
     funding of such services and the uncoordinated and 
     incomplete structure of the delivery systems.  

5.   Equally imposing to the barrier of poorly coordinated 
     service delivery systems is the lack of awareness of parents 
     and potential technology users of their entitlement to 
     assistive technology devices and services across overlapping 
     public program funding streams.

6.   The literature on the financing of assistive technology 
     points out that little
     recognition is given to the ongoing nature of a person with 
     a disability's need for technological support.  Equipment 
     was and still is often viewed as a one-shot event, a 
     viewpoint which is reflected in the policies of the sources 
     for funding assistive technology.  Assistive technology 
     services do not fit well into service delivery systems 
     geared towards cure, closure, aging out or some other fixed 
     end point.  The concept of continuity in service delivery of 
     assistive technology is not evident in existing public 
     policy about the role of government.  

7.   Access to assistive technology funded by public programs 
     will depend on:

     a.   the degree to which services and funding are 
          coordinated between programs and are consistent from 
          locality to locality and state to state;
     b.   the degree of consistency in determining eligibility;
     c.   the extent of gaps in eligibility for services under 
          public and non-public programs;
     d.   the degree to which maintenance and repair of devices 
          is difficult or costly;
     e.   the degree to which consumers are sufficiently informed 
          about their funding options and aware of the latest 
          technology innovations;
     f.   the degree to which consumers are effectively involved 
          in service delivery; and
     g.   the extent of available adequately trained therapists, 
          and rehabilitation providers.

8.   The literature indicates that there is a significant 
     shortage of trained personnel in key discipline 
     knowledgeable about assistive technology.  The literature 
     suggests several reasons for this which are associated with 
     financing which may contribute to the aversions to the 
     field:  ever changing reimbursement policies; wide variety 
     of eligibility criteria; low fee schedule; licensing laws; 
     large volume of paperwork necessary to establish medical 
     necessity or secure coverage.

9.   The literature on the financing and services delivery of 
     assistive technology confirms that most efforts to date have 
     given insufficient attention to the training and assistance 
     needed by individuals with disabilities, parents, and 
     professionals to maximize the utilization of assistive 
     technology.

10.  The serious unfamiliarity with available assistive 
     technology and related services among clinical and payment 
     decision makers is well documented.  This unfamiliarity in 
     many cases translates into either underutilized or 
     inappropriate application of existing technology.

11.  The literature reveals that there are few mechanisms in 
     public and private programs for allowing individual users' 
     desires to be taken into account.

12.  The new emphasis in disability policy on recognizing 
     potential and removing the obstacles to participation in all 
     aspects of community life creates a
     growing demand for assistive technology to enable persons 
     with disabilities to function as independently as possible.  
     This has important implications for redefining the goals of 
     health policy which have previously been primarily oriented 
     to preventing death and sustaining life.

13.  The literature on health care financing for assistive 
     technology describes the medical process through which it is 
     determined and whether different forms of assistive 
     technology will be covered.  This process depends on 
     documentation of medical necessity, judgements about 
     cost-effectiveness, certification of providers, and a resort 
     to an appeals process.


14.  The literature on health care coverage for assistive 
     technology takes a consumer advocacy view which indicates 
     what has to be done to increase the chance that a health 
     insurer will cover assistive technology.  The emphasis is on 
     documenting medical necessity, indicating how the functional 
     limitation is attributable to an injury or illness, 
     describing the assistive technology as a form of prosthesis 
     which replaces the function of a body part, and 
     demonstrating the cost-effectiveness of the assistive 
     technology from the insurer's point of view by reducing 
     future health care costs.  This literature shows how the 
     reimbursement process should conform to the requirements of 
     the funding source.

15.  The literature on health care financing generally supports 
     the view that the terms of the insurance contract dictate 
     what is and is not covered.  But this generalization though 
     basically true, does not take into account conditions under 
     which insurers are very willing to exercise 
     extra-contractual agreements to pay for certain services 
     including assistive technology under certain conditions in 
     order to avoid more costly services which are covered by the 
     insurance contract.  Moreover, the literature on the health 
     care financing of assistive technology does not specifically 
     analyze the incentives which underlie different forms of 
     insurance.

16.  Health insurance has traditionally financed assistive 
     devices that were medically necessary; but these criteria do 
     not provide an adequate basis for determining the type of 
     assistive technology that is appropriate.  The literature 
     suggests several reasons for this:  (1) the criterion of 
     medical necessity does not provide any guidance as to the 
     appropriateness of assistive devices; (2) the need for 
     assistive devices is not limited to technologies that 
     sustain life; (3) the need for the assistive devices are all 
     related to the existence of the health condition; (4) 
     traditional criteria for measuring the effectiveness of 
     medical treatment such as physiological change and ability 
     to perform minimal activities of daily living do not take 
     account of how persons function in their environments; and 
     (5) physicians are often not knowledgeable about the types 
     of assistive devices which are most appropriate. 

17.  In general, most private insurance plans do not explicitly 
     include or exclude coverage of assistive technology in their 
     benefits; therefore, consumers do
     not know what they are entitled to.

18.  It is clear through the literature that payment 
     decision-making criteria are not well defined at policy 
     levels, making it more difficult for clinical and claims 
     representatives at the case level to judge with confidence 
     the appropriateness of given alternatives.  In the absence 
     of criteria for appropriate assistive technology, insurers 
     have relied on arbitrarily excluding major categories of 
     assistive technology (e.g. augmentative communications 
     devices) in order to achieve cost-containment goals.

19.  The literature on health insurance and assistive technology 
     also describes the coordination problems among different 
     funding sources when they compete to be payor-or-last-resort 
     or when a health insurer will refuse to cover a health 
     related need because it was identified in an Individualized 
     Education Program or a Vocational Rehabilitation Plan.
20.  Several sources on the financing of assistive technology 
     indicated that many individuals with disabilities' access to 
     assistive technology depends upon their ability to purchase 
     it on their own without the benefit of third party payment 
     reimbursement.

Table 3 on the following page summarizes the findings and 
identifies eight major barriers to the acquisition of needed 
technology.

The majority of literature reviewed identified several issues in 
need of further investigation:

1.   The financing of assistive technology through the tax code 
     (i.e. incentives, credits, medical deductions) has been 
     raised in several sources.  Further study is needed to 
     determine the cost of providing tax credits, accelerated 
     write-offs or other incentives for business and/or 
     individuals who purchase or lease assistive technology for 
     themselves or their employees.

2.   There are no Federal research priorities in the area of 
     assistive technology that consider cost-benefit and 
     cost-effectiveness information that translates into 
     decision-making factors for third party payors.

3.   Assistive financing or loan guarantees, credit financing, 
     revolving loan funds and/or subsidy programs are sound 
     alternatives to financing assistive technology.  No 
     information is available on the cost of implementing a 
     federal initiative of this nature.  Analogous to this is the 
     need for more information on federal and state incentives to 
     attract the substantial resources of the credit market into 
     the assistive technology product market.

4.   The literature on funding sources for assistive technology 
     attempts to identify different types of insurance that could 
     pay for assistive technology, but does not provide any 
     theoretical explanations for the types of coverage that are 
     provided by different types of insurance.  Nor does the 
     literature provide any empirical evidence of the frequency 
     of coverage for assistive technology.

5.   For the first time in the TECH Act, (P.L. 100-407), public 
     policy dictates a standard of consumer responsiveness in the 
     delivery of technology-related assistance.  A review of the 
     literature reveals a lack of research to help define 
     consumer responsive best practices as it relates to funding 
     and service delivery options.

6.   The nexus between civil rights coverage and access to 
     assistive technology as an affirmative obligation on 
     government contractors, business and industry, and the 
     providers of public services has been a subject of limited 
     inquiry.  Further research is needed to define the outer 
     boundaries of constitutional and statutory protections of 
     freedom of speech and assembly, and their interpretation to 
     include access to communication and mobility supports.  
     Research is needed to define the economic arguments to 
     shifting obligations from the public to the private sector, 
     and sharing the costs of access across the general consumer 
     public (access surcharge to fund equipment acquisition).  

                              Table 3

                   ACCESS BARRIERS TO TECHNOLOGY


1.   Lack of awareness by persons with disabilities, their family 
     members and professionals about available technologies and 
     their appropriate use.

2.   Lack of awareness of rights (public programs, civil rights, 
     tax incentives).

3.   Lack of experience in applying rights protections to secure 
     individual benefits.

4.   Inconsistent implementation of public mandates (interagency 
     coordination, degree of enforcement, state, local, public, 
     private).

5.   Degree of discretion of public and private funders 
     (inconsistent reimbursement policies).

6.   Resource allocation decisions by public programs (state, 
     local containment of costs, scope of benefits, competing 
     interests).


7.   Lack of direct consumer control of resources (consumer 
     involvement and responsiveness).

8.   Shortage of skilled professional experts (knowledge gap, 
     inadequate higher education programs).

9.   Lack of enforcement of Section 508, compounded by lack of 
     information and misunderstanding of the requirements among 
     federal and state agencies.

REVIEW OF THE LITERATURE ON THE FINANCING OF ASSISTIVE TECHNOLOGY 
AND RELATED SERVICES



Alliance for Public Technology.  Public Telecommunications 
Technologies in the 1990s: Achieving Universal Services.  Report 
of the Board of Directors.  Washington:  July 1990.  Available 
from:  Alliance for Public Technology, 901 15th Street, NW 
Washington, DC  20005-2301; 202-408-1403; 20 pages and appendix. 
 
Summary:  This report describes a vision of the 
telecommunications infrastructure of the 1990s and beyond, 
premised on the goal of universal access to all information 
services.  The report outlines the steps necessary to begin to 
foster access to, and availability of, useful and affordable 
services and communication for all people, with the public 
telephone network playing a central role as an efficient and 
equitable means to achieve universal access.  With the public 
telephone network as an Information Services Platform, universal 
access to low-cost information would encourage development of a 
much wider range of electronic services to meet the myriad needs 
and interests of all individuals, including individuals with 
disabilities. 

Target Audience:  All individuals concerned with fostering access 
to, and availability of, useful and affordable information 
services and communication technology for all people.

Issues Raised/Conclusions:  The report concludes that universal 
access to information services must be a telecommunication policy 
goal of the United States in the 1990s and recommends several 
public policies which will foster this goal. First, policies 
should promote continued progress in universal services for the 
94% of households served today, moving toward a goal of 100% 
served.  Second, local telephone rates should continue to be set 
at affordable levels. Third, fair competition within the 
telecommunications industry, specifically regarding information 
services, should be protected.  An increased role of the public 
telephone network will require public policies that ensure that 
competition among information vendors and providers is enhanced 
by the expanded network functionality and the larger number of 
consumers and services.

No information is available to indicate how much it would cost to 
implement universal access.  Although most of the infrastructure 
is already in place, some upgrades will be needed to allow the 
public telephone to function as an Information Services Platform. 
The report urges policy makers to collect data to forecast the 
costs.  This will require that providers and regulators in each 
state conduct needs and cost-assessments for their own 
constituents. 


Anderson, S., Stevens, J., and Trachtman, L.  A Guide to Funding 
Resources for Assistive Technology in South Carolina.   Columbia, 
SC:  January 1990.  Available from:  Center for Rehabilitation 
Technology Services, South Carolina Vocational
Rehabilitation Department, 1410-B Coston Avenue West, Columbia, 
SC 29171-0051; 45 pages and appendices.

Summary:  This guide is a product of the symposium, "Funding 
Resources for Assistive Technology in South Carolina," which was 
held July 11-13, 1989.  Divided into six sections, the guide is 
an overview of funding options in the state.  Section Three 
contains a discussion on developing a funding strategy:  
questions to ask, guidelines to follow and brief explanations.  
Section Four is devoted to getting systems to work together, and  
implementing a strategy.  Included is a discussion of alternative 
funding sources and appeals when customary channels do not work.  
Section Five is specific to South Carolina, and includes 
important eligibility criteria and what services and assistive 
technology will/will not be covered by most agencies in the 
State.  Section Six contains references and sample documents.  

Target Audience:  Consumers, families, practitioners, advocates, 
policy makers, Title I state funding coordinators.

Issues Raised/Conclusions:  The guide is a clear and concise 
explanation of funding options within South Carolina, complete 
with addresses and phone numbers. It does not, however, contain 
all the programmatic detail that may be necessary for success in 
obtaining funding for assistive technology within specific 
programs.  The guide is a model other regions could follow when 
preparing material about their own funding resources. 


American Council on Education, Higher Education and Adult 
Training for People with Handicaps.  Financial Aid for Students 
with Disabilities.   Available from:  HEATH Research Center, One 
Dupont Circle, N.W., Suite 800, Washington, D.C. 20036-1193; 
202-939-9320 or 800-544-3284 Voice/TDD; 11 pages.  

Summary:  This guide describes the various types of financial aid 
available for students with disabilities. Particular attention is 
given to expenses that are considered disability related, and 
suggestions are made about ways in which some of those expenses 
may be met.  There follows a brief discussion of Vocational 
Rehabilitation Agencies, the services that they may provide, and 
the interaction between the state VR agency and the Financial Aid 
Office of a post-secondary institution.  Suggestions are offered 
about additional possibilities for financial assistance. 

Target Audience:  Students, VR clients pursuing post-secondary 
education, Title I state funding coordinators.

Issues Raised/Conclusions:  An analysis of Federal and state 
policies affecting the financing of post-secondary education for 
students with disabilities is beyond the scope of this document.



Barnart, S., Seelman, K., and Gracer, B.  "Policy Issues in 
Communications
Accessibility."  Journal of Disability Policy Studies, Vol. 1, 
No. 2 (Summer 1990).  Available from:  Dr. Kay Shriner, Ed., 
University of Arkansas at Fayettville, Dept. of Rehabilitation 
and Education Research, 346 North West Avenue, Fayettville, AK  
72701; (501) 575-3656. 

Summary:  The paper considers communications accessibility for 
individuals with sensory disability as equivalent in importance 
to that of architectural accessibility for people with mobility 
impairments.  Communications accessibility is a basic civil right 
of people who are deaf or hearing impaired to receive and 
understand information and signals presented directly or over 
public alerting, public address and public telecommunications 
systems.  

Some existing statutes and regulations do apply to communications 
accessibility, but many changes are still needed in laws and 
regulations at the federal, state, and local levels.  The article 
defines and describes ideal communications accessibility in 
different situations, identifies factors which affect its 
viability, and examines economic and legal/regulatory issues.  

Target Audience:  Policy makers, advocates.

Issues Raised/Conclusions:  Communications accessibility expands 
the conceptual, legal and economic issues raised by architectural 
accessibility.  These issues need to be addressed as laws and 
economic policies relating to accessibility are developed.


Batavia, A.  The Payors of Medical Rehabilitation: Eligibility 
Coverage and Payment Policies.  Washington:  January 1989.  
Available from:  National Association of Rehabilitation 
Facilities, P.O. Box 17675, Washington, D.C. 20041; 703-648-9300; 
62 pages and bibliography.

Summary:  This five part monograph describes the major payors of 
medical rehabilitation services. These are: Medicare, Medicaid, 
Veterans Administration, Vocational Rehabilitation, health 
insurance, Preferred Provider Arrangements, HMOs, Disability 
Insurance Plans, and casualty insurance. Descriptions are 
provided of eligibility, coverage, and payment policies.
This monograph is a good overview of what is known about payment 
decisions regarding medical rehabilitation services.  

Target Audience:  Individuals with disabilities, policy makers, 
Title I funding coordinators.  

Issues Raised/Conclusions:  By comparing the eligibility rules 
and coverage criteria among different public and private 
programs, this study suggests that more effective coordination is 
necessary to avoid over-coverage for some persons, under-coverage 
for others, and no coverage for a growing number of Americans.  
The author believes that a comprehensive National Health 
Insurance Program for the entire population will eventually be 
adopted.



Batavia, A. and Hammer, G.  Toward the Development of Consumer 
Based Criteria for the Evaluation of Assistive Devices.  
Washington:  Fall 1990.  Available from:  Andrew Bativia 700 7th 
Street S.W., #813, Washington, D.C. 20024.  12 pages. 

Summary:  This study identifies and prioritizes factors used by 
long term users of assistive technology in assessing their 
devices.  In total the study identified and prioritized 17 
factors for 11 types of technologies.  The study constitutes an 
initial step toward the development of design engineering and 
selection criteria based on specific concerns of consumers.  The 
factors in order of priority include: affordability, 
compatibility, consumer repairability, dependability, durability, 
ease of assembly, ease of maintenance, effectiveness, 
flexibility, learnability, operability, personal acceptability, 
physical comfort, physical security, securability, and supplier 
repairability.  Under each factor the study provides key 
questions a user should ask when selecting his or her equipment. 

Target Audience:  Individuals who use assistive technology and 
their families, manufacturers, product designers, agencies, 
providers, information referral services. 

Beckett, J.  Health Care Financing: A Guide for Families.   Iowa 
City, IA:  1989.  Available from:   National Maternal and Child 
Health Resource Center, College of Law Building, The University 
of Iowa, Iowa City, IA 52242; 319-335-9067; 74 pages and 
appendix.

Summary:  This is a practical guide to help families understand 
the existing system, both public and private, for delivery and 
financing of health care.  Written by a mother of a child with 
severe disabilities, the guide combines practical solutions to 
funding, including a listing of resource agencies and 
organizations, with a history of advocacy in the financing of 
health care for families with children with disabilities and 
other chronic conditions. The author emphasizes the importance of 
advocacy in overcoming barriers to finding financing and changing 
policy surrounding financing, and the difficulties faced by 
families of children with special needs.

This guide also contains a Private Insurance Checklist, an HMO 
and PPO checklist, a good description of the CHAMPUS program 
(Civilian Health and Medical Program of the Uniformed Services) 
including its shortfalls, and a description of state supplemental 
family support programs.

Target Audience:  Consumers, families, practitioners, advocates 
and policy makers.

Issues Raised/Conclusions:  The book contains some important 
recommendations in selecting health insurance: 

.    Consult with your child's physician and other providers and 
     assess current and future needs; 
.    Prior to changing jobs, evaluate the insurance options in 
     relation to your child, including the type of coverage and 
     the amount, duration and scope of services allowed; 
.    Obtain coverage details in writing; and 
.    If your child has health insurance, get a copy of the 
     policy, HMO/PPO contract.

The author recommends careful record-keeping of claims filed and 
payments made. The appendix contains a completed Medical 
Insurance Summary Form, developed by Parent Education and 
Assistance for Kids (PEAK). Using this form will help parents 
keep track of insurance-covered expenses and out-of-pocket 
expenses.  

Behney C. Technology and Disability: Policy Issues in the Year 
2000. Washington, D.C.: February 1986. Available from: The 
Annenberg Washington Program and the Gallaudet Research Institute 
Joint Forum on "Marketplace Problems in Communication Technology 
for Disabled People, 1455 Pennsylvania Avenue N.W. Suite 200 
Washington, D.C. 20004 (202) 393-7100; 33 pages and references.

Summary  Written by one of the authors of the 1982 OTA Report, 
Technology and Handicapped People, the paper presents a series of 
assumptions covering technological developments, federal 
policies, demographies and other determinants of the future for 
technology and people with disabilities.  The paper describes 
three possible scenarios for the future:   (1) Marginal 
technology improvements with relative lack of resolution of 
policy issues; (2) Technology turning point and relative lack of 
resolution of policy issues; (3) Technology turning point and 
successful resolution of many policy issues.   

Target Audience:  Individuals concerned with fostering access to, 
and availability of, useful and affordable technology for all 
individuals with disabilities.

Issues Raised/Conclusion:  The author concludes that scenario (2) 
is most likely to occur but offers no definitive reason on the 
choice.  Many possibilities are offered for the future of 
technology but nothing in the way of recommendations for 
advocates or policy makers.  The paper declines to suggest that 
any progress has been made since the 1982 OTA report, Technology 
and Handicapped People.   

Burns A. Communications Technology for Disabled People: 
Third-Party Policies and Financial Aids and Barriers. Washington, 
D.C.: February 1986. Available from: The Annenberg Washington 
Program and the Gallaudet Research Institute Joint Forum on 
"Marketplace Problems in Communication Technology for Disabled 
People, 1455 Pennsylvania Avenue N.W. Suite 200 Washington, D.C. 
20004 (202) 393-7100; 47 pages and references.

Summary: This paper presents information about payment policy for 
communication technology for people with disabilities.  The 
points made emphasize communications technology, however, they 
apply to other assistive technology for individuals with 
disabilities.  The paper provides an overview of the system of 
technology selection, use and funding with a focus on 
government's and society's roles.  The premise is that the use of 
technologies by people with disabilities appears to depend 
primarily on the public and nonpublic programs and services for 
which the individuals users are eligible.  Through their 
affiliation with these programs and services, users either 
receive technologies directly, have them
financed, or learn about them.  Much of the information and 
analysis in the paper is updated from the OTA report Technology 
and Handicapped People. 
Target Audience:  Individuals concerned with fostering access to, 
and availability of, useful and affordable technology for all 
individuals with disabilities.

Issues Raised/Conclusion: The author was the analyst on the OTA 
project responsible for the delivery, use and financing issues.  
By reexamining the 1982 report, the conclusion is that although 
capabilities have continued to grow, the problems of financing 
and use system largely remain the same.  There have been only 
minor changes in the program.   


Bergman, A.  "Active Treatment:" An Entitlement for Assistive 
Technology Services for Individuals with Physical, Cognitive and 
Multiple Disabilities Living in ICFs/MR.  Washington:  April 
1989.  Available from:  United Cerebral Palsy Associations, Inc., 
Community Services Division, 1522 K Street, N.W., Suite 1112, 
Washington, D.C. 20005; 1-800-USA-5UCP Voice/TDD; 8 pages.

Summary:  On October 3, 1988, the Health Care Financing 
Administration's (HCFA) new regulations for certification of 
intermediate care facilities for persons with mental retardation 
and related conditions (cerebral palsy, epilepsy, autism, etc.) 
took effect.  These regulations apply to approximately 140,000 
children and adults residing in ICFs/MR throughout the nation.  
The regulations mandate an individual entitlement to a 
"continuous active treatment program," as defined in the 
regulations and as individually tailored for each resident 
through the development of an individualized habilitation plan 
(IHP).  This 24 hour, 7 day a week plan must encompass all 
aspects of life to assure that the services are directed toward 
"the acquisition of the behaviors necessary for the client to 
function with as much self determination and independence as 
possible."

Target Audience:  Families, advocates, policy makers, ICF/MR 
providers, nursing homes, PT's, OT's, ST's and others who may be 
involved in the development of IHP's.

Issues Raised/Conclusions:  This exhaustive extraction of 
specific sections of the regulations provides the framework for 
justifying the inclusion of the full range of assistive 
technology services and devices within an individual's IHP, which 
then constitutes an entitlement to the assistive technology 
services, as well as the ongoing maintenance and repair of such 
equipment as eyeglasses, hearing aids, communication aids, 
braces, wheelchairs, etc.
     The author urges family, advocate and provider training 
regarding an awareness of the range of assistive technology and 
its application to persons residing in ICFs/MR, the mechanisms to 
include the assistive technology is the IHP and to assure 
compliance  by the providers.  Bergman also develops the linkage 
between the ICF/MR regulations and the impact they have on the 
estimated 40,000-60,000 people with mental retardation and 
related conditions residing in nursing homes, whose services fall 
under the nursing home reform provisions in the Omnibus Budget 
Reconciliation Act of 1987.  Following these regulations should 
assure each individual residing in an ICF/MR or nursing home of 
the appropriate
assistive technology for his/her needs.


Bergman, A.  "Parents Right to Say 'No'...to Education Request to 
Bill Health Insurers."  Family Support Bulletin,  (Summer 1990):  
16-17.   Available from:  United Cerebral Palsy Associations, 
Inc., Community Services Division, 1522 K Street, N.W., Suite 
1112, Washington, D.C.  20005; 800-USA-5UCP Voice/TDD.

Summary:  Public Law 99-457 established new Part H provisions to 
utilize all public and private sources to pay for Part H services 
for infants and toddlers ages birth to three years, and their 
families, including private insurance.  An unintended result of 
this policy is that an increasing number of local school 
districts are now "asking" parents of children 5-21 years of age 
to "voluntarily agree" to allow the school district to bill their 
health insurance company for related services provided under P.L. 
94-142.  

The new Part H provisions, however, do not apply to P.L. 94-142, 
The Education for All Handicapped Children's Act, which assures 
the right to a free appropriate public education for all children 
with disabilities. Accordingly, parents do not have to use their 
health insurance for education-related services when they will 
face a realistic threat of financial loss including but not 
limited to:  a decrease in available lifetime coverage, an 
increase in premiums, or an out-of-pocket expense such as payment 
of a deductible.  This article provides the statutory language 
and regulatory citation to clarify the issue for parents and 
states.  

Target Audience:  Parents, special educators, policy makers, 
advocates, providers, funding specialists, practitioners, PTs, 
OTs and others who may be involved in developing a child's IEP. 

Issues Raised/Conclusions:  The author urges parents to "just say 
no" to allowing the local school authority to bill private 
insurance for special education related services.  Bergman also 
raises a number of implementation issues:

.    Are parents given all of the factual information in order to 
     make an "informed" decision?
.    Are parents led to believe that without insurance payments, 
     fewer services will be provided to their child?
.    Do parents feel intimidated into signing over their 
     insurance?
.    Do parents feel "guilty" or believe that if they don't sign, 
     then they will be hurting their child?



Berkowitz, M.  Measuring the Efficiency of Public Programs:  
Costs and Benefits in Vocational Rehabilitation.  Available from:  
Temple University Press, Broad and Oxford Streets, Philadelphia, 
PA. 19122; 215/787-8787; 263 pages and index.

Summary:  This book examines the difficulties in assessing the 
efficiency of Vocational Rehabilitation programs.  The book 
narrows the scope of its study
exclusively to the cost/benefit method of assessing program 
efficiency and emphasizes the paucity of accurate cost/benefit 
data available for use in assessment.  The inaccuracy results 
from an inability to find a truly representative group of 
individuals with disabilities, who use the Vocational 
Rehabilitation program, for use as a control group in data 
collection.  As a result of the inaccurate data the policy makers 
lack the firm evidence they need to support increased public 
investment in Vocational Rehabilitation.

Target Audience:  Individuals with disabilities, advocates, 
anyone allied with Vocational Rehabilitation, policy makers.

Issues Raised/Conclusions:  The book concludes that a 
cost/benefit model is not the best method of assessing the value 
of Vocational Rehabilitation.  The cost/benefit method of 
assessment measures how the program failed the individual; a 
better method of assessment would examine the individual's status 
if he  or she had not had the benefit of the program.  This type 
of assessment method would include models designed to evaluate 
the change in behavior of the individual clients and counselors.  

If however the cost/benefit approach continues to be utilized, 
Berkowitz recommends 1) monitoring the client's progress 
throughout the Vocational Rehabilitation program as well as 
his/her progress from other programs with similar benefits and 2) 
use of Functional Assessment Inventory (FAI) as the method of 
assessing a persons physical or mental functioning before and 
after the Vocational Rehabilitation.

Bradley, V.  Family Support Services in the United States: An End 
of Decade Status Report.   Cambridge:  February 1990.  Available 
from:   Human Services Research Institute, 2336 Massachusetts 
Avenue, Cambridge, MA 02140; 617-876-0426; 280 pages, $20.00. 

Summary:  This report is one part of a larger effort to provide 
states with technical assistance related to the development of a 
systematic approach to family supports.  State family support 
programs are a very important and frequently overlooked funding 
source for assistive technology.  This report describes states' 
efforts, program detail, and eligibility criteria, and provides 
the addresses and phone numbers of contact persons.   

A review of the literature and discussions with policy makers, 
providers and parent groups around the country crystallized the 
need to develop an up-to-date base of information on the current 
status of state family support efforts, before launching into an 
intensive technical assistance effort. The report provides a 
historical context for family support, a synthesis of state 
family support efforts including funding of assistive technology, 
and a description of some of the key issues surrounding the 
development of family support.  This section is followed by a 
description of the family support activities in each state.

Target Audience:  Consumers, information and referral sources, 
state and local program administrators, policy makers, Title I 
state funding coordinators.

Issues Raised/Conclusions:  The report found that 41 states have 
developed programs with a special focus on supporting families 
who are raising a child with a developmental disability.  These 
programs provided some services to at least 127,777 families 
during the last fiscal year.  States working to improve access to 
assistive technology through the coordination of existing systems 
and programs should recognize the tremendous value of the 
information contained in this report.  The report encourages 
supports that are family centered, culturally sensitive, 
community-centered, and well coordinated, all of which are found 
to be central to the acquisition of assistive technology and 
related services. 


Brady, P.  Guide to Transportation Funds.  Washington:  1989.  
Available from:   United Cerebral Palsy Associations, Inc., 
Community Services Division, 1522 K Street, N.W., Suite 1112, 
Washington, D.C. 20005; 800-USA-5UCP Voice/TDD; 23 pages.

Summary:  This guide provides a directory of federal, state and 
local resources which will help nonprofit organizations/agencies 
interested in pursuing federal assistance for community-based 
specialized transportation services.

Each year, the federal government awards in excess of $35,000,000 
to community-based nonprofit organizations to assist with the 
acquisition of vans, buses and other equipment to provide 
transportation services to individuals with disabilities.  The 
program, known as the 16(b)(2) Capital Assistance Program for 
Nonprofit Organizations Transporting Elderly and Handicapped, 
provides funds for capital purchases and is directed to areas 
where existing services are either insufficient, unavailable or 
inappropriate.  The guide includes a sample completed application 
form for the Section 16(b)(2) Capital Assistance Program that was 
funded in Oregon.

The guide describes several other programs through the Urban Mass 
Transit Administration for specialized transportation systems and 
provides other information on a variety of community 
transportation related topics. 

Target Audience:  Organizations/agencies interested in improving 
community-based transportation options for individuals with 
disabilities.


Burgdorf, R. Communication Technology, People with Disabilities, 
and the Law. Washington, D.C.: February 1986. Available from: The 
Annenberg Washington Program and the Gallaudet Research Institute 
Joint Forum on "Marketplace Problems in Communication Technology 
for Disabled People, 1455 Pennsylvania Avenue N.W. Suite 200 
Washington, D.C. 20004 (202) 393-7100; 33 pages and references.


Summary:   This paper is a clear and detailed summary of the 
current legal discussion around communication technology for 
people with disabilities and explores the impact of various legal 
requirements.  The paper offers a legal
framework on the requirement of access to communication 
technologies for individuals with disabilities.  A few proposals 
are offered that might provide more comprehensive direction to 
employers, program and service providers and communication 
industry as to what is legally required.  The paper suggests that 
there is a need for additional federal statutory clarification of 
certain issues. 

Target Audience: Government agencies, the communications 
industry, employers, and persons with disabilities, advocates.

Issues Raised/Conclusions: The most obvious need in the area of 
communications technology, disability and the law is for more 
clear and specific legal requirements and standards regarding the 
right to access to communication devices and systems including:  

a)   Equal employment opportunity for individuals with 
     disabilities should be protected in all businesses engaged 
     in an industry affecting commerce.

b)   FCC licensees should be subject to a requirement that the 
     assure equal access for people with disabilities to their 
     facilities, services, and programming.  

c)   The Architectural and Transportation Barriers  Compliance 
     Board (ATBCB) in consultation with other pertinent agencies, 
     should be directed to develop minimum guidelines for TDDs, 
     computer terminals and software, and their communication 
     devices and systems used or regulated by Federal agencies.  
     Based upon these minimum guidelines, the FCC, the GSA and 
     other Federal agencies should develop regulations regarding 
     such systems and devices for the programs and activities 
     they conduct or regulate.


California, State of.  Department of Health Services.  Durable 
Medical Equipment (DME): Guidelines for Recommendations for 
Purchase.  Sacramento:  December 1987.  Available from:  Dept. of 
Health Services, California Children Services, 714 P Street, 
Sacramento, CA 95814; 10 pages. 

Summary:  This guide is used by California Children Services 
(CCS) state agency personnel when recommending a state purchase 
of durable medical equipment (DME).  The guide lists those items 
which may be a CCS benefit for children with disabilities and 
outlines criteria which must be met before recommending equipment 
to the treatment team for consideration and prescription. The 
guide charts medical condition and criteria for the use of 
equipment for self-care, mobility, and positioning devices.

The guidelines included in this document were developed by a 
committee of CCS therapists to assist staff in making timely and 
appropriate equipment decisions, and to assist counties and state 
regional offices in achieving uniformity in CCS purchases.  

Target Audience:  State program directors, policy makers, 
consumers and families,
providers and vendors.

Issues Raised/Conclusions:  This approach by California is 
noteworthy and deserves further exploration as a method to 
resolve state purchasing inconsistencies.  Other states could 
benefit from a similar model. Families and persons with 
disabilities will learn from the terminology and explanations 
used to justify equipment purchases.  Issues that need to be 
explored are how the committee evaluates new technology, the 
extent to which consumers are involved in the decision-making 
process, how quickly the committee reacts to changes in the law 
and in the technology, how maintenance and repair financing 
decisions are made, and quality assurance.


Castagna, A.D., Ph.D.  An Agenda for Change:  Unshackling Old 
Ideas Towards the Disabled.  California: May 1990.  Available 
from: A.D. Castagna, Quest Technologies Corporation, Sunnyvale, 
CA. 10 pages.

Summary:  This report discusses the need for appropriate 
incentives to encourage the development and financing of 
assistive technology.  The basic premise of the paper is that a 
"market-based" orientation is the only mechanism that will lead 
to better quality, cost effective outcomes for persons with 
disabilities.

Target Group:  Individuals with disabilities and their families, 
product developers, manufacturers, suppliers, agencies, 
advocates.

Issues Raised/Conclusions: A market-based approach towards 
assistive technology will improve services only if the market for 
assistive technology can become more competitive.  The report 
offers several reasons why the current market for assistive 
technology is not competitive: 1) current regulations are 
inadequate to force public demand for assistive technology; 2) 
when looking for information on assistive technology, persons 
with disabilities often have to rely on service providers who may 
have economic incentive not to disseminate information which may 
be costly to them; 3) stereotypes about persons with disabilities 
have led to an ill-informed public that fails to view persons 
with disabilities as a potential consumer market; and 4) persons 
with disabilities are often not seen as the actual financiers of 
the technology since the technology is often financed through 
third party reimbursement systems.  

The report offers several suggestions for change including:  1) 
establishing a financial intermediary that can target individuals 
with disabilities as costumers; 2) changing the current 
ineffective legislation concerning assistive technology; and 3) 
changing the stereotype about persons with disabilities from that 
of passive recipients to that of active consumers. 

Center for Rehabilitation Technology Services. "Special Issue on 
Funding."  Spectrum (Fall 1989).  Available from:   The Center 
for Rehabilitation Technology Services, 1410-C Boston Avenue, 
P.O. Box 15, West Columbia, SC 29171-0015; 803-822-5362; 8 pages.

Summary:  This issue of Spectrum is devoted to funding.  Six 
priority areas for improving access to funds are discussed. The 
priorities emerged from a 1989 funding symposium entitled, 
"Funding Resources for Assistive Technology in South Carolina."  
The priority areas are:  access to information, use of advocacy 
and support groups, improved networking and communication, use of 
case management techniques, better systems integration, and the 
development of education and training materials on funding.  More 
detail on the priorities can be found by obtaining a copy of the 
Symposium's proceedings.

The newsletter also contains an article entitled, "Funding: the 
Private Practice Perspective," a interview with a medical 
equipment supplier, and a short but good list of available 
funding resources.

Target Audience:  Consumers, families, practitioners, advocates, 
policy makers, and funding specialists.


Center for Special Education Technology.  Assistive Technology 
Resource Directory. Reston, VA:  January 1990.  Available from:  
The Council for Exceptional Children, 1920 Association Drive, 
Reston, VA 22091; 703-620-3660 or 800-873-8255; 62 pages.

Summary:  The Center for Special Education Technology at the 
Council for Exceptional Children is a national information center 
funded by the U.S. Department of Education, Office of Special 
Education Programs.  The Center has compiled an annotated 
directory of resources to assist in locating key organizations, 
agencies and projects at the national, state, and local level 
which are involved in the delivery of assistive technology 
services.  The directory provides a general overview of each 
agency and its services, as well as information  about current 
technology related activities.  Also included are the first nine 
recipients of the state technology-related assistance grants and 
the national technical assistance project funded by NIDRR under 
the P.L. 100-407.

Target Audience:  Consumers, families, practitioners, advocates 
and policy makers.


Cohen, R., Roth, P., and Morris, M.  A New Way of 
Thinking--Getting to Work, Understanding SSI Benefits for People 
With Disabilities.   Washington:  1990.  Available from:  United 
Cerebral Palsy Associations, Inc., Community Services Division, 
1522 K Street, N.W., Suite 1112, Washington, D.C. 20005; 
800-USA-5UCP Voice/TDD; 16 pages, $2.50.

Summary:  This brochure explains P.L. 99-643, The Employment 
Opportunities for Disabled Americans Act, Section 1619 (a) and 
(b), which allows people who receive SSI to work without losing 
all of their benefits. Section 1619 (a) allows people to earn 
money on a job and still keep all or part of their monthly SSI 
payments.  Section 1619 (b) ensures that people can keep their 
Medicaid benefits as long as they need them to continue working.  
The brochure also explains the PASS program, Plans for Achieving 
Self Support, which allows people to save
money beyond the asset limits for SSI for a special work-related 
reason.  A PASS can be written for assistive technology needed 
for work, if the technology is part of a feasible goal for 
becoming self-supporting. 

Target Audience:  Consumers with disabilities who receive SSI, 
SSDI benefits who want to work and/or are planning a career, or 
are working and are interested in purchasing assistive 
technology; parents and consumer advocates.  


Commerce Clearing House.  Medicare and Medicaid Guide.  Chicago:  
1991.  Available from:  Commerce Clearing House, Inc. 4025 W. 
Peterson Avenue, Chicago, Illinois, 60646; 202-626-2200; $905.00 
per year. 

Summary:  Medicare and Medicaid Guide in five volumes with 
regular biweekly reports, is a resource which covers the 
questions of who is eligible for Medicare, what services are 
covered by Medicare, and how non-institutionalized services are 
paid.  These explanations are based on the law, regulations, 
pertinent rulings, court decisions and explanatory bulletins. 

Volume 1 contains Medicare Part B coverage for Durable Medical 
Equipment (3144), Prosthetic Devices (3152) and Braces, Trusses, 
and Artificial Limbs and Eyes (3156), Comprehensive Outpatient 
Rehabilitation Facility Services (3130), Physical and 
Occupational Therapy Services (3128), Speech Pathology Services 
(3129), and Home Health Services (3118).  There is also a section 
on Exclusions From Medicare Coverage (4000) dealing with Services 
Not Reasonable and Necessary (4030) and Personal Comfort Items 
(4075).

Volume 5 contains a topical index to new developments, Medicare 
Coverage Issues Manual (27,201), which is republished and updated 
quarterly in the Federal Register.  The index describes whether 
certain specific medical items, services, treatment procedures, 
or technologies can be paid for under Medicare.  The volume also 
contains a Durable Medical Equipment Reference List (27,221) 
which lists the coverage status of certain pieces of DME, and 
provides a brief explanation for DME equipment which is not 
covered.  The rest of Volume 5 and accompanying Transfer Binders 
provide updated references to new developments which affect both 
the Medicare and Medicaid programs.

Target Audience:   Regional, State and local providers, vendors 
of durable medical equipment and area carriers, program 
administrators.


Community Transportation Association of America.  "Community 
Transportation Resource Guide." Community Transportation 
Reporter. 1991 Annual Issue on Resources.  Available from:  
Community Transportation Reporter, 725 15th St. N.W., Suite 900 
Washington, D.C. 20005; $10.

Summary:  Community Transportation Reporter is a monthly 
technical assistance publication of the Community Transportation 
Association of America, devoted to improving transportation in 
rural areas, small cities and other areas where older
Americans, people with disabilities or low-income people do not 
have access to conventional public transit. 

Divided into four sections, this issue contains information on 
national resources, federal funding resources, federal and 
regional contacts, state contacts and funding levels. The federal 
funding sources are explained in detail, including program 
overview, eligibility criteria, and funding levels.  Names, 
addresses and phone numbers are provided for all the funding 
resources including state, regional and national sources.

Target Audience:  Organizations/agencies interested in improving 
community-based transportation options for individuals with 
disabilities, advocates.

Issues Raised/Conclusions:  Each year, the U.S. Department of 
Transportation provides over $250 million in funds for 
specialized transit.  


Costen, C.  Planning and Implementing Augmentative Communications 
Services Delivery.   Washington:  1988.  Available from:  RESNA 
Press, 1101 Connecticut Avenue, N.W., Suite 700, Washington, D.C. 
20036; 204 pages, $25.00.

Summary:  This document contains the proceedings of the National 
Planners Conference on Assistive Device Service Delivery, 
Chicago, IL, April 1987.  Divided into four sections: Planning, 
Funding, Service Delivery, Assessment/Evaluation, the book 
contains a good overview of the issues and problems that state 
education agencies and other involved agencies will need to 
address in providing assistive technology and services to 
individuals with communication and mobility impairments. The book 
provides examples of planning and service delivery models that 
illustrate coordination among several agencies; and an overview 
of issues and considerations relative to funding equipment and 
financing service delivery.

Section Two: Funding For Assistive Device Programs and Equipment, 
explores available funding models used by various programs, 
acquisition of funding to assist clients with the cost of 
assessment and securing assistive technology, and a discussion of 
funding issues with a primary focus on Medicare, Medicaid and 
private insurance.  

Target Audience:  Individuals affiliated with state or local 
education agencies interested in, or responsible for, the 
development of programs or delivery of equipment or services to 
individuals who require assistive technology. 



DeWitt, J.C. and Mendelsohn, S.  Establishing Nonprofit 
Foundations to Pay for Assistive Technology.  Washington:  
September 1990.  Available from:  Rehabilitation Engineering 
Society of North America - Technical Assistance Project, 1101 
Connecticut Avenue, N.W., Suite 700, Washington, D.C. 20036, 
202\857-1140; 12 pages, references and bibliography.

Summary:  This report examines the use of a foundation as an 
alternative funding source for assistive technology devices and 
services.  The report emphasizes that there is a valuable role to 
be played by public-private partnerships in state program 
development. In addition to the foundation's benefit as a funding 
source, it provides the benefit of greater speed and flexibility 
in administering the program since foundations require much less 
administrative red tape than do government agencies. Foundations 
will also be able to broaden the assistive technology 
constituency within the community.  
     The report does not attempt to provide "how to" guidelines, 
however, it does mention important considerations that must be 
addressed within the partnership. For example, considerations 
include whether the foundation will be pro-active and address 
long range goals or be reactive and address only emergency needs; 
whether it will be public or private, corporation or trust; who 
the foundation will serve; and what services it will provide.

Target Audience:  people with disabilities, Title I state funding 
coordinators, foundations and other non-profit, charitable 
organizations.

Issues Raised\Conclusions:  Key to establishing a foundation is 
deciding clearly who the organization will serve and what 
services will be provided.  This can be done only by having full 
knowledge of the existing technology and establishing eligibility 
criteria.  An important situation to guard against is using 
foundation funds to replace rather than augment public resources.  
When determining what the scope of the foundation should be, it 
is essential to have an active, consumer responsive governing 
board and involvement from the profit sector and service 
providers in the community.  

The report cautions against the use of a foundation as a donor 
for families, employers and others who wish to contribute funds 
which would be used to benefit a specific individual.  Such 
programs however, can and continue to be useful. 

Eckstein, R.  Handicapped Funding Directory.   Margate, FL:  
Seventh Edition, 1990.  Available from:  Research Grant Guides, 
P.O. Box 4970, Margate, Florida 33063; 251 pages, $23.50.

Summary:  The directory, designed as a resource in the quest for 
grant funds, profiles over 700 foundations, corporations, 
associations, and government agencies which have funded programs 
and services in disability-related areas.  The directory's 
orientation is on obtaining program funding rather than grants to 
individuals.  The directory includes associations, foundations 
and corporations listed by state, plus an index of federal 
programs listed by agency.

Target Audience:  Practitioners, advocates, information referral 
sources, consumers, policy makers and funding specialists.


Electronic Industries Foundation.  Provision of Assistive 
Technology Planning and Implementation: Report of a Workshop.   
Washington:  March 1989.  Available
from:  Electronic Industries Foundation, Rehabilitation 
Engineering Center, 1901 Pennsylvania Ave., N.W., Suite 700, 
Washington, D.C. 20006; 206 pages and appendices.

Summary:  This valuable volume of information describes key 
components that should be part of a comprehensive assistive 
technology delivery service program. The manual includes a 
description of processes which might be used to plan and 
implement such a program. Chapter VII, "Payment Issues and 
Options in the Utilization of Assistive Technology," reviews the 
basic principles of funding, major federal funding sources, 
credit-based funding systems, tax subsidization of assistive 
technology, and financing through cost sharing. This section 
places special emphasis on state discretion in these programs and 
highlights those funding streams that remain a large but as yet 
untapped resource for assistive technology (i.e., Section 508 of 
the Rehabilitation Act, SSI, SSDI program work incentives.)

Target Audience:  This document will help states, regional and 
local groups plan and implement a program that would make maximum 
use of every resource available.

Issues Raised/Conclusions:  All the papers presented have 
implications for policy, practice and research. On financing 
options, the author concludes:

.    The SSDI and SSI work incentive programs of the Social 
     Security Act represent a largely untapped resource in the 
     financing of work-related assistive technology;
.    State assistive technology funding coordinators and 
     information sources need to know in detail the mechanics of 
     these Social Security work incentive programs and 
     opportunities;
.    In VR, as with other categorical state grant programs, it is 
     imperative for professionals, students, clients, and 
     advocates to familiarize themselves with their respective 
     state plans as they pertain to the financing of assistive 
     technology;
.    Excessive reliance on self-financing through credit will 
     indirectly exclude the most disadvantaged individuals with 
     disabilities; and
.    Section 508 of the Rehabilitation Act, Accessible Electronic 
     Office Equipment, constitutes an important new direction in 
     public policy.  This directive has profound implications in 
     incorporating disability access to technology for other 
     (non-government) large scale purchasers of electronics and 
     other equipment.  



Enders, A.  Assistive Technology Sourcebook.  Washington:  1990.  
Available from:  RESNA Press, 1101 Connecticut Avenue, N.W., 
Washington, D.C. 20036;
202-857-1199; 576 pages, $60.00. 

Summary:  This resource is an encyclopedia of assistive 
technology and related services, filled with information for 
everyone involved with providing or using assistive technology.  
The book is organized into 18 chapters covering all areas of 
service delivery including: identifying what is currently 
available; resources for matching technology to an individual's 
needs; resources for specific areas of technological support; and 
ensuring that technology reaches those who can benefit from it.   
The Sourcebook is most comprehensive in its coverage of topics 
related to assistive technology.

Target Audience:  Policy makers, state financing coordinators, 
information referral sources, consumers, manufacturers and 
suppliers.

Issues Raised/Conclusions:  The information in Chapter 16, 
"Systems and Policy Issues," raises many important public policy 
issues and should be required reading by all individuals involved 
in policy decisions related to assistive technology. The author 
concludes that although technology has advanced, it is not 
benefiting the people who need it most.  She criticizes the 
fragmented financial support system and warns against continued 
movement toward a complex patchwork of financing support that is 
rapidly polarizing toward the largely outdated Medicare (Part B) 
durable medical equipment model.  

Among the compendium of program considerations in this section 
are the following public policy recommendations: 

.    Public policy should avoid an overly restrictive view of who 
     might benefit from creative applications of technology; 
.    Federal, state, and private sector partnerships must be 
     evolved that will ameliorate social and administrative 
     deficiencies in our delivery system and its financial 
     support structure; 
.    Comprehensive planning between agencies is needed; 
.    Multi-agency government and private sector participation is 
     essential, especially at the statewide delivery level.  
     Chapter 16 also provides an extensive annotated bibliography 
     on the funding of assistive technology.


Enders, A. Writing National Policy on Work Disability  Paper No. 
5:  Assistive Technology.  Washington:  November 1990. Available 
from:  University of Montana, Rural Institute on Disability, 
Missoula, Montana 59812; 406/243-5481; 10 pages and appendix.

Summary:  This work examines the problem of policy makers 
treating technology as a method of rehabilitation to be utilized 
strictly as a last resort, i.e., only for use
if the equipment is medically necessary, and never solely for 
purposes of integrating persons with disabilities into the 
community regardless of medical necessity.  Enders suggests areas 
where policy makers can undo the last resort tradition and place 
increased emphasis on the service delivery system for assistive 
technology.  

Target Audience:  Individuals with disabilities, design 
manufacturers, service providers, policy makers, the general 
public.

Issues Raised/Conclusions:  Assistive technology has capital 
asset value because it pays for its public cost by creating 
sustainable employment for individuals with disabilities.  Most 
importantly, the report emphasizes that policy makers should not 
keep attempting to tinker with an unworkable system which sees 
technology as useful only if it is medically necessary.  
Broadening the roles of assistive technology will increase market 
demand and private sector incentives to create and invest in 
assistive technology.


Ensign, A.  "Assistive Devices: Funding Resources in Michigan." 
PAM Repeater, 42 (September 1987).  Available from:  PAM 
Assistance Center, 601 Maple Street, Lansing, MI 48906; 
517-371-5897 in Michigan, 800-426-7426 Voice/TDD; 24 pages, 
$2.00.

Summary:  The PAM Assistance Center provides information about 
assistive technology with descriptions of items, what they cost, 
and how they might be secured.  This publication addresses the 
process of obtaining funding for assistive technology in 
Michigan.  The publication takes the reader through a three-step 
process of:  1) gathering information; 2) identifying appropriate 
agencies; and 3) applying for funds.

This edition contains a chart of State funding sources and the 
devices most likely to be covered, outside funding sources, 
private insurance information, and other sources of information 
for funding in Michigan.   

Target Audience:  The publication is specifically directed toward 
individuals with disabilities and their families and may be a  
model for other regions preparing material relevant to their own 
funding resources. 

Fox, H., Wicks, L., Kelly, R., and Greaney, A.  An Examination of 
HMO Policies Affecting Children With Special Needs.   Washington:  
September 1990.  Available from:  Fox Health Policy Consultants, 
Inc. 1140 Connecticut Avenue, N.W., Suite 1205, Washington, D.C. 
20036; 202-223-1500; 123 pages.

Summary:  This publication will acquaint readers with Health 
Maintenance
Organizations (HMOs) and their advantages and disadvantages in 
relation to children with special needs.  The report is based on 
a review of existing literature on HMOs, interviews with parents 
and professionals experienced in the care of children with 
special-needs, data collected from a nationally representative 
sample of HMOs, and interviews with several HMO directors for 
their perspective on HMOs strengths and weaknesses in caring for 
children with special needs.  The report also investigates the 
experiences of states enrolling Medicaid recipients in HMOs 
through interviews with Medicaid directors and staff.

Target Audience:  Families, advocates, HMOs, state insurance 
industry regulators, state Medicaid agencies, and state programs 
for children with special health care needs.

Issues Raised/Conclusions:  According to the report, 8.5 million 
or 13% of individuals served by HMOs are children.  This includes 
400,000 children who have chronic health conditions. The report 
specifies the concerns raised by advocates for children regarding 
HMO care for children with special needs, including: restrictive 
interpretation of "medically necessary;" cumbersome authorization 
and control mechanisms; waiting lists for limited number of 
affiliated programs; impeded access to specialty providers; 
disruption of ongoing treatment; deficits in HMOs' grievance 
process; deficits in coordination with non-medical human 
services. 

The report documents many problems with HMOs, several of which 
may affect access to assistive technology as a covered service, 
including: limited access to particular specialty providers; 
restrictions on the receipt of covered services; policy barriers 
to timely and appropriate care, especially for children with 
special needs; denial of covered services because of failure to 
meet strict medical necessity criteria.  The impact of obstacles 
to appropriate care under HMO plans is compounded for families of 
children with special needs by the widespread lack of information 
about benefits and general confusion about how HMOs operate.


Fox, H., and Yoshpe, R.  Technology-Dependent Children's Access 
to Medicaid Home Care Financing.   Washington:  June 1986.  
Available from:  Fox Health Policy Consultants, 1140 Connecticut 
Avenue, N.W., Washington, D.C. 20036; 47 pages.

Summary:  The purpose of this report is to examine the 
opportunities that technology-dependent children have for 
obtaining home care coverage under the Medicaid program.  Three 
of these options require the states to obtain a federally 
approved waiver of usual Medicaid rules.  The report is divided 
into four sections that provide information on: the Medicaid 
options available for financing technology-dependent children's 
home care; the current level of state activity in each of the 
options; state policies and practices that limit the number of 
children
able to participate in the Medicaid home care program options; 
and the Medicaid and Crippled Children's Services (CCS) financing 
opportunities that would be available in five states for three 
hypothetical technology-dependent children. The states are 
California, Georgia, Kansas, Maryland, and Missouri.  

Target Audience:  Policy makers, advocates.

Issues Raised/Conclusions:  Although a significant number of home 
care waivers and state plan amendments are available, in many 
states not as many children with severe disabilities as might be 
expected are participating.  Variations in participation rates 
are frequently a function of the way a program is structured with 
regard to income eligibility, categorical eligibility, 
cost-effectiveness determinations, and service coverage. Policies 
of this type are discussed in Section III of the report, "State 
Policies and Practices that Limit the Number of Severely Disabled 
Children Able to Receive Home Care Services Under the Four 
Options."



Fuhrer, M.J.  Rehabilitation Outcomes:  Analysis and Measurement.  
Copyright 1987.  Available from:  Paul H. Brookes Publishing Co., 
P.O. Box 10624, Baltimore, Maryland 21585-0624; 271 pages, 
references and index.  

Summary:  The goal of this book is to provide information which 
will promote  a more accurate assessment of rehabilitation 
services.  The book reviews current outcome analysis in the areas 
of medical rehabilitation, the rehabilitation of persons with 
mental retardation, psychiatric rehabilitation, vocational 
rehabilitation, and independent living.  The author examines each 
of these areas in terms of the nature of service interventions 
and target groups; kinds of outcomes and how they are placed into 
operation; time frames within which outcomes are assessed; and 
additional research that warrants priority.  The specific target 
groups examined are:  multiple sclerosis, arthritis, burns, 
visual impairments, head injuries and spinal cord injuries.  The 
book highlights controversial issues and recommends solutions to 
the problem of measurement, including detailed suggestions on 
which criteria would help standardize outcome assessment and how 
current policy and financing changes are likely to effect future 
approaches to outcome analysis. 

Target group:   Rehabilitation professionals and those familiar 
with rehabilitation policy, manufacturers, agencies, program 
developers.

Issues raised/Conclusions:  The most important change to be made 
in rehabilitation assessment is to improve the studies done from 
a cost/benefit approach. One way to improve the cost/benefit 
assessment is to develop a uniform data system which would 
include:  uniform language, definitions and measurements; data 
that adapt to the level of the disability and cost of care; cost 
effectiveness of the rehabilitation
care; better feedback to health care providers; establishment of 
criteria for admission, discharge and referral to other services; 
and a uniform method for evaluating research.


Funding and Assistive Technology: A STAR Program Workshop.  
Minnesota:  1991.  Available From:  300 Centennial Building, 658 
Ceder Street, St. Paul, Minnesota 55155;  36 pages and 
references.

Summary:  A perfect source for those in the first stages of 
learning about assistive technology.  It offers basic easy-to- 
understand definitions of assistive technology vocabulary as well 
as consumer friendly explanations of the various pieces of 
legislation that require the provision of federal funds for 
assistive technology.  A reader is given basic information about 
each of the available assistive technology funding sources in 
Minnesota.  Information which includes step by step guidelines on 
how to apply for funding through each source, starting with where 
to obtain the application and the name of the agency contact 
person and ending with how to appeal a denial of funding. 

Target Audience:  Individuals with disabilities and their 
families, providers and foundations in Minnesota, policy makers 
and agencies in other states interested in designing a similar 
information resource.



Griss, B.  "Strategies for Adapting the Private and Public Health 
Insurance Systems to the Health Related Needs of Persons with 
Disabilities or Chronic Illness."  Access to Health Care Vol. 1, 
Nos. 3 & 4 (March 1989).  Available from:  United Cerebral Palsy 
Associations, Inc., 1522 K Street, N.W., Suite 1112, Washington, 
D.C. 20005; 91 pages.

Summary:  This policy bulletin focuses on the capacity of private 
and public health insurance systems to respond to the health 
related needs of persons with disabilities and persons with 
chronic illness.  Included are a brief history of health 
insurance, a description of the limitations of both public and 
private insurance plans, and a discussion of options for change 
at the federal and state levels.  This publication concludes with 
suggestions for the role of the disability movement in health 
insurance reform.

Target Audience:  State and federal policy makers, consumer 
advocates and service providers

Issues Raised/Conclusions:  Health insurance reform is on the 
public agenda for many reasons, and the disability movement has a 
special contribution to make in
this reform.  By exposing the limitations of private and public 
health insurance, the disability community can help influence the 
way different groups access the various options for health 
insurance reform.  Because people with disabilities or chronic 
illness are likely to have higher health care costs, they are 
sensitive to the principles of affordability and the equity of 
health care financing.  Because persons with disabilities or 
chronic illness are likely to need a range of health related 
services that extend beyond acute care, they are in a critical 
position to help broaden the definition of health care to include 
both preventive services and long-term support. Furthermore, 
because persons with disabilities recognize how barriers to 
health care create obstacles to employment and to meaningful 
participation in the community, the disability movement can 
effectively advocate for health care as a right to which all 
citizens should be entitled.


Heil Jr., J. B. Disabled People Can Be An Important Market 
Segment. Washington, D.C.: February 1986 Available from: The 
Annenberg Washington Program and the Gallaudet Research Institute 
Joint Forum on "Marketplace Problems in Communication Technology 
for Disabled People, 1455 Pennsylvania Avenue N.W. Suite 200 
Washington, D.C. 20004 (202) 393-7100; 16 pages.

Summary:  This paper offers a large business approach to 
technology financing for persons with disabilities and calls 
attention to some of the issues that impede prompt and continuous 
flow of new products to the market place.  By describing the 
product planning process, it calls attention to voids in 
communication and information which deter technology from 
reaching the consumer with disabilities.  

Target Audience: All individuals concerned with fostering access 
to, and availability of useful and affordable technology for all 
people with disabilities.

Issues Raised/Conclusions:  The author offers a full range of  
important suggestions for improving private sector financing of 
assistive technology including the areas of private insurance, 
telecommunications and marketing techniques.  These issues are 
not new, however, they have been expressed time and time again.    
Hipp E. State Telecommunication Policy and Disabled Persons. 
Washington, D.C.: February 1986. Available from: The Annenberg 
Washington Program and the Gallaudet Research Institute Joint 
Forum on "Marketplace Problems in Communication Technology for 
Disabled People, 1455 Pennsylvania Avenue N.W. Suite 200 
Washington, D.C. 20004 (202) 393-7100; 27 pages.

Summary: State utility commissions have at their disposal a 
significant amount of discretion to design programs and adopt 
regulations to serve the telecommunications needs of customers 
with disabilities.  Although some states have adopted 
wide-ranging, innovative approaches to meet these needs, the 
author emphasizes a great deal can still be done.  The paper 
presented by the
Commissioner of the North Carolina Utilities Commission describes 
guidelines designed for future state regulatory action to aid the 
states in their work on what actions to take regarding the 
provision of telecommunication equipment and services to their 
constituents with disabilities.

Target Audience:  State utility commissions and other individuals 
concerned with fostering access to, and availability of useful 
and affordable technology for people with sensory impairments.

Issues raised/Conclusions  Key recommendations include:
Special Services
a.   Businesses Offices Assistance - States should require all 
     telephone companies to provide TDD access to their business 
     offices.
b.   Operator Assistance - States should require all telephone 
     companies offering intralata and/or interlata operator 
     assistance to provide for TDD access to this service to 
     insure that deaf and severely hearing-impaired subscribers 
     can obtain assistance with credit card calls, collect calls, 
     person-to-person calls, and calls billed to third numbers.
c.   Directory Assistance - States hold require all telephone 
     companies offering directory assistance to provide for TDD 
     access to this service.
Rates
     States should require that all carriers offering intralata 
     and/or interlata toll service reduce their rates for such 
     service for TDD users by a commission-established amount.
Equipment
a.   Specialized Customer Premises Equipment -  One good 
     alternative is to establish a program whereby customers of a 
     local telephone company who have been certified by a 
     physician, may obtain specialized equipment from their local 
     telephone company at no charge. A state should finance such 
     a program by some means other than a surcharge.
b.   Public Telephone Access - States should require local 
     telephone companies to provide, install and maintain a 
     reasonable number of TDD-equipped pay telephone in public 
     places.



Hofmann, A.  The Many Faces of Funding.   Petaluma, CA:  
1981-present.  Available from:   A. Hofmann, Phonic Ear Inc., 
3880 Cypress Drive, Petaluma, CA  94954-7600, 1-800-277-0735. 
Funding Book and Newsletter subscription $45.00; one-year 
subscription to the Monthly Funding Newsletter is $8.00.

Summary:  This booklet, produced by a manufacturer of 
communication devices, represents a commitment of the company to 
provide all persons in the augmentative and alternative 
communication field with the information necessary
to evaluate, plan and obtain needed funding.  The booklet 
provides the reader with the necessary guidelines to pursue 
various funding sources. The first section is an overview of 
major third-party funding programs including federal, state, 
educational, insurance, and private sources. The second section, 
"Methods of Procedure," explores three topics: knowing your 
patient, relating to technology, and individuals with 
disabilities.  The final section of the booklet consists of The 
Many Faces of Funding newsletters and contains sections on case 
histories and legislation as well as important topics including: 
funding through vocational rehabilitation; loan banks on the 
rise; legal documentation to challenge Medicaid denial; the 
Medicare appeals process; Medicaid coverage process; and 
insurance coverage.  

Target Audience:  The comprehensiveness of this book contributes 
to making it an invaluable resource for consumers and families.

Issues Raised/Conclusions:  Approvals of funding of communication 
devices are most often related to the completeness of information 
provided and the method of presentation.  


Humphreys, R. The Dissemination of Sensory and Communication 
Technology from the Perspective of the Small Producer. 
Washington, D.C.: February 1986. Available from: The Annenberg 
Washington Program and the Gallaudet Research Institute Joint 
Forum on "Marketplace Problems in Communication Technology for 
Disabled People, 1455 Pennsylvania Avenue N.W. Suite 200 
Washington, D.C. 20004 (202) 393-7100; 22 pages and appendix.

Summary: This paper is a limited assessment of the problems of 
assistive devices dissemination and potential solution to these 
problems.  With the number one problem being the paucity of the 
distribution of the assistive devices to the people who need 
them, the author establishes the root cause of this problem as 
the lack of money.  Using the profile of a typical assistive 
devices producer, the author illustrates the barriers to 
production including marketing and cost factors.

Target Audience: All individuals concerned with fostering access 
to, and availability of useful and affordable technology for all 
people with disabilities.

Issues Raised/Conclusions: The author concludes that nothing 
short of a national policy change, and commitment to 
implementation of that policy will modify the vicious cycle that 
now inhibits dissemination of sensory and communication aids on a 
broad scale. Such a change would necessitate involvement of 
Congress and the Executive Branch.  Conceding that a change in 
administration policy is less than imminent, the author suggests 
three options: first utilize state, local and private resources, 
much in the way devices currently are distributed; second wait
for a change in philosophy of the current administration, or wait 
for a new one; and third, develop a policy that can be shown to 
be cost-neutral or cost-beneficial.
     On a national level, the author recommends 1) a tax credit 
for purchase of devices by consumers with disabilities and their 
families 2) reimbursement for devices under Medicare and 
Medicaid, and 3) a program of low interest loans and loan 
guarantees for individuals, nonprofit agencies and employers of 
persons with disabilities.  In addition, consideration should be 
given to amending the Targeted Jobs Tax Credit law to include 
specifically the provision of sensory and communications aids.
     A final alternative is the creation of an "orphan devices" 
program similar to P.L. 97-414, the Orphan Drug Act.


Jackson C., Sloan, C. Federal Communications Regulations Services 
to Handicapped People. Washington, D.C.: February 1986. Available 
from: The Annenberg Washington Program and the Gallaudet Research 
Institute Joint Forum on "Marketplace Problems in Communication 
Technology for Disabled People, 1455 Pennsylvania Avenue N.W. 
Suite 200 Washington, D.C. 20004 (202) 393-7100; 39 pages 
including glossary.

Summary: This paper reviews the role of the Federal 
Communications Commission and the authority of Communications Act 
of 1934 as they relate to services to individuals with 
disabilities. It also provides a overview of the legislative 
history of the existing communication system for individuals with 
sensory impairments including the Telecommunications Enhancement 
Act of 1983.  

Target Audience: All individuals concerned with fostering access 
to, and availability of useful and affordable technology for all 
people with sensory disabilities.

Issues Raised/Conclusion: The authors conclude that the impact of 
federal regulation on communications for individuals with 
disabilities is mixed, and no simple conclusion can be drawn 
about the benefits of regulation or deregulation,  For example, 
it is undeniable that the open, deregulated terminal equipment 
marketplace has allowed many valuable products to be offered.  
Conversely, the problems of hearing-aid compatibility with 
telephones illustrates well that, in some areas, regulation can 
benefit the individuals with disabilities at little cost to 
society. 
     The authors notes that at the federal level, almost all 
regulatory attention on telecommunications for individuals with 
disabilities has focused on the deaf and hearing-impaired.  For 
the future, advocates should work toward a more broad based 
approach to universal solutions to accessibility.

Kaplan, S. and Webb, B. Wooten.  "Assistive Technology: The Right 
of Every Child with Special Needs."   S.M.A.R.T. Moves, 4 (Winter 
1990).  Available from:  The
S.M.A.R.T. Exchange, P.O. Box 724704, Atlanta, GA 30339; 
1-800-SMARTIE; 4 pages.

Summary:  The S.M.A.R.T. Exchange is a federally funded project 
designed to improve the delivery of technology-related services 
to people with disabilities.  S.M.A.R.T. Moves is an information 
service of the Exchange. This issue of their newsletter is 
devoted to the right of a child with a disability to assistive 
technology devices and services under P.L. 94-142. The issue 
reprints the August 10th, 1990, policy letter from the Office of 
Special Education Programs (OSEP), along with related information 
from United Cerebral Palsy Associations which describes action 
steps to be taken at the local and state levels to ensure a 
student's right to assistive technology.

The S.M.A.R.T. Exchange believes that this letter and the related 
information are so valuable that its contents are being further 
disseminated as a S.M.A.R.T. Moves Fact Sheet available through 
the S.M.A.R.T. Exchange.  Parents and advocates are encouraged to 
share the information with others.

Target Audience:  Consumers, families, advocates, practitioners, 
and policy makers.
     

Kaplan, S. and Webb, B. Wooten.  "The Power Within Us Increasing 
Access to Assistive Technology." S.M.A.R.T. Moves Number 3 (Fall 
1990).  Available from:  The S.M.A.R.T. Exchange, P.O. Box 
724704, Atlanta, GA  30339; 800-SMARTIE; 4 pages.

Summary:  This issue of S.M.A.R.T. Moves is devoted to strategies 
that individuals can use to access technology. The newsletter 
reviews advocacy techniques, grievance procedures, the importance 
of developing vendor-rapport, and work-incentives.  The 
newsletter also contains a resource list of organizations. 

Target Audience:  Consumers, families, practitioners, advocates, 
and policy makers.
  
Issues Raised/Conclusions:  The authors conclude that personal 
knowledge and perseverance will determine each person's success 
in gaining access to the tools that can make a difference.


Kreider, J.R. and Wissel, E., Ph.D. The Privates:  Principles of 
Insurance Rehabilitation. Washington:  January 1985.  Available 
from:  National Association of Rehabilitation Facilities, P.O. 
17675, Washington, D.C. 20041; 703/556-8848; 69 pages.

Summary:  This book examines the legal aspects of insurance 
rehabilitation as practiced by the private for-profit sector and 
addresses some of the areas of confusion and discomfort.  
Specifically, a chapter on law and testimony provides some of the 
ground rules of testimony on insurance rehabilitation for use in 
rehabilitation journals.  Another section is devoted specifically 
to health care and medical insurance programs and provides clear 
reasons for the involvement of private insurance companies in 
rehabilitation.

Target Audience:  Rehabilitation professionals, agencies, 
consumers, health care insurers and providers.

Issues Raised/Conclusions: The book concludes that a better 
understanding of the reasoning and goals behind private insurance 
companies' involvement in rehabilitation will mean greater 
involvement by these companies, and rehabilitation services which 
are more updated and accessible.


LaPlante, M.  "Disability in Basic Life Activities Across the 
Life Span."  Disability Statistics Report 1, 1991. Washington, 
D.C.: April, 1991. Available from: National Institute on 
Disability and Rehabilitation Research; U.S. Department of 
Education Office of Special Education and Rehabilitation Services 
20202-2648; 42 pages.

Summary:  This study examines how the population living outside 
of institutions and needing assistance in basic life activities 
is distributed across the life span and to what extent the 
characteristics of assistance needs vary by age.  The study draws 
some important conclusion which may help policy makers predict 
assistive technology utilization needs by age.  The data reported 
are estimates from the 1979 and 1980 Home Care Supplement (HCS) 
to the National Health Interview Survey (NHIS).  The NHIS is a 
continuing survey of the health of the U.S. population, covering 
about 40,000 households and 120,000 persons annually.  The sample 
with assistance needs in basic life activities consists of 5,215 
persons.  Estimates represent only the civilian institutionalized 
population. 

Target Audience: Policy makers/researchers in the area of 
long-term care.   

Issues Raised/Conclusions:  Researchers are now beginning to 
questions the bases for age distinctions in long-term care and to 
identify similarities between nonelderly and elderly persons with 
long-term services needs (Zola, 1988).  This report shows that 
the population with long-term services needs is more evenly 
distributed across the life span than is generally acknowledged.  
Furthermore, in terms of other indicators of disability and 
hospital utilization, the characteristics of community-resident 
nonelderly and elderly persons with long-term services needs are 
in fact the same.  Therefore, the needs of the total long-term 
care population should be acknowledged more adequately in 
research and policy efforts.  

     The high cost of caring for the elderly is often given as a 
reason for the focus of long-term care policy on the elderly.  
Based on this analysis, acute medical services costs, and 
possibly long-term services' costs, can be expected to be similar 
for community-resident nonelderly and elderly persons with 
assistance needs in basic life activities.


Loew, R., Knoll, J., Freud, E., Wells, A., et al.  Support for 
Families of People with Disabilities: Bibliography and Resource 
Guide.   Cambridge:  June 1990.  Available from:  Human Services 
Research Institute, 2336 Massachusetts Avenue, Cambridge, MA 
02140; 617-876-0426; 81 pages plus appendices, $15.00.

Summary:  This bibliography is one piece of a larger effort to 
provide consumers, policy makers, service providers, and 
advocates with information related to the development of family 
supports.  This document addresses pertinent issues relating to 
family support including those which have a direct relationship 
on the financing of assistive technology--information on state 
stipends or cash subsidy programs; estate planning; home care 
financing; health care financing; effective advocacy; dependent 
care tax provisions and policy; trusts and contributions, and 
much more.

Three appendices provide additional information concerning family 
support.  The first appendix contains a list of journals and 
newsletters that address family support. The second appendix 
presents a list and description of directories that publish 
nationwide information. The last appendix contains the names, 
addresses, and telephone numbers of organizations and agencies 
which provide information and/or services specific to children 
with chronic illness and disabilities and their families.

Target Audience:  Consumers, families, practitioners, advocates, 
and policy makers.

Issues Raised/Conclusions:  This bibliography and resource guide 
should be used in conjunction with the Family Support Services in 
the United States: An End of Decade Status Report (HSRI, 1990). 


McManus, M.  Understanding Your Health Insurance Options.  A 
Guide for Families Who Have Children With Special Health Care 
Needs.  Bethesda, MD:  1989.  Available from:  Association for 
the Care of Childrens' Health, 7910 Woodmont Suite 300, Bethesda, 
MD, 20814; 301-654-6549; $3.95 

Summary:  This consumer guide is aimed at helping families assess 
their insurance needs and understand various types of insurance 
policies.  Section One addresses factors affecting insurance 
choice, recommended pediatric benefits and making a final 
decision. Section Two describes private insurance the major 
distinctions among traditional health plans, health maintenance 
organizations and preferred provider
organizations.  Section Three presents public insurance options 
under state Medicaid and Title V Programs for Children with 
Special Health Care Needs.  The Fourth Section includes a case 
study comparing enrollment requirements, costs and benefits in 
two traditional and two HMO plans offered to federal employees in 
1987.  This section also presents a hypothetical family profile 
comparing the four insurance plans. Blank insurance plan 
comparison and cost worksheets are included in the appendix.  
This publication is a good introduction for families trying to 
tackle the complex topic of health insurance.

Target Audience:  Individuals with disabilities and their 
families, Title I funding coordinators.


Mendelsohn, S.  Financing Adaptive Technology: A Guide to Sources 
and Strategies for Blind and Visually Impaired Users.  Available 
from:  Smiling Interfaces, P.O. Box 2792 Church Street Station, 
New York, NY 10008-2792; 212-222-0312; 207 pages, $23.00.  
Available in all types and audio, specify format. 

Summary:  This guide focuses on the sensory aids and service 
systems that are of particular concern to individuals with visual 
impairments; however, everyone interested in the financing of 
assistive technology and related services will find this resource 
a good source of financing strategy suggestions, many of which 
are not commonly known to consumers and professionals.  
Mendelsohn reviews the opportunities for self-funding and third 
party financing which exist in vocational rehabilitation, social 
security, special education, veterans benefits, non-profit and 
governmental loan guarantee programs, tax deductions, credit, 
foundations, civic organizations and more.  The book explains 
when and how each of these can play a role, and what must be 
known and done to incorporate each into a successful acquisition 
strategy.  The book also analyzes issues and problems that may 
arise in various funding streams.   
     Written by a consumer who is an attorney and rehabilitation 
practitioner, the material brings a unique perspective to the 
area of funding.  The analysis of legislation is especially 
valuable, since it takes an advocate's approach. The guide is 
fully documented, with extensive legal, bibliographical, and 
other resource information.  

Target Audience:  Public or private agencies serving individuals 
who are blind and visually impaired, advocates, practitioners, 
policy makers.

Issues Raised/Conclusions:  The author defers any real analysis 
of major payment streams in the health care reimbursement system 
(primarily Medicare).  This is to be expected as sensory aids are 
not often reimbursed in medical systems. Therefore, the reader is 
cautioned not to overlook the importance of medical reimbursement 
options when purchasing other types of assistive technology.


Mendelsohn, S.  Payment Issues and Options in the Utilization of 
Assistive Technology.  Washington:  March 1989.  Available from:  
Electronic Industries Foundation Rehabilitation Engineering 
Center, 1901 Pennsylvania Avenue, Suite 700, Washington, D.C. 
20006; 18 pages.

Summary:  This is a complete and very detailed report on the 
financing structures that currently exist for individuals as end 
users to obtain assistive technology.  Specifically it discusses 
how to develop state-and other technology service delivery 
models; methods for assessing available resources; criteria for 
determining an individual's need for technology; and standards 
for measuring professional training, product evaluation and the 
overall success of funding programs.

Target Audience:  Individuals with disabilities, program 
administrators, funding coordinators, advocates.

Issues Raised/Conclusions:  The extreme depth of discussion about 
the strengths and weaknesses of Vocational Rehabilitation means a 
reader will not need to look elsewhere to complete his or her 
research.  Mendelsohn's conclusion is that, if you can cut 
through the bureaucracy, there are surprising opportunities for 
Vocational Rehabilitation funding.  He suggests there is an 
advantage to funding through Vocational Rehabilitation over other 
public funding sources and this is that the eligibility criteria 
and decision makers are better known.

The work also discusses, in a clear and complete manner, the 
advantages and disadvantages of loan and other credit models.  
The chapter is especially helpful because it provides listings of 
additional resources for the advanced reader to continue his or 
her research.

Mendelsohn also suggests that tax deductibility of assistive 
technology may be the most universally applicable source of 
subsidization we have yet.  Furthermore,  tax deductions to 
charities would be extremely valuable.  Another essential change 
suggested by the author is to assure that buildings, software, 
computers etc. are accessible from the very early stages of 
design.


Metropolitan Center for Independent Living.  Used Equipment 
Marketplace: A Strategy for Cutting Equipment Costs.   St. Paul, 
MN:  1989. Available from:  Metropolitan Center for Independent 
Living, 1619 Dayton Avenue, St. Paul, MN 55104; 612-646-8342, 
TDD: 612-646-6048; 15 pages, appendices, and bibliography, $9.00. 

Summary:  This booklet describes a, "used equipment referral 
service," (UERS) or clearinghouse, which is operated by the 
center.  The UERS matches people who want to donate or sell used 
equipment with people who need equipment.  The service is a 
referral system only, and the center does not store any equipment 
in its own or other
facilities.  The booklet contains all of the components necessary 
to establish a UERS, including the various forms, sample needs 
assessment, recommendations for funding, and sample budget.

Target Audience:  Title I funding coordinators, program planners.


Morris, M. and Golinker, L.  Assistive Technology: A Funding 
Workbook.  Washington:  January 1991.  Available from:  RESNA 
Press, 1101 Connecticut Avenue, N.W., Suite 700, Washington D.C. 
20036; 202-857-1140; 200 pages, appendices and references.  

Summary:  This resource is a task-oriented workbook to assist 
states in creating a roadmap of federal-state government funding 
programs, private insurance and other sources while coordinating 
the involvement of all potential stakeholders.  The book is 
divided into two parts.  Part I, A Roadmap to Funding Sources, is 
devoted to understanding funding streams and creative ways to 
eliminate current funding barriers. Part II,  An Outline of 
Federal Laws and Rules, identifies and interprets specific 
sections of the laws and rules that are resources for assistive 
technology funding.  The knowledge gained from this outline 
should be used as a tool in a careful and comprehensive review of 
the Medicaid, Special Education and Vocational Rehabilitation 
programs operating in each state.

This workbook will assist Title I States (P.L. 100-407) to 
identify funding barriers to assistive technology, by supplying a 
standard -- the scope of the federal laws and rules -- against 
which states and local laws and rules, interpretations and 
practices can be measured.  A comparison will result in the 
identification of inconsistent state- or locally- created funding 
barriers.  By providing information about the full scope of each 
program in relation to assistive technology funding, states can 
negotiate the formal elimination of the barriers with responsible 
state and local government agencies and/or the state legislature.

Target Audience:  All funded Title I States will receive two 
complimentary copies through the RESNA TA Project. The workbook 
is highly recommended for advocates, program administrators, 
consumers and families, practitioners, technology manufacturers 
and dealers and state agency officials.

Issues Raised/Conclusions:  In the past twenty-five years, 
Congress has established over thirty programs that affect 
Americans with disabilities.  There are over a dozen agencies on 
the federal level charged with the responsibility of managing 
these programs, interpreting Congressional mandates, and 
monitoring state implementation.  Federal support for individuals 
with disabilities continues to grow and become more complex.  It 
is important to realize that the variety of funding options 
provides consumers with multiple opportunities for funding and 
reimbursement.

Muscular Dystrophy Association.  Funding of Non-Vocal 
Communication Aids: Current Issues and Strategies.  Available 
from:  Muscular Dystrophy Association, Patient and Community 
Services Department, 810 Seventh Avenue, New York, NY 10019; 
212-586-0808; 30 pages.

Summary:  This paper outlines a four-step procedure to obtain 
funds for communication aids: self-evaluation; professional 
education; client evaluation; and exploration of funding sources 
and strategies. The paper includes an exhaustive list of funding 
options, combined with key procedures and suggestions recommended 
for specific sources.  The paper also lists insurance companies 
that have funded augmentative communication devices.

Target Audience:  Parents, individuals with disabilities.


National Information Center for Children and Youth with 
Handicaps.  "Technology: Becoming an Informed Consumer."  News 
Digest,  (November 13, 1989).  Available from:  National 
Information Center for Children and Youth with Handicaps 
(NICHCY), P.O. Box 1492, Washington, D.C. 20013; 800-999-5599; 20 
pages.

Summary:  This issue of News Digest targets parents of children 
with disabilities and addresses some of the most important issues 
related to the use and funding of assistive technology that are 
commonly overlooked in other resources. The digest contains six 
articles including "Becoming an Informed Consumer," "Integrating 
Technology into a Student's IEP," and "A Parent's Perspective," 
which are oriented to helping parents through the financing maze 
and guiding parents in understanding the implications of 
technology in the lives of children with disabilities.  The 
article on financing, "Starting the Funding Process," serves as 
an overview of the options available but is not intended to be 
all inclusive.  The newsletter contains a bibliography, and lists 
organizations, clearinghouses, magazines, newsletters, national 
information service providers, computerized databases, and 
product availability resources.

Target Audience:  Parents, teachers, state education agencies, 
consumer advocates.

Issues Raised/Conclusions:  Parents need to become informed 
consumers of assistive technology.  This process begins with an 
understanding of the potential benefits of assistive technology 
in the lives of their children with disabilities.


Ostrow, P., Spencer, F. and Johnson, M.  The Cost-Effectiveness 
of Rehabilitation: A Guide to Research Relevant to Occupational 
Therapy.  Rockville, MD:  1987.  The American Occupational 
Therapy Association, Inc., 1383 Piccard Drive, Rockville, MD 
20850; 170 pages, extensive references, appendices and charts, 
$25.00 (members)
$32.50 (nonmembers).

Summary:  This is a guide to research related to rehabilitation, 
including occupational therapy. The material covers formal 
cost-effectiveness and cost-benefit studies involving  
multidisciplinary rehabilitation, including the provision of 
assistive technology and related services.  Thirty abstracts 
display the state-of-the-art in research on cost-effectiveness 
and cost-benefits.  Each abstract is accompanied by comments from 
a panel and a cost-effectiveness consultant's critique.

Target Audience:  Students, professionals, and policy makers will 
want to use this book to heighten their awareness of 
cost-effectiveness methods.

Issues Raised/Conclusions:  The authors support the finding that 
there is a significant lack of cost-effectiveness and 
cost-benefit information in rehabilitation and that most of the 
research emphasis is overwhelmingly toward effectiveness studies.   


Paralyzed Veterans of America.  Tax Incentives for Cost of 
Providing Access to Individuals With Disabilities.  Washington:  
December 1990.  Available from:  National Service Office, 801 
Eighteenth Street, N.W., Washington, D.C. 20006; 202-USA-1300, 
202-785-4452; brochure and fact sheets.

Summary:  This brochure explains recent changes in the tax code 
which will enable businesses to make accessibility improvements. 
Congress legislated an annual tax credit of $5,000 "for the 
purpose of enabling ... eligible small businesses to comply with 
applicable requirements under the Americans with Disabilities Act 
of 1990."  The amount which may be taken as a credit is 50% of 
the amount exceeding $250 but less than $10,000 per tax year 
[Section 44 of the Internal Revenue Code].  Any qualified 
expenditures made after November 5, 1990, are eligible for the 
Section 44 credit.  Additionally, Section 190 of the Internal 
Revenue Code allows $15,000 to be deducted annually for qualified 
architectural and transportation barrier removal expense 
[Previously, Section 190 provided a $35,000 tax deduction].   
This provision is in effect beginning in the tax year 1991. These 
changes to the tax code are included in P.L. 101-508, the Omnibus 
Budget Reconciliation Act of 1990.

Target Audience:  Consumers, consumer advocates, employers, job 
placement personnel, including job coaches, and rehabilitation 
engineers. 

Issues Raised/Conclusions:  This tax credit can be used to 
promote accessibility for both consumers and employees with 
disabilities.


Peltz Strauss K. Telecommunication Issues for Disabled Person: 
The Role of Federal and State Regulation. Washington, D.C.: 
February 1986. Available from: The
Annenberg Washington Program and the Gallaudet Research Institute 
Joint Forum on "Marketplace Problems in Communication Technology 
for Disabled People, 1455 Pennsylvania Avenue N.W. Suite 200 
Washington, D.C. 20004 (202) 393-7100;  26 pages.

Summary: This paper is devoted to federal involvement in and 
reaction to the restructuring of the telecommunication industry.  
The paper reviews the Telecommunications for the Disabled Act of 
1982 and its implementation and regulation and looks at state and 
local programs to distribute Specialized Customer Premises 
Equipment (SCPE) which were developed in response to the need for 
people with disabilities to access the telephone network, and 
deregulations resulting from the AT&T divestiture.  Whether these 
programs have succeeded and how they can be improved is also 
examined.  The paper reviews various approaches for reducing 
telephone charges to consumers for equal access.  Finally the 
paper addresses closed and open television and movie captioning 
as a means of expanding communication to individuals who are 
hearing impaired and deaf.

Target Audience: All individuals concerned with fostering access 
to, and availability of useful and affordable technology for  
individuals with sensory disabilities.

Issues Raised/Conclusion:  Most federal and states efforts have 
been focused on improving telecommunication access to individuals 
who are deaf and hearing impaired.  Little has been done to 
ensure access for persons with mobility and visual impairments 
and other disabilities.  Additionally, as many as thirty-six 
states have detariffed specialized equipment; yet programs to 
provide such equipment at reduced rates have sprung up in only 
seventeen states.  The majority of persons with disabilities are 
not covered by the vast majority of those programs.  Most of 
these programs provide no specific funding for the research and 
development of new technologies in specialized customer 
equipment.  Until states take a more active role in ensuring 
telecommunications access, other types of legislation will be 
urgently needed to protect the interests of individuals with 
disabilities.



Phillips, L.  Consumer Needs Assessment: A Qualitative Study of 
the Needs of People With Disabilities; Results of the First Year 
of the Five-Year Study.  Washington:  1990.  Available from:  
Electronics Industries Foundation, Rehabilitation Engineering 
Center, 1901 Pennsylvania Avenue, N.W., Suite 700, Washington, 
D.C. 20006; 202-955-5810, TDD: 202-955-5836; 14 pages and 
appendix.

Summary:  This report contains the results of the first year of a 
five-year study to determine the adaptive equipment or 
technological needs of individuals with disabilities, using input 
from consumers as the major source of information.  The study, 
when completed, will identify the needs and concerns of consumers 
with
disabilities across the country from virtually all categories of 
functional limitations.

Target Audience:  Consumers, advocates, device manufacturers, 
rehabilitation professionals, policy makers, and the general 
public. 

Issues Raised/Conclusions: Although it is too early in the study  
to reach any conclusions, several patterns have emerged.  First, 
the single issue identified most often is the need for a better 
understanding of the needs of people with disabilities.  Second, 
group participants did not see new technology or new "gadgets" as 
the answer to their problems. Instead, consumers would simply 
like to have the means to afford technology that already exists. 
Third is the awareness of people with diverse disabilities of the 
importance of the computer.  The computer can contribute to 
increased independence, employment, and convenience for all. 
Consequently, attention should be given to maintaining and 
increasing universal accessibility to computers.


Prentke Romich Company.   How to Obtain Funding for Augmentative 
Communication Devices. Available from:  Prentke Romich Company 
(PRC), 1022 Heyl Road, Wooster, Ohio 44691; 800-262-1084; 22 
pages, $5.00. 

Summary:  The booklet is a step-by-step "how to" guide to 
successful funding of devices. Based on experiences and successes 
of PRC's Funding Department, the booklet covers the various 
elements related to funding including basic terms, funding 
options, components of a medically based request, outlines for 
letters of medical necessity, sample letters, and supportive 
letter request forms.

Target Audience:  Parents, individuals with disabilities, 
advocates, practitioners, equipment suppliers, Title I state 
funding coordinators.

Issues Raised/Conclusions:  This booklet emphasizes the kind of 
information which is necessary to document "medical necessity" 
for augmentative communication devices which pertains to other 
forms of assistive technology.


Reeb, K.  Assistive Financing for Assistive Devices: Loan 
Guarantees for Purchase of Products by Persons with Disabilities.  
Washington:  January 1989.  Available from:  Electronics 
Industries Foundation, Rehabilitation Engineering Center, 1901 
Pennsylvania Ave., N.W., Suite 700, Washington, D.C. 20006; 19 
pages, references and appendices. 

Summary:  This paper documents the loan guarantee concept, 
introduces some existing models, and discusses some program 
elements to replicate and others to avoid in financing assistive 
technology.  The term "assistive financing" implies that the
consumer will become eligible for market rate financing in the 
future, after demonstrating a responsible credit rating under a 
loan guarantee program. In credit financing, the lender provides 
money. The interest rate charged to the consumer reflects the 
lender's costs and profit, plus security against the loan not 
being repaid.  Under the loan guarantee concept, a third party 
participates in the transaction and assumes some of the risk, 
thus allowing the lender to reduce the costs of providing credit 
financing. The savings can then be passed on to the consumer.  
This information is drawn from a sample of programs across the 
country currently offering loan guarantees to purchase assistive 
technology, including Canon USA, the General Electric Capital 
Corporation, and Telesensory Systems, Inc.  

Target Audience:  Federal and state policy makers, private 
financial institutions.  

Issues Raised/Conclusions:  Reeb concludes that private financial 
institutions are receptive to innovative assistive financing 
programs and that these programs encourage consumers to become 
more active participants in the purchase of assistive products.  
Although assistive financing holds promise, credit is not used 
extensively to pay for assistive technology.  There is a need to 
further explore ways to attract the substantial resources of the 
credit industry into these product markets. Federal incentives to 
stimulate access to credit financing of assistive technology 
should be further explored.
     

Reeb, K.  Enhanced Consumerism Within Commercial Rehabilitation 
Product Markets: A Goal for Independent Living.  Washington:  
January 1986.  Available from:  Electronics Industries 
Foundation, Rehabilitation Engineering Center, 1901 Pennsylvania 
Avenue, N.W., Suite 700, Washington, D.C. 20006; 202-955-5810, 
TDD: 202-955-5836; 36 pages, references and appendix.

Summary:  This paper focuses on encouraging more active 
participation by individuals with disabilities as consumers of 
commercial assistive technology aids and devices.  The paper 
introduces a compilation of exemplary programs involved in 
providing such services to support individuals with disabilities 
as active consumers.   A number of approaches were studied that 
assist individuals select, procure, and utilize commercial 
assistive technology.  

Target Audience:  Program planners, administrators and managers 
of independent living services, device manufacturers, 
distributors, advocates, individuals with disabilities.

Issues Raised/Conclusions:  Reeb cites financing of assistive 
technology as the most important problem encountered by program 
planners and administrators. The paper profiles several exemplary 
financing programs that provide alternatives for individuals with 
disabilities (i.e. revolving loan funds, low interest loans, no 
interest loans). Each
of the programs profiled is different, yet all have innovative 
and successful approaches to consumer financing for assistive 
technology.  Most importantly, each loan program encourages a 
more active consumer role.  The approaches used by these 
organizations to support consumerism merit close examination 
within commercial markets for rehabilitation technology service 
delivery.

The paper also includes information on clearinghouses, training 
services, maintenance and repair services, used equipment 
clearinghouses, and group purchasing opportunities.   The 
appendix includes a complete directory of all programs profiled.  


Reeb, K.  Final Report of the National Task Force on Third-Party 
Payment for Rehabilitation Equipment.  Washington:  February 
1987.  Available from:  Electronics Industries Foundation, 
Rehabilitation Engineering Center, 1901 Pennsylvania Ave., N.W., 
Suite 700, Washington, D.C. 20006; 49 pages, appendix which lists 
Task Force participants.

Summary:  This report discusses problems related to third party 
payment of assistive technology and related services, and 
outlines potential strategies for dealing with these problems.  

Target Audience:  Policy makers, individuals involved with 
third-party payment systems, individuals with disabilities, and 
advocates.

Issues Raised/Conclusions:  The report offers valuable 
suggestions for resolving many of the concerns raised by the 
National Task Force on Third Party Payment for Rehabilitation 
Equipment, and presents ideas which warrant further investigation 
and/or implementation.

Recommendations of the Task Force include:

.    Public policy decisions on third party payment systems 
     should consider increasing integration of case management 
     into third party payment systems and expand general 
     familiarity with technology among case managers;
.    There is a need to generate more reliable information 
     tailored to the quality assurance needs of clinical/payment 
     decision-makers;
.    Public policy should encourage integration of assistive 
     technology specialists into the service delivery system; and
.    Public policy decisions regarding third party payment 
     systems should pursue strategies directed toward improved 
     communication among all parties interdependently involved in 
     selection/payment for rehabilitation equipment.

Reeb, K.  An Overview of Medicaid Reimbursement for 
Rehabilitation Equipment in the
United States.  Washington:  April 1988.  Available from:  
Electronics Industries Foundation, Rehabilitation Engineering 
Center, 1901 Pennsylvania Ave., N.W., Suite 700, Washington, D.C. 
20006; 11 pages, references and appendices.  

Summary:  This overview of the Medicaid program is a starting 
point for readers wishing to familiarize themselves with their 
respective state programs. The paper helps clarify the types of 
assistive technology for which Medicaid is a likely payment 
source and indicates situations where Medicaid is not a payment 
alternative.

The paper combines information taken from review of the 
literature, including federal Medicaid regulations and state 
manuals, with information received through a survey of 
administrative representatives from each of the fifty state 
Medicaid agencies and the District of Columbia about their 
payment policies and procedures related to "rehabilitation 
equipment."  Responses were received by 88% of the agencies 
contacted.  

Target audience:  Consumers, family members, Title I state 
funding coordinators, practitioners, equipment suppliers and 
others who deal with or work within the Medicaid system.

Issues Raised/Conclusions:  There is tremendous variation among 
state Medicaid programs.  The most important conclusion gained 
from the study is that it is essential for anyone dealing with 
Medicaid to develop lines of communication with state Medicaid 
personnel, particularly those who deal with prior authorization 
and policy decisions.

Important amendments to Medicaid's Early and Periodic Screening, 
Diagnosis, and Treatment (EPSDT) program were enacted after this 
paper was published. Because these amendments directly affect the 
treatment of assistive technology in the Medicaid program, the 
reader is cautioned against using the information contained in 
this paper as a deciding factor about whether or not to seek 
Medicaid funding for assistive technology.


Reeb, K.  Private Insurance Reimbursement for Rehabilitation 
Equipment.  Washington:  July 1987.  Available from:  Electronics 
Industries Foundation, Rehabilitation Engineering Center, 1901 
Pennsylvania Ave., N.W., Suite 700, Washington, D.C. 20006; 15 
pages and bibliography.

Summary:  This paper provides a basic understanding of private 
insurance as an agreement between equal parties in a market 
transaction based on an assessment of risk. The paper outlines 
four types of private insurance: health insurance; disability 
insurance; workers compensation; and liability insurance.  

Target Audience:  This overview of health insurance will be 
helpful to persons with disabilities who want to understand the 
insurance industry's perspective on insurance.

Issues Raised/Conclusions:  The paper suggests a two-prong 
approach to understanding how private insurance might pay for 
assistive technology: First, study the various insurance policies 
under which one is covered.  Second, identify and develop rapport 
with key decision makers, particularly those who represent 
insurance companies. Policy recommendations for improving access 
to private insurance are beyond the scope of this paper.


Reeb, K.  Procurement of Durable Medical Equipment under the 
Medicare Part B Program.  Washington:  June 1985.  Available 
from:  Electronics Industries Foundation, Rehabilitation 
Engineering Center, 1901 Pennsylvania Ave., N.W., Suite 700, 
Washington, D.C. 20006; 15 pages and bibliography.

Summary:  This paper describes the Medicare Part B programs with 
particular emphasis on coverage for the rental or purchase of 
durable medical equipment which is "medically necessary."  
Assistive technology can be covered under Medicare Part B as 
durable medical equipment, prostheses, or orthotics.

Target Audience:  Policy makers, advocates.

Issues Raised/Conclusions:  Medicare excludes products such as 
sensory aids, environmental control and communication devices and 
convenience or comfort items.  A fairly extensive set of 
guidelines have been generated by the Health Care Financing 
Administration to assist Medicare carriers when making 
reimbursement decisions about coverage and about how maintenance, 
repair, replacement and delivery costs are covered. 


Reeb, K.  Revolving Loan Funds: Expanding Equipment Credit 
Financing Opportunities For Persons with Disabilities.   
Washington:  June 1987.  Available from:  Electronics Industries 
Foundation, Rehabilitation Engineering Center, 1901 Pennsylvania 
Ave., N.W., Suite 700, Washington, D.C. 20006; 46 pages, 
references and appendices.

Summary:  This guide profiles in detail the revolving loan fund 
concept.  Staff from several organizations with existing 
revolving funds share the strengths of their programs while 
commenting about areas in need of improvement. 

Revolving loan funds can be used either to provide equipment 
loans directly or to guarantee commercial loans. The central 
feature of the revolving fund model is that it relies upon 
perpetuation of at least the base fund used to supply financing  
which distinguishes it from grant programs where a pool of money 
is exhausted and
replenished  periodically from external sources.  In addition to 
this central feature, there is a wide range of possibilities for 
designing the various parts of the loan (terms, title, interest, 
down payment, administrative costs, payment schedule, insurance, 
etc.).  

Target Audience:  Consumers, private industry, program planners, 
policy makers.

Issues Raised/Conclusions:  The author concludes there are a 
significant number of persons with disabilities who could 
effectively handle the financial responsibilities associated with 
purchasing needed equipment.  The revolving loan fund is a sound 
alternative to financing assistive technology.  


Reeb, K., and Stripling, T.  Payment for Assistive Devices by the 
Veterans Administration.  Washington:  July 1987.  Available 
from:   Electronics Industries Foundation, Rehabilitation 
Engineering Center, 1901 Pennsylvania Ave., N.W., Suite 700, 
Washington, D.C. 20006; 16 pages and references.

Summary:  The Veterans Administration is one of the largest 
purchasers of assistive devices.  It is also a highly centralized 
system for providing a large volume of equipment.  This paper 
explains the VA structure and the decision-making 
responsibilities in detail in an effort to lead to better access 
to assistive technology with the ultimate goal of procuring 
appropriate equipment in a timely manner.

Despite the volume of assistive technology transactions, the VA 
has a fairly decentralized decision-making system.  The VA 
invests in support of its field personnel through development of 
product standards and technical specifications, product 
evaluation, on going training of prosthetics personnel, program 
evaluation, and other support.

Target Audience:  Veterans who require assistive technology, 
product developers, manufacturers, suppliers, and contractors.
 
Issues Raised/Conclusions:  A comparative analysis of the VA 
program to other financing programs serving other populations is 
beyond the scope of this resource.  Further examination of the 
funding criteria under the VA program would be valuable 
especially mechanisms by which newly developed technology are 
provided by the VA system and whether such new technologies are 
being adequately incorporated into the lives of veterans with 
disabilities.


Reed, P.  Funding Assistive Technology Devices: A Resource Manual 
for Oregon.  Roseburg, Oregon: April 1990.  Available from:  
Oregon Technology Access Project, 1871 NE Stephens, Roseburg, 
Oregon 97470; 503/440-4791; 37 pages, bibliography
and appendices.  

Summary:  This is a manual meant to assist parents and 
professionals in Oregon to identify and pursue assistive 
technology funding sources.  The information in the manual 
specifically addresses computers, augmentative communication 
devices and powered mobility.  Additionally, it provides names, 
addresses, references to other sources, sample forms used to 
apply for funding sources in Oregon and sample letters used to 
prepare your case.

Target Audience:  Individuals with disabilities living in Oregon 
and their families, information and referral sources, providers 
of assistive technology, professionals from other states 
interested in designing a similar resource guide.


Rehabilitation Engineering Society of North America.  
Rehabilitation Technology Service Delivery: A Practical Guide. 
Washington:  1987.  Available from:  RESNA Press, 1101 
Connecticut Avenue, N.W., Suite 700, Washington, D.C. 20036; 
202-857-1199; 175 pages.      

Summary:  This guide, written by rehabilitation technology 
service delivery providers, was developed to document the 
state-of-the-art in rehabilitation technology services 
delivery,and to create a manual that would help in the 
development of new technology services delivery programs as well 
as increase the effectiveness of existing programs.  Based on 
practical experience with more than 30 exemplary rehabilitation 
technology programs, effective models of services delivery are 
described.  The guide emphasizes the necessary questions to be 
addressed in planning, developing and implementing a technology 
services delivery program including experience-based rules of 
thumb. 

Chapter Five, "Funding Sources and Strategies," deals with three 
central issues: funds to start a rehabilitation engineering 
program and sources that might initially be sought; identifying 
and pricing capabilities that will earn money; and identifying 
the needs for which payers will spend their funds.  

Target Audience:  Current practitioners who want to make their 
operations more efficient as well as those entering the field. 

Issues Raised/Conclusions:  The guide concludes with a review of 
the major payment sources, and notes one important common 
denominator--the thread common to any payment source is its 
reliance on individuals for decision making.  No matter how 
steeped it may be in policies and procedures, no payment program 
can totally divorce the human element from its decision-making 
process.


Rehabilitation Engineering Society of North America.  Section 
508: Its Effect on States
Funded Under P.L. 100-407. Washington:  November 1990.  RESNA 
Technical Assistance Project, 1101 Connecticut Avenue, N.W., 
Suite 700, Washington, D.C. 20036; 202-857-1199; 6 pages.

Summary:  This publication contains questions and answers about 
Section 508 of the Rehabilitation Act, as amended by P.L. 99-506, 
and the effect 508 will have on States funded under P.L. 100-407, 
the Technology-Related Assistance Act for Individuals with 
Disabilities Act of 1988.  Section 508 was adopted to promote 
equal access for people disabilities to federal jobs, including 
public information services and electronic tools. States funded 
under Title I will be required to demonstrate that they are in 
compliance with Section 508 in the third year of their projects 
in order to be eligible to apply for extension grants.

Target Audience:  Title I state funding coordinators.

Issues Raised/Conclusions:  The federal government is the single 
largest purchaser of computers and other high tech office 
equipment.  This law should stimulate development, manufacturing 
and marketing of equipment which can be used--or adapted for 
use--by people with disabilities. 


Rehabilitation Engineering Society of North America.  Workshop on 
Funding for Assistive Technology.  Washington:  March 1990.  
Available from:  RESNA, Inc., 1101 Connecticut Avenue., N.W., 
Suite 700, Washington, D.C. 20036; 202-857-1199; six cassettes: 
$30.00, plus $5.00 for shipping and handling.

Summary:  These are tapes of the presentations at a workshop  
designed for the first nine states to receive funding under the 
Technology-Related Assistance Act, (P.L. 100-407). The sessions 
include:  "Perspectives on Private Insurance: The Who and How of 
Decisions on Coverage;"  "Medicaid: Federal Mandates/State 
Options;"  "Medicare/Medicaid Combinations and other Public 
Sources;"  "Programs That Fund Technology for Kids; Funding 
Technology for Adults;" and "Assistive Technology in 
Developmental Disabilities Programs." 
 
Target Audience:  Title I funded states, policy makers; 
consumers; practitioners, advocates, third-party payors, state 
program administrators. 

Issues Raised/Conclusions:  The presenters include professionals 
who have had a significant impact on the public policy 
surrounding the funding of assistive technology.  They provide a 
basis for states in reviewing their own funding streams, 
identifying gaps in public and private sector in financing 
assistive technology, and providing recommendations on ways to 
better access funding.  Common to all the presentations is the 
belief that many funding opportunities exist at both the federal 
and state level; however the opportunities are uncoordinated, 
lack continuity and continuum in service
delivery, are not readily available to parents and consumers, and 
are fraught with funding barriers. Case examples are provided 
throughout.


Rosenfeld, L., Worley, G., and Lipscomb, J.  Saving Money and 
Getting Help: Advice for Families of Children with Spina Bifida 
and Other Health Problems.  Newton, NC:  1987.  Available from:   
Spina Bifida Association of North Carolina, 1427 Robin Lane, 
Newton, NC 28658; 100 pages, $8.50.

Summary:  This manual, the result of a project of the North 
Carolina Spina Bifida Association, contains practical advice for 
any family with a child with disabilities.  The project's goal 
was to help families of children with disabilities reduce their 
medical bills while getting the medical care and services their 
children need. Sixty families were taught management and advocacy 
skills which enabled them to work more effectively with doctors, 
hospitals, health insurance companies, and social services 
agencies.  The manual includes a summary of the costs of raising 
a child with spina bifida, which can serve as an example of the 
large costs of caring for a child with a chronic health problem; 
tips on reducing hospital and doctor bills; tips on improving 
access to private health insurance; guides to public programs and 
family support programs; income tax tips; advocacy tips; and 
guides for planning for long term security.

Target Audience:  The manual is dedicated to parents as 
advocates. Although the information is specific to North 
Carolina, many of the recommendations will be helpful to all 
families with children with disabilities.  The comprehensive and 
well-organized nature of this book contributes to making it an 
invaluable resource for families. 

Issues Raised/Conclusions:  Assistive technology is not 
specifically mentioned in the manual.  

Ruggles, V.  Funding of Mobility Equipment: Current Issues and 
Strategies.  New York:  September 1981.  Available from:   
Muscular Dystrophy Association, Patient and Community Services 
Department, 810 Seventh Avenue, New York, NY 10019; 212-586-0808; 
13 pages, appendices and resources.

Summary:  This paper outlines a four-step procedure to obtain 
funds for mobility equipment. The steps are: self-evaluation; 
expanding information resources; advocacy; and exploring funding 
sources and strategies. The document provides a good overview of 
funding options, advocacy suggestions, and sample letters of 
support that parents and consumers may find useful. The resources 
listed, however, are outdated and are not considered the best 
funding resources.

Target Audience:  Parents, individuals with disabilities.

Scadden, L.A. Communication Technology for Disabled People: 
Problems In the
Marketplace. Washington, D.C. : February 1986. Available from: 
The Annenberg Washington Program and the Gallaudet Research 
Institute Joint Forum on "Marketplace Problems in Communication 
Technology for Disabled People, 1455 Pennsylvania Avenue N.W. 
Suite 200 Washington, D.C. 20004 (202) 393-7100; 17 pages.

Summary: This paper explores the causes of the gap between the 
potential and the reality in the use of technology by people with 
communication disabilities by describing some of the obstacles 
that currently limit the flow of communication technology and 
identifies some potentially useful tools for eradicating these 
obstacles.  
     The paper begins with a good overview of the various types 
of sensory technology including technology for individuals with 
vocal disabilities.  The author notes that the conclusions of the 
1982 OTA study, Technology and Handicapped People associated with 
inadequate diffusion of rehabilitation technology to intended 
users still hold true for the current marketplace for technology.  
The causes can be roughly lumped into two categories, economic 
issues and policy issues.
     The author identifies several barriers to adequate diffusion 
of rehabilitation technology noting two primary causes: product 
price and uncertainty of payment.  The paper then analyses the 
causes for the relatively high price of rehabilitation technology 
in an effort to directly address the concern and offer some 
solutions.
     A number of exemplary private sector programs that have been 
established for the purpose of acquiring assistive technology are 
described including price subsidies, low interest loans, and 
lease/rentals.  Finally the papers considers the status of the 
recommendations from the 1982 OTA report.   

Target Audience: All individuals concerned with fostering access 
to, and availability of useful and affordable technology for all 
people.

Issues Raised/Conclusions: The author concludes that efforts must 
be made to identify and to implement program policies that 
address the marketplace problems of communication technology.  
Using the example of the California State Public Utilities 
Commission requiring each telephone company operating in 
California to provide TDDs to telephone users who are deaf or 
severely hearing impaired, the paper concludes that a combination 
of public and private sector action will be needed to attain 
optimal diffusion of this technology.


Scarborough, D.  Plans for Achieving Self-Support (PASS); A 
Workshop Trainer's Guide.  Arlington, TX:  1990.  Available from:  
Association for Retarded Citizens of the United States, P.O. Box 
6109, Arlington, TX 76005; 52 pages.
 
Summary:  A PASS (Plans for Achieving Self Support) is an option 
available to individuals with disabilities receiving Social 
Security who enter or return to work.
PASS is an income and resource exclusion that allows a person to 
set aside income and/or resources for an occupational objective 
without losing their benefits.  The Trainer's Guide provides an 
easily understood explanation of the PASS work incentive. The 
guide provides good explanations of other work incentives 
available through Social Security. The guide includes presenter 
support materials, handouts, and a publications list.

Target Audience:  Consumers, professionals working with 
individuals with disabilities who are recipients of Social 
Security, Title I state funding coordinators, advocates.

Issues Raised/Conclusions:  PASS can be used to purchase 
assistive technology that is necessary for employment.  


Schlachter, G.  Financial Aid for the Disabled and Their 
Families.  San Carlos, CA:  1990.  Available from:  Reference 
Service Press, 1100 Industrial Road, Suite 9, San Carlos, CA  
94070; 415-594-0743; 270 pages, $32.50 + $3.00 shipping.

Summary:  This document contains an annotated resource list of 
scholarships, fellowships, loans, grants, awards, and internships 
designed primarily or exclusively for persons with disabilities 
and their families.  Included are state sources of benefits and 
reference sources of  financial aids.

Target Audience:  Consumers, families, students, advocates, and 
policy makers.

Scott, S., and Dennis, D.  Payment of Occupational Therapy 
Services.  Rockville, MD:  March 1988.  Available from:  American 
Occupational Therapy Association,  1385 Piccard Drive, Rockville, 
MD 20850; $50 members, $65 nonmembers.

Summary:  This resource describes various forms of payment for 
occupational therapy services within state, federal and private 
payment systems. The book includes information on documentation, 
billing, coverage of durable medical equipment, and information 
on processing denials.  It also contains strategies and resources 
to assist professionals in expanding current coverage in their 
local area.  As is the case with assistive technology, many 
patients who need and receive occupational therapy have 
insufficient insurance coverage or none at all and must pay for 
services out-of-pocket.  The report emphasizes the importance of 
providers in understanding health care financing options that may 
be available to consumers.

Target Audience:  Consumers, families, practitioners, OT's, 
advocates and policy makers.

Tanenbaum, S.  Engineering Disability: Public Policy and 
Compensatory
Technology.  Philadelphia:  1986.  Available from:  Temple 
University Press, Broad and Oxford Streets, Philadelphia, PA, 
19122; 215-787-8787; 171 pages, $32.95 + shipping.

Summary:  Tanenbaum looks at the array of compensatory options 
provided to persons with the same physical need, the loss of an 
arm due to an amputation above the elbow--through various 
compensatory systems including the Veterans Administration 
system, Workers Compensation, and Social Security Disability 
Insurance with its link to Medicare, Vocational Rehabilitation, 
Medicaid, private health insurance, liability insurance, and 
private disability insurance.  Although primarily interested in 
whether each of these systems will fund a relatively 
sophisticated electronic prosthesis called the Boston Elbow, she 
also considers other compensatory options such as monetary 
compensation, retraining (physical and psychological), and 
environmental changes (social and physical), as well as other 
prostheses under the option of replacements for the loss of the 
arm.  

Target Audience:  Policy makers

Issues Raised/Conclusions:  This comparison across many 
compensatory systems is sharpened by the focus on the likely 
response to the same physical need. This focus allows Tanenbaum 
to identify incentives and competing constituencies which exist 
in different compensatory systems and which ultimately determine 
what kind of assistive technology individuals with the same 
functional impairment will be able to access.  Descriptions of 
each compensatory program are based on aggregate figures where 
available and are supplemented with anecdotal information from 
interviews with participants in the various programs, primarily 
in Massachusetts (where the study was conducted) and at the 
Federal level.  

By comparing the logic of different systems, Tanenbaum's analysis 
shifts the focus from obstacles to funding in specific programs 
to the larger context of what is appropriate public policy for 
access to assistive devices.  Tanenbaum shows how each 
compensatory system has different mandates with different 
eligibility criteria and fiscal constraints which shape the kinds 
of compensation which are offered.

Trachtman, L.  Innovative and Alternative Programs for Funding 
Assistive Technology, Special Session on Service Delivery.  RESNA 
13th Annual Meeting, Washington, DC.  Washington:  June 1990.  , 
Available from:  RESNA Press, 1101 Connecticut Avenue, NW, Suite 
700, Washington, D.C. 20036, 202/857-1199, 24 pages. 

Summary:  The paper includes six unique models for providing 
funding to purchase assistive technology including programs which 
provide low interest loans, loan guarantees, and loan subsidies 
including California Department of Rehabilitation Loan Programs, 
Telesensory Corporation, Maine's Adaptive Equipment Loan Fund,
Electronic Aids Program of Associated Services for the Blind, the 
AFB Loan Program For the Kurzwell Personal Reader, Equipment Loan 
Fund for the Disabled of New York State. Background papers are 
included which represent considerations and challenges related to 
developing funding options (Reeb 1989; Ward 1989 monographs).  

Target Audience:  Advocates, private industry, program planners, 
policy makers, agencies/organizations serving individuals with 
disabilities.

Issues Raised/Conclusions:  Trachtman concludes that consumers 
must take proactive roles to create alternative financing systems 
by identifying plausible models while noting risks and failures 
and begin to provide payment options for families.


United States.  Senate.   Assistive Technology for Persons with 
Disabilities; Hearings Before the Subcommittee on the 
Handicapped, of the Committee on Labor and Human Resources.  (S. 
HRG. 100-761).  Washington:  May 1988.  Available from:  
Superintendent of Documents, Congressional Sales Office, U.S. 
Government Printing Office, Washington, D.C. 20402; 388 pages.

Summary:  This Senate document is the culmination of two days of 
hearings chaired by Senator Tom Harkin (IA), about the role that 
assistive technology devices and services can play in enhancing 
opportunities for people with disabilities. 

Target Audience:  Policy makers, advocates, consumers, families, 
and practitioners.

Issues Raised/Conclusions:  The report provides many 
recommendations from witnesses to improve access to funding 
assistive technology, many of which did not become part of P.L. 
100-407, the Technology-Related Assistance Act for Individuals 
with Disabilities. Key recommendations include: 

.    Federal loan fund for assistive technology; 
.    Amend the Internal Revenue Code to provide tax credits, 
     accelerated write-offs or other incentives for businesses 
     which purchase or lease assistive technology for employees 
     with disabilities; 
.    Amend the Internal Revenue Code to provide tax credits for 
     individuals with disabilities who purchase or lease 
     assistive technology; 
.    Expand the definition of "medical necessity" 
     to include reduction of functional dependence; 
.    Amend Medicare and Medicaid to expand the definition of 
     "durable medical equipment."

Many problems related to assistive technology service delivery 
discussed in the hearings remain unresolved, including:

.    Gaps in service continuum;
.    Financing maintenance and repair services;
.    Improved quality assurance to increase decision making 
     confidence of third-party funding sources; 
.    Improved quality assurance in personnel training and product 
     development;
.    Improved quality assurance in information networks; 
.    Public education and professional training; and
.    FDA clearance obstacles. 


United States.  Executive Office of the President, Office of 
Management and Budget.  Catalog of Federal Domestic Assistance 
1990.   Washington:  1990.  Available through the Superintendent 
of Documents, U.S. Government Printing Office, Washington, D.C. 
20402; $38.00.

Summary:  The Catalog contains a listing of 1,176 financial and 
nonfinancial assistance programs administered by 53 Federal 
agencies. Program information is cross referenced by functional 
classification, subject, applicant index, deadlines for program 
application submission, and authorization legislation.   The 
Catalog is published annually, usually in June, with an update 
usually published in December reflecting completed Congressional 
action on the President's budget proposals and on substantive 
legislation as of the date of compilation. The Catalog is also 
available on tape and diskettes through Federal Domestic 
Assistance Staff (WKU), General Services Administration, Ground 
Floor, Reporters Building, 300 7th Street, S.W., Washington, D.C. 
20407. 202-708-5126. 

Target Audience:  Consumers, families, advocates, practitioners, 
and policy makers.


United States Government.  General Services Administration, 
Clearinghouse on Computer Accommodation.  Managing End User 
Computing For Users With Disabilities.  Available from:  
Clearinghouse on Computer Accommodation, Information Resources 
Management Services, General Services Administration, Room 2022, 
KGDO, 18th & F Streets, N.W., Washington, D.C. 20405; 
202-523-1906 Voice/TDD; 16 pages and appendices.

Summary:  This handbook presents guidance to federal employees  
on the policy implementing Section 508 of P.L. 99-506, The 
Rehabilitation Amendments Act of 1986, regarding electronic 
office equipment accessibility in federal procurements. The 
handbook provides information and extensive resources on: 
accessing
accommodation requirements; policy and regulatory information, 
and accommodation products and training. 

Target Audience:  Federal employees, policy makers.


United States Government.  Internal Revenue Service Publications.  
Available from the IRS Forms Distribution Center for your area, 
or by calling 800-TAX-FORM. 

Summary:  Information about tax credits and deductions can be 
found in the following publications: 

     Publication #502 Medical and Dental Expenses
     Publication #503 Child Care and Disabled Dependent Care.
     Publication #907 Tax Information for Handicapped and
       Disabled Individuals

These publications clarify allowable deductions and credits for 
medical, dental, and dependent care expenses. Medical and dental 
expense deductions only apply to individuals who itemize on 
Schedule A (Form 1040) and whose medical expenses exceed 7.5% of 
adjusted gross income.  Medical expenses may include payments for 
diagnosis, treatment, or prevention of disease; prescription 
medicines; insurance premiums; transportation and lodging to 
receive medical care; capital expenses for medical equipment; 
home modifications; improvement for property rented by a person 
with disabilities, special schools, etc. 

Target Audience:  Consumers, families, advocates, practitioners, 
and policy makers.



United States Government.  Office of Technology Assessment.  The 
Implications of Cost-Effectiveness Analysis of Medical 
Technology.   Springfield, VA:  August 1980. Available from:  
U.S. Office of Technology Assessment, National Technical 
Information Services, Springfield, VA 22161; 187 pages, 
appendices and references, $31.00.

Summary:  This report outlines options to aid in decisions 
concerning the possible use of cost-effectiveness 
analysis/cost-benefit analysis in federal health programs. 
Congress asked OTA to explore the applicability of 
cost-effectiveness analysis, cost-benefit analysis (CEA/CBA) to 
medical technology. 

Target Audience:  Researchers, policy makers, program planners.

Issues Raised/Conclusions:  The OTA stresses that decision-making 
cannot be made solely on the basis of CEA/CBA and that other 
issues must be factored in.  Decision-making could be improved, 
however, by the process of identifying and considering all the 
relevant costs and benefits of a decision.  The report concludes 
that it is unrealistic to expect that CEA/CBA, in itself, would 
be an effective tool for reducing or controlling overall 
expenditures for medical care.


United States Government.  Office of Technology Assessment.   
Market for Wheelchairs Innovations and Federal Policy.  
Springfield, VA:  November 1984.  Available from:  U.S. Office of 
Technology Assessment, National Technical Information Services, 
Springfield, VA 22161; 54 pages and appendixes, $17.00. 

Summary:  This case study focuses on how federal government 
policies affect innovations in wheelchair characteristics.  
Through Medicare, Medicaid and the Veterans Administration, the 
federal government is a major purchaser of wheelchairs.  The 
report indicates that overemphasis on price over performance in 
these government reimbursement procedures for a general manual 
wheelchair has probably discouraged innovation. Since 
manufacturers have difficulty selling a higher priced, higher 
quality manual wheelchair, they probably have little reason to 
produce one.

Target Audience:  Policy makers.

Issue Raised/Conclusion:  The report suggests that the policies 
of these three reimbursement programs may hinder innovation.  
Medicaid pays in full, but only for the least costly chair 
needed. Medicare pays only part of the allowable charge, which 
may itself be less than the actual charge. A supplier who accepts 
Medicare payment on assignment must agree not to demand in total 
more than Medicare's allowable charge.  This policy creates an 
incentive to encourage a consumer to buy the "least costly model" 
that satisfies a given prescription.

On maintenance and repair, the report notes that Federal payers 
currently focus their payment decisions on purchase price without 
considering maintenance and repair costs. Therefore decisions 
made on basis of total annualized costs would appropriately 
reward more durable models.


United States Government.  Office of Technology Assessment,  
Technology and Aging in America. Washington:  June 1985.  
Available from:  National Technical Information Service, U.S. 
Department of Commerce, Springfield, VA. 22161; 703/487-4660; 368 
Pages and appendices; $50.00 plus shipping and postage.

Summary:  This report examines five major areas where assistive 
technology can
be beneficial for elderly individuals: dementia, incontinence, 
hearing impairment, osteoporosis, and osteoarthritis.  The study 
addresses: 1) the efficiency of drug treatment technology as a 
major resource for elderly persons with disabilities; 2) how to 
better tap into information technology for the elderly; 3) the 
need for assistive technology as a long term care service; 4) the 
effectiveness of cost containment efforts; and  5) the untapped 
potential of "in the home" and workplace technologies for elderly 
individuals with disabilities.

Target Audience:  Elderly individuals with disabilities and their 
families, advocates, rehabilitation professionals, device 
manufacturers, service providers.

Issues Raised/Conclusions:  Despite the huge potential of 
assistive technology for elderly individuals with disabilities it 
largely remains largely untapped.  

In the area of drug technology, the problems exist because of 
poor education for patients and service providers as to current 
options.  In the area of information technology for elderly 
individuals, problems exist, first, because of  the continued 
stereotype that the elderly are not receptive to new technologies 
and second because there is inadequate training provided on the 
equipment.  As a result of the stereotype, has been little study 
done on the use of information technology for elderly individuals 
with disabilities.  

Technology is rarely used for long term care because the federal 
and state programs which fund these services tend to de-emphasize 
assistive technology.  Furthermore, much of the technology used 
in the home is low cost and can often be financed through new 
equity based financing instruments.  

 
United States Government.  Office of Technology Assessment.  
Technology and Handicapped People.  Washington:  1982.  Study for 
U.S. Congress, Office of Technology Assessment, 600 Pennsylvania 
Avenue, S.E., Washington D.C. 20510.  Available from:  (PB 83-172 
056) Springer Publishing Company, 536 Broadway, New York, NY 
10012; 212-431-4370; 203 pages and references, $29.50 + 2.50 
shipping and postage.

Summary:  At the request of the Senate Committee on Labor and 
Human Resources, the Office of Technology Assessment (OTA) 
conducted a comprehensive assessment on technology and 
individuals with disabilities.  The purpose of the project was to 
examine policies and specific processes through which 
technologies are developed, evaluated, diffused, delivered, and 
used.  The Committee asked OTA to take a comprehensive look at 
the role played by technology, identify problems and suggest 
policy options for Congressional consideration. 

Target Audience:  Policy makers, advocates, practitioners.

Issues Raised/Conclusions:  The reports' major conclusion is that 
despite the existence of numerous problems related to developing 
technologies, the more serious questions are social ones--of 
financing, of conflicting and ill defined goals, of hesitancy 
over the demands of distributive justice, and of isolated and 
uncoordinated programs.

In the area of funding, Chapter 9, "Delivery, Use, and Financing 
of Technologies," provides a good overview of funding programs 
and issues.  The report indicates the following problems related 
to funding:

.    lack of coordination and consistency in funding sources; 
     eligibility requirements and rules for payment for similar 
     technologies;
.    gaps in services due to definitions in eligibility;
.    no access/funds for maintenance and repair services;
.    lack of consumer involvement in the provision of assistive 
     technology; and
.    shortage of rehabilitation professionals.
     
Although this study was conducted in 1982, readers will find the 
information to be very relevant.  The report continues to be an 
excellent analysis of the entire field of assistive technology, 
and the issues raised are as pertinent today as they were ten 
years ago.
 
Ward, C.  Design for All Consumer Needs Assessment Project Year 
2; Results of the Second Year of a Five Year Study.  Washington:  
July 1990.  Available from:  Electronics Industries Foundation, 
Rehabilitation Engineering Center, 1901 Pennsylvania Avenue, 
N.W., Suite 700, Washington, D.C. 20006; 202-955-5810, TDD: 
202-955-5836.

Summary:  This paper summarizes the results of Year Two of a 
five-year project created to learn directly from consumers about 
their experiences with products, what design features make a 
product work for them, and what features make a product 
inaccessible.  A focus group research methodology was used to 
learn about the products.  Time-limited meetings were held in 
which a trained moderator posed a broad range of questions to 
small groups of participants (product users).  Throughout the 
five-year project, EIF/REC is collecting data on both general 
consumer products, such as computers, telephones, televisions and 
ovens, as well as equipment specially designed for persons with 
disabilities. 

Target Audience:  The reports are distributed to device 
manufacturers, rehabilitation professionals, policy makers, and 
the general public. 

Issues Raised/Conclusions:  Persons who were "newly" disabled 
were less likely to
view assistive technology as an important element in their 
day-to-day existence.  Those who have lived with disabilities 
over a period of time generally seem more comfortable and attuned 
to assistive technology.  No one appears to view technology as a 
panacea. Rather, it is a tool -- one that many of the group 
members prefer using over other alternatives. Group members 
commented repeatedly on how much individuals with disabilities 
differ and that there is no easy way to characterize group 
members. Participants were able to identify specific product 
features that both positively and adversely influence their 
ability to operate equipment. They include cost, 
durability/strength, maneuverability, ease of assembly and 
disassembly, repair issues, height, location, size texture, color 
and brightness of controls, safety features, simple instructions, 
aesthetics, and the ability to keep devices anchored while in 
use.  

Consumer involvement is paramount to every level of assistive 
technology services delivery.  Encouraging more active 
participation by individuals with disabilities as consumers of 
commercial assistive technology is an important and appropriate 
goal for public policy development in technology and related 
services.

Ward, C. "Subsidies from Nonprofit Agencies," an excerpt from 
Subsidy Programs for Assistive Devices.  Sensory Aids Foundation: 
February 1990.  Available from:  Electronic Industries Foundation 
Rehabilitation Engineering Center, 1901 Pennsylvania Avenue, 
Suite 700, Washington, D.C. 20006. 5 pages.

Summary:  Provides in-depth description of the assistive 
technology funding subsidies available from Associated Services 
for the Blind, Braille Institute of America, Opportunities for 
the Blind, Foundation for the Advancement of the Blind, Inc. and 
Blind San Franciscans, Inc.  The excerpt is especially valuable 
because it lists all eligibility requirements mandated by the 
different funding sources.

Target Audience:  Individuals who are blind or visually impaired 
and their families, information and referral services, program 
administrators.


Ward, C.  Subsidy Programs for Assistive Devices.  Washington:  
September 1989.  Available from:  Electronics Industries 
Foundation, Rehabilitation Engineering Center, 1901 Pennsylvania 
Ave., N.W., Suite 700, Washington, D.C. 20006; 29 pages and a 
listing of subsidy programs.

Summary:  This monograph examines subsidy programs as an 
alternative payment strategy for assistive devices. These 
programs lower the cost of technology, or in some cases, provide 
it for free.  A subsidy may be a grant, a discount, or a rebate 
and may target a specific disability group or include other 
eligibility criteria.  The report defines subsidies, identifies 
different models, and describes obstacles to program development, 
implementation, and evaluation.  The document also covers
the important philosophical issues which must be raised when 
considering the establishment of programs that provide subsidies 
to persons with disabilities.

Through interviews and written materials, this study uncovered 
twenty-one subsidy programs for consumers.  The subsidies are 
offered by community service organizations, charities, 
manufacturers, partnerships between device manufacturers or 
retailers and voluntary organizations, private non-profit 
corporations, and public utility regulating agencies. 

Target Audience:  Community service organizations, charities, 
manufacturers, device manufacturers or retailers, voluntary 
organizations, private, non-profit corporations, and public 
utility regulating agencies. 

Issues Raised/Conclusions:  Subsidy programs can respond to the 
problem of providing technology to persons with disabilities who 
may have difficulties financing such devices.  However, they are 
not without their obstacles. For example, raising money for 
initial start up and support of an ongoing equipment program can 
be difficult.  In addition, staffing, information dissemination, 
and program evaluation can present barriers to operating 
programs.  Philosophically, one must consider whether providers 
are reinforcing negative stereotypes of people with disabilities 
by providing discounts based on physical attributes rather than 
on  economic need.  In the end, Ward suggests that subsidies 
represent a laudable goal but the newness of these initiatives 
makes it difficult to define their outcomes.

Wilson, P. Tax Preferences for Specialized Communications 
Equipment for the Handicapped.  February 1986.  Available from: 
The Annenberg Washington Program and the Gallaudet Research 
Institute Joint Forum on "Marketplace Problems in Communication 
Technology for Disabled People, 1455 Pennsylvania Avenue N.W. 
Suite 200 Washington, D.C. 20004 (202) 393-7100; 31 pages and 
glossary.

Summary: This paper examines both the advantages and 
disadvantages of using the tax system for the purpose of 
specialized communication equipment, paying particular attention 
to the problems encountered in designing such preferences.  Part 
I introduces the perceived problem:  Failure of the market to 
respond adequately to the need for specialized communications 
equipment for individuals with disabilities.  Part II builds on 
that analysis to draw some tentative conclusion about appropriate 
tax incentives for the purchase or production of specialized 
communications equipment.  Special attention is paid to the 
possible use of the existing Orphan Drug tax credit as a model.

Target Audience:  Policy makers. Persons interested in a  review 
of existing tax options for financing assistive technology. 

Issues Raised/Conclusions:  This paper raises several fundamental 
questions about the appropriateness of such a tax incentive.  
First, is the focus on specific products appropriate, or should 
the goal be a general increase in purchasing power among people 
with disabilities, to be spend as they wish.  Second, is tax 
policy the best means to subsidize production of specialized 
equipment.  Other options may well be preferable, depending on 
the goal.  
     The author concludes that equal access prices are best 
pursued through regulation, and subsidies for low-income 
consumers are best provided by direct government expenditures.  
For those interested primarily in aiding low-income consumers, 
achieving more complete coverage for such equipment under 
Medicare and Medicaid is more important than obtaining a tax 
credit for its purchase.
     If society desires to subsidize specialized communication 
equipment, and chooses to do so through the tax system, a tax 
credit is the preferred form of tax preference.  Whether the tax 
credit should be given to the consumers or producers depends 
partly on whether it is important to target the benefits toward 
lower-income consumers.  If the goal is to encourage production 
of products that would not otherwise be marketed, than a subsidy 
for pre-marketing research costs (similar to the orphan drug 
credit) might be most desirable.  
     Before advocating particular forms of tax incentives, 
additional information is needed in several areas.  Policy makers 
need better demographic information on individuals with 
disabilities, their incomes, and the taxes they pay.  
In addition, studies of the demand for individuals types of 
products would be also be necessary. 



Wobschall, R. and Baranik, D., Directory of Funding Resources for 
Assistive Technology in Minnesota.  Available from:  The 
Minnesota Star Program, 300 Centennial Building, 658 Ceder 
Street, St. Paul, Minnesota 55155;  29 pages.

Summary:  This book is perfect for individuals in Minnesota who 
want to locate all of the available funding sources within the 
state for specific types of assistive technology devices and 
determine which funding source will be best for them.  Each page 
in the directory represents a public or private funding resource, 
a program that loans equipment, or a program that offers 
financial loans for the purchase of equipment.  Listings contain 
the name, address, contact person and telephone number for the 
agency, as well as brief descriptions of who is served, the 
eligibility and income criteria, and the appeals process.

Target Audience:  Individuals with disabilities and their 
families, foundations and agencies in Minnesota.

Issues Raised\Conclusions:  This book is designed to be used in 
conjunction with Funding and Assistive Technology:  A STAR 
Program Workshop


Wobschall, R.  "Technology and People with Disabilities: 
Implementing a State Plan."   Northridge, CA:  November 1988.   
Available from:  California State University, Office of Disabled 
Students, Northridge, CA; pp.494-504. 

Summary:  This paper, presented at the Fourth Annual Conference 
on Contemporary Application of Computer Technology, reviews the 
efforts of the Minnesota Governor's Advisory Council on 
Technology for People with Disabilities in the implementation of 
key federal initiatives in Minnesota. The paper provides steps to 
be taken along with a list of "critical success factors"  that 
will help ensure successful public-private initiative on 
technology service delivery at the state level.

Target Audience:  Based on Minnesota's exemplary work in 
advancing the availability of assistive technology and related 
services, this paper could be a valuable tool for any state 
looking for ways to improve assistive technology service 
delivery.  

Issues Raised/Conclusions:  In the area of funding of assistive 
technology and related services, the assessment revealed that: 1) 
State agency definitions of key terms, particularly "medical 
necessity" and "prevailing community standard," are unnecessarily 
restrictive and are therefore preventing or delaying full, 
appropriate use of technology; 2) public funding policies do not 
recognize rehabilitation engineering as a reimbursable service, 
even though rehabilitation engineering skills are needed to 
conduct assessments in order to select appropriate equipment and 
to provide training to ensure the full, proper and safe use of 
equipment; and 3) the definitions of medical necessity used by 
private insurance carriers that cover the majority of families 
with children with disabilities and adults with disabilities are 
even narrower and even more restrictive that those used by public 
entities.   

The Advisory Council worked to improve funding on several fronts.  
The results were:
 
     1)   Medicaid Rule Revision: development of a new rule that 
          will allow habilitative, as well as rehabilitative, 
          technologies to be covered by Medicaid;
     2)   Policy Coordination: coordinate all policies relating 
          to assistive technology services and devices for people 
          with disabilities within different public programs;
     3)   Private sector funding: increase awareness of the 
          private-sector funding among Minnesota organizations; 
          and 
     4)   Support other agency efforts.

Zola, I.K. Ph.D  Aging, Disability and the Home Care Revolution.  
39th Annual John
Stanley Coulter Lecture:  November 1989.  Available from:  Dr. 
Zola, Department of Sociology, Brandeis University, P.O. Box 
9110, Waltham, MA. 02254-9110; 4 pages.

Summary:  This report examines the recent increase in individuals 
with disabilities living longer and reaching old age and its 
importance to home health care.  There is currently a push to 
improve home health care funding in order to avoid 
hospitalization of elderly individuals with disabilities.  
Technology has brought great improvement to home health care 
opportunities, however, the advances are often hindered by a lack 
of adequate financing of home health in the health care system.

Target Audience: The general public, individuals with 
disabilities, elderly individuals, health care providers, policy 
makers.

Issues Raised/Conclusions:    A lack of choice as to the design 
of the technology and type of caregiver results from a health 
coverage system that inadequately funds home health care. 
Coalition building between individuals who are elderly and 
individuals with disabilities will help to change current 
stereotypes of these individuals from just individual patients in 
need, to a minority group attempting to augment their decision 
making power.  An increase in size will mean a veto power that 
can bring about the needed change in financing of home health 
care.

                     STUDIES/PROJECTS UNDERWAY


Alpha One Center for Independent Living.  "Credit Able."  Will be 
available from:  Alpha One Center for Independent Living, 85 E 
Street, Suite One, South Portland, ME 04106; 207-767-2189.

Summary:  Alpha One, a nationally recognized Independent Living 
Center, proposes Credit Able, a two-year project to demonstrate 
the viability of income-contingent loan programs for children, 
adults, and elderly people with disabilities, for the acquisition 
of assistive technology.  As administrator of the Maine Adaptive 
Equipment Loan Program, Alpha One will demonstrate the viability 
of income-contingent loan programs for people with disabilities 
and to offer technical assistance to prospective loan programs.  
During the first year, Credit Able will conduct an extensive 
assessment of the availability of the Adaptive Equipment Loan 
Program.  Over the two-year funding period, a Credit Able 
Technical Assistance Team, currently involved in management of 
the Adaptive Equipment Loan Program, will offer technical 
assistance to 12 to 14 prospective loan programs across the 
nation.  Credit Able will target prospective loan programs across 
the nation.  This project is funded under Title II of the Tech 
Act.

Target Audience:  Consumers, families, practitioners, advocates 
and policy makers.


Connecticut Rehabilitation Engineering Center.  Funding of 
Assistive Technology Devices for the Consumer with A Disability.  
Available in March 1991 from:  Connecticut Rehabilitation 
Engineering Center, Institute for Human Resource Development, 78 
Eastern Boulevard Glastonbury Ct. 06033; 203-659-1166; In 
Connecticut: 800-752-4988.

Summary:  According to the project design information, this 
resource will be a consumer's guide and curriculum materials 
which will assist in obtaining funding for assistive technology 
devices and related services.  The manual will provide an 
overview of each type of funding source along with a comparison 
of the existing funding options.  The format of the guide will be 
structured in a way that allows the consumer to quickly determine 
which funding program hold promise.  Case examples will be used 
within and across various program to illustrate the effect of 
implementation policies on the funding process.

Target Audience:  Consumers, families, advocates, practitioners, 
funding specialists, and policy makers.


Golinker, L.  Principal Assistive Technology Caselaw.  
Washington:  February 1991.  Available from:  United Cerebral 
Palsy Associations, Inc., 1522 K Street, N.W., Washington, D.C. 
20005; 800-USA-5UCP; 37 pages. 

Summary:  This paper is a summary of the most important caselaw 
decisions and administrative policy directives to date with 
regard to entitlement to assistive technology funding. The paper 
also includes key references to the statutes and regulation 
defining the scope of the programs.  The decisions are found 
primarily in three federal programs:  Medicaid including EPSDT, 
Special Education and Vocational Rehabilitation.    

Target Audience:  State program administrators, professional 
advocates (P&As, CAPs, LSC), policy makers, consumers, providers. 

Issues Raised/Conclusions:  There are few caselaw decisions 
related to assistive technology because of the general lack of 
awareness of the potential use and benefits of assistive 
technology, the lack of professional advocates who can pursue 
appeals, and the pressure for out-of-pocket settlements rather 
than court decisions that can set legal precedents for the 
program as a whole.  Nevertheless, there are several important 
legal cases which provide a basis for getting Medicaid, Special 
Education and Vocational Rehabilitation to pay for assistive 
technology which increases the capacity for independence or 
self-care, makes a child's educational program more meaningful, 
or enhances functional capacity to expand employment and 
independent living opportunities.  These determinations, however, 
must be made on a case-by-case basis.


National Easter Seal Society.  Computer Assisted Technology 
Services.  Will be available from:  National Easter Seal Society, 
70 East Lake Street, Chicago IL 60601; 312-667-8400. 

Summary:  The National Easter Seal Society will demonstrate the 
viability of loans made to families or employers of persons with 
disabilities to provide technology-related assistance to maintain 
and enhance the level of functioning in major life activities.  
The program will serve all individuals with disabilities. Loans 
will range from $1000 to $3200 during the first year, to increase 
the number of applicants/participants of the program.  Easter 
Seals will take a lead in providing the technical support and 
access to resources under this Tech Act Title II demonstration
grant.

Target Audience:  Consumers, families, practitioners, advocates, 
funding specialists and policy makers.








VI.  APPENDIX





ù    Definition of Assistive Technology Device and Assistive 
     Technology Service in P.L. 100-407 The Technology-Related 
     Assistance Act of 1988



ù    Policy Letter: Office of Special Education



ù    Policy Letter: Rehabilitation Services Administration







                  NATIONAL COUNCIL ON DISABILITY




          ACCESS TO THE FINANCING OF ASSISTIVE TECHNOLOGY






                  ANALYSIS OF POLICY AND PRACTICE
                        IN FEDERAL PROGRAMS





                         January 23, 1992



                                 

                                 
                                 
                                 
Contractor:  United Cerebral Palsy Associations, Inc.
                  1522 K Street, N.W., Suite 1112
                       Washington, DC 20005


For Further Information Contact: Michael Morris (202) 842-1266
          ACCESS TO THE FINANCING OF ASSISTIVE TECHNOLOGY
        ANALYSIS OF POLICY AND PRACTICE IN FEDERAL PROGRAMS

                         TABLE OF CONTENTS
                                                      Page Number
SECTION I   THE POLICY CONTEXT................................. 1
            The Technology-Related Assistance for Individuals
            with Disabilities Act of 1988...................... 1
            Federal Policy Goals for Individuals with 
            Disabilities....................................... 3
            Access To Financing................................ 4

SECTION II  APPROACH TO THE ANALYSIS........................... 6
            LOGIC MODEL........................................ 6
            1.   The Definition Of Assistive Technology........ 6
            2.   Selection Of Federal Programs................. 8
            3.   Development Of The Criteria For
                 Program/Policy Effectiveness.................. 9
                 A.  FACILITATORS............................. 10
                 B.  BARRIERS................................. 10
            4.   Information Sources.......................... 11
            5.   Limitations.................................. 11
            6.   Products Of The Analysis..................... 12

SECTION III  FEDERAL SUPPORT FOR THE FINANCING OF
            ASSISTIVE TECHNOLOGY.............................. 13
            Federal Program Characteristics:  Overview........ 13
            1. Program Goals And Purposes..................... 14
            2. Legislative History............................ 14
            3. Program Magnitude.............................. 15
            4. Target Populations And Eligibility Criteria.... 15
            TABLE 1  State Flexibility........................ 16
            5. Methods Used To Finance Assistive Technology... 17
            6. State Flexibility.............................. 19

SECTION IV  PROFILES OF INDIVIDUAL FEDERAL PROGRAMS .......... 21
            I.   Title XVIII of Social Security Act (Medicare) 21
            II.  Title XIX of Social Security Act (Medicaid).. 52
                 1.  Medicaid Mandatory & Optional Services... 54
                 2.  Early Periodic Screening, Diagnosis
                     & Treatment Program (EPSDT).............. 62
Table of Contents (continued)
                                                      Page Number

SECTION IV (continued) Profiles....
                 3.  Intermediate Care Facilities For People
                     with Mental Retardation & Related
                     Conditions (ICFs/MR)..................... 64
                 4.  Home & Community Based Services (HCBS or
                     Section 2176 Waivers).................... 68
                 5.  Community Supported Living
                     Arrangements (CSLA)...................... 71

            III. Title V of Social Security Act (Maternal & 
                 Child Health Services........................ 73
                 1.  Maternal & Child Health Block Grant...... 74
                 2.  Children With Special Health Care Needs . 77
                 3.  Special Projects of Regional & National
                     Significance............................. 80
            IV.  Individuals With Disabilities Education Act . 82
                 1.  Part B. State & Local Grant Program for
                     Special Education........................ 83
                 2.  Part H. State Grants for Infants & Toddlers 90
            V.   Related Programs............................. 97
                 1.  Education of Handicapped Children in State
                     Operated or Supported Schools (P.L. 89-13) 97
                 2.  Vocational Education (Carl D. Perkins
                     Voc. Ed. & Applied Technology Education Act 101
            VI.  Rehabilitation Act of 1973 (as amended)..... 104
                 1.  Title I, Basic State Grants............. 106
                 2.  Title VI-C, Supported Employment........ 114
                 3.  Title VII, Independent Living .......... 118
            VII. Disability Programs of Social Security Act.. 123
                 1.  Title II, Social Security Disability 
                     Insurance (SSDI)........................ 123
                 2.  Title XVI, Supplemental Security Income  128
                 3.  Impairment Related Work Expenses (IRWE)  133
            VIII.Veterans' Benefit Programs ................. 136
                 Prosthetic Appliances & Sensory Aids........ 137
                 Related Programs............................ 138
            IX.  Older Americans Act of 1965 (as amended).... 143
Table of Contents (continued)
                                                      Page Number

            X.   United States Tax Code...................... 148
                 Medical Expenses............................ 148
                 Business Deductions ........................ 149
                 Employee Business Expenses ................. 149
                 Targeted Jobs Tax Credit.................... 150
                 Tax Credit for Architectural & Transportation
                   Barrier Removal Expenses.................. 150
                 ADA Tax Credit for Small Business .......... 151
                 Charitable Contributions Deduction.......... 152
            XI.  Civil Rights Legislation.................... 154
                 1.  The Americans With Disabilities Act (ADA) 154
                 2.  Section 504 of the Rehabilitation Act... 163
                 3.  Section 508 of the Rehabilitation Act... 166
            XII. Technology Related Assistance For Individuals
                 With Disabilities Act of 1988............... 170
            XIII.Telecommunications Accessibility Enhancement
                 Act of 1988 and The Telecommunications
                 for the Disabled Act of 1982.................176

SECTION V   Implications For Policy Reform & Federal Initiatives 184
            TABLE 2:  Financing of Assistive Technology:
                Barriers and Facilitators.................... 185
            Nine Reform Strategies........................... 188

SECTION VI  Seven Suggestions for Further Research........... 194

Appendix A  Information Sources
Appendix B  Individuals Providing Information/
            Perspectives on Programs
Appendix C  Copies of Policy Documents
Appendix D  Definitions of Assistive Technology
Appendix E  A Medicare Carriers Manual

          ACCESS TO THE FINANCING OF ASSISTIVE TECHNOLOGY

SECTION I.  THE POLICY CONTEXT

     "Gaps in the coverage provided by Medicaid, the lack of 
     individuals with insurance, the lack of therapists in the 
     state and the lack of assistive technology services 
     available through the public schools or other service 
     providers provide extreme problems for children seeking 
     utilization and funding of assistive technologies.  These 
     problems, combined with a fragmented service delivery system 
     of more than seventeen state and federal agencies serving 
     people with disabilities, are confusing and frustrating for 
     those seeking public funding and access to assistive 
     technologies." 
     -- Testimony at NCD Public Forum

The significance of assistive technology to people with 
disabilities has been a public policy issue for over forty years.  
A 1982 report by the federal Office of Technology Assessment 
discussed the significance of providing supports that enable 
people with disabilities to work or attend schools with their 
neighbors, and making their lives easier, safer, and more 
fulfilling. The report recommended also the elimination or 
reduction of the effects of the causes of disability. [Office of 
Technology Assessment (OTA), 1982].  In its review of federal 
programs and policies OTA reported a major conclusion:

     (D)espite the existence of numerous important problems 
     related to developing technologies, the more serious 
     questions are social ones of financing, of conflicting and 
     ill-defined goals, of hesitancy over the demands of 
     distributive justice, and of isolated and uncoordinated 
     programs;
     [OTA, 1982]

A comprehensive review of testimony and comments from hundreds of 
people with disabilities, family members and other concerned 
citizens in 1986 by the National Council on Disability (NCD) 
produced the observation that "whatever the limitations 
associated with particular disabilities, people with disabilities 
have been saying for years that their major obstacles are not 
inherent in their disabilities, but arise from barriers that have 
been imposed externally and unnecessarily" (NCD, 1986).

Although the Council's subsequent review of their recommendations 
to reduce barriers noted considerable progress, clearly many 
barriers remain. ["On The Threshold of Independence," January 
1988.]
The Technology-Related Assistance for Individuals with 
Disabilities Act of 1988
P.L. 100-407, the Technology-Related Assistance for Individuals 
with Disabilities Act of 1988, received overwhelming support in 
both the U.S. House and Senate.  The testimony of dozens of 
witnesses, including many individuals with disabilities who use 
technology, provided firsthand information on the importance of 
assistive technology in people's lives as well as the 
difficulties often encountered in gaining access to technology.  
The findings of the Congress are summarized in the legislation 
which includes the following statement:

     For some individuals with disabilities, assistive technology 
     is a necessity that enables them to engage in or perform 
     many tasks.  The provision of assistive technology devices 
     and assistive technology services enables some individuals 
     with disabilities to - (A) have greater control over their 
     own lives; (B) participate in and contribute more fully to 
     activities in their home, school, and work environments, and 
     in their communities; (C) interact to a greater extent with 
     nondisabled individuals; and (D) otherwise benefit from 
     opportunities that are taken for granted by individuals who 
     do not have disabilities.
     [29 USC 2201]
 
Congress found that resources are lacking that would help people 
with disabilities obtain and use assistive technology (i.e., 
including both devices and related services).  For example there 
is a lack of:

.    Sources of payment for assistive devices and services; 
.    Trained personnel to provide assistive devices and services 
     and to help individuals with disabilities use assistive 
     technology effectively; 
.    Information about assistive technology, for individuals, 
     family members, and professionals working with individuals 
     with disabilities; 
.    Coordination among public programs and between public and 
     private sector programs; and 
.    Capacity of both public and private sector programs to 
     provide necessary technology-related assistance.
[(29 USC 2201].

The objectives or purposes of the Technology-Related Assistance 
Act were designed to respond to these findings.  They include the 
provision of federal
assistance to the states for the development of a 
consumer-responsive statewide program that includes increased 
access to funding for assistive technology; and enhancing the 
ability of the federal government to provide technical 
assistance, information, training, public awareness programs and 
funding for demonstration/innovation projects on assistive 
technology to the states. 

Other purposes of the Act were promotion and identification of 
federal policies that facilitate payment for assistive 
technology, identification of policies or practices that impede 
or act as barriers to assistive technology financing, and 
discovery of ways to eliminate barriers to financing.

Federal Policy Goals for Individuals with Disabilities 
Because people with disabilities are people first, every federal 
program that affects people without disabilities affects those 
who do have disabilities.  People with disabilities are therefore 
affected by all federal policies that help shape our society, 
from federal budget reform, tax and employment policies to 
foreign policies dealing with the new world order.  At the same 
time there are dozens of programs -- some targeted specifically 
to people with disabilities, such as the Individuals with 
Disabilities Education Act (IDEA), and some with multiple 
eligible populations, such as the Medicaid and Supplemental 
Security Income (SSI) programs -- that are based on federal 
policy goals and that have special importance to people with 
disabilities.  Over the past twenty-five years, Congress has 
established over thirty programs that affect Americans with 
disabilities (NCD, 1991a).  Some of the policy goals in the 
authorizing legislation for these programs state they will:

.    Assure that all children with disabilities have available 
     ... a free appropriate public education (Individuals with 
     Disabilities Education Act);
.    Develop and implement ... comprehensive and coordinated 
     programs of vocational rehabilitation and independent living 
     for individuals with handicaps in order to maximize their 
     employability, independence, and integration into the 
     workplace and the community (The Rehabilitation Act);
.    (Have) national objectives that include the best possible 
     physical and mental health for older persons and efficient 
     community services with emphasis on maintaining a continuum 
     of care for the vulnerable elderly (Older Americans Act);
.    Provide a clear and comprehensive national mandate for the 
     elimination of discrimination against individuals with 
     disabilities (The Americans
     With Disabilities Act).

Additional information on federal policy goals is included in 
Section IV, Profiles Of Individual Programs.

Access To Financing

     "What is missing from this patchwork of funding streams is a 
     clear concept of entitlement to assistive technology in 
     order to increase independence and improve the quality of 
     life for individuals with disabilities.  The problem is we 
     are not recognizing disability as a functional issue -- 
     rather we are leaving coverage to the awkward and incomplete 
     rationales afforded by the current educational, vocational 
     and medical categories."
     -- Testimony at NCD Public Forum 

Despite policy statements that appear to support access to the 
financing of assistive technology devices and services, many 
questions exist about federal and state program effectiveness in 
meeting the technology needs of individuals with disabilities.  
The legislation mandates that a study on the financing of 
assistive technology be conducted by the National Council on 
Disability that will produce recommendations to the Congress and 
to the President concerning: 

.    Federal laws, regulations, procedures, and practices that 
     facilitate or impede the ability of the States to develop 
     and implement consumer-responsive statewide programs of 
     technology-related assistance for individuals with 
     disabilities;

.    Federal and State laws, regulations, procedures, and 
     practices that facilitate or impede the acquisition of, 
     financing of, or payment for assistive technology devices 
     and assistive technology services for individuals with 
     disabilities;

.    Policies, practices, and procedures of private entities 
     (including insurers) that facilitate or impede the 
     acquisition of financing of, or payment for assistive 
     technology devices and assistive technology services for 
     individuals with disabilities; and 

.    Alternative strategies for acquiring or paying for assistive 
     technology devices and assistive technology services.

[29 USC 2231] 
 
This report responds to the mandate for the National Council on 
Disability and focuses, in particular, on analysis of three 
areas:

(1)  Features of federal programs and policies that are 
     facilitators and promote access to the financing of 
     assistive technology;

(2)  Features that act as barriers or impediments to financing; 
     and

(3)  Implications for federal strategies and reforms that would 
     reduce inappropriate barriers to financing and enhance 
     individual access to consumer-responsive assistive 
     technology.

The approach to this analysis of the effectiveness of federal 
programs and policies in financing assistive technology is 
described in the following section.
SECTION II.  APPROACH TO THE ANALYSIS

The approach used in analyzing federal programs was grounded in 
the requirements of the Technology-Related Assistance Act.  This 
meant a review of facilitators and barriers, identification of 
implications for reform, and discovery of related findings and 
purposes.  Federal policy goals and perspectives of people with 
disabilities were reviewed also.  An analytical framework or 
logic model was developed that describes the relationship between 
individuals with disabilities and those federal programs and 
policies including assistive technology.  The model follows: 

LOGIC MODEL
     IF people with disabilities are knowledgeable about and have 
     access to technology, and

     IF professionals are knowledgeable about the benefits and 
     types of technology available, and

     IF financing is available to make technology affordable to 
     individuals with disabilities and their families, and

     IF financing is adequately funded, consistent, predictable, 
     available as needed over time, and

     IF such financing provides access to technology that is of 
     high quality, designed to meet individual needs and 
     preferences, and supported by qualified personnel, and

     IF financing promotes coordinated access to technology and 
     the availability of technology across the full range of 
     activities of living,

     THEN people with disabilities will enjoy increased 
     independence and self-sufficiency, full community 
     participation, and greater quality of life.

1.   The Definition Of Assistive Technology

Assistive technology has been defined throughout the analysis to 
include both
assistive technology devices and services, based on the following 
definitions found in the Technology Related Assistance Act:

Assistive technology device:  Any item, piece of equipment, or 
product system, whether acquired commercially off the shelf, 
modified, or customized, that is used to increase, maintain, or 
improve functional capabilities of individuals with disabilities.

Assistive technology service:  Any service that directly assists 
an individual with a disability in the selection, acquisition, or 
use of an assistive technology device.  Such term includes --

(A)  the evaluation of the needs of an individual with a 
     disability, including a functional evaluation of the 
     individual in the individual's customary environment;
(B)  purchasing, leasing, or otherwise providing for the 
     acquisition of assistive technology devices by individuals 
     with disabilities;
(C)  selecting, designing, fitting, customizing, adapting, 
     applying, maintaining, repairing, or replacing of assistive 
     technology devices;
(D)  coordinating and using other therapies, interventions, or 
     services with assistive technology devices, such as those 
     associated with existing education and rehabilitation plans 
     and programs;
(E)  training or technical assistance for an individual with 
     disabilities, or, where appropriate, the family of an 
     individual with disabilities; and
(F)  training or technical assistance for professionals 
     (including individuals providing education and 
     rehabilitation services), employers, or other individuals 
     who provide services to, employ, or are otherwise 
     substantially involved in the major life functions of 
     individuals with disabilities.
     [P.L. 100-407]

This definition of assistive technology encompasses a wide range 
of supports in the use of assistive technology as well as the 
devices themselves.  The definition of devices, because it 
includes any item, equipment or product that can maintain or 
enhance functional capabilities of an individual with a 
disability, encompasses the full range of technology:  from 
prosthetics and durable medical equipment such as wheelchairs to 
home modifications, and from low tech applications such as 
especially shaped eating utensils to the most complex computer 
communications systems.
2.   Selection Of Federal Programs

A quick review of the array of federal programs which finance or 
which potentially could finance assistive technology, conducted 
with the literature review of information sources on financing 
(NCD, 1991a), identified some forty or more programs.  The list 
was narrowed to twenty-six programs, using the following 
criteria:

.    Major or potentially major source of assistive technology 
     financing;
.    Range of age groups as target populations (e.g., children, 
     elderly, veterans);
.    Financing with various emphases (e.g., health care, 
     education, employment); and
.    Variation in financing mechanisms.

On this basis, the following programs were reviewed and are 
included in this analysis:

MEDICARE

MEDICAID
(1)  Required and Optional Services
(2)  Early Periodic Screening, Diagnosis and Treatment (EPSDT)
(3)  Intermediate Care Facilities for people with Mental 
     Retardation and Related Conditions (ICF/MR)
(4)  Section 2176 Waivers (Home and Community Based Services 
     Waivers, Model Waivers)
(5)  Community Supported Living Arrangements

MATERNAL AND CHILD HEALTH (MCH)
(1)  MCH Block Grant
(2)  Children with Special Health Care Needs
(3)  Special Projects of Regional and National Significance 
     (SPRANS)

EDUCATION
(1)  Individuals with Disabilities Education Act (IDEA) Part B
(2)  IDEA Part H (Infants and Toddlers)
(3)  State Operated Programs (89-313)
(4)  Vocational Education

VOCATIONAL REHABILITATION
(1)  Title I: State Grants
(2)  Title VI-C: Supported Employment
(3)  Title VII: Independent Living

SOCIAL SECURITY
(1)  Title II:  Social Security Disability Insurance (SSDI)
(2)  Title XVI:  Supplemental Security Income (SSI)
(3)  Impairment Related Work Expenses

DEPARTMENT OF VETERANS AFFAIRS (VA)
Prosthetics and Sensory Appliances Program

OLDER AMERICANS ACT

U.S. TAX CODE

CIVIL RIGHTS
(1)  The Americans with Disabilities Act (ADA)
(2)  Section 504 of the Rehabilitation Act
(3)  Section 508 of the Rehabilitation Act

THE TECHNOLOGY-RELATED ASSISTANCE ACT

TELECOMMUNICATIONS ENHANCEMENT ACT OF 1988

THE TELECOMMUNICATIONS FOR THE DISABLED ACT OF 1982

Federal policies with major impact on the financing of assistive 
technology through private insurance, in particular the Employee 
Retirement and Income Security Act (ERISA), are included in a 
separate report.

3.   Development Of Criteria For Program/Policy Effectiveness

The Logic Model illustrated above provides the basis for the 
review of federal programs and policies and their effectiveness, 
i.e., what are the facilitators and barriers.  The list was 
refined during the review process to reflect input from three 
regional Public Forums on "Financing Assistive Technology".  The 
forums were convened by NCD to support the analysis.  The first 
public forum
was held in Los Angeles, California, March 21-22, 1991, another 
in Portland, Maine, on July 11 and 12th, and the most recent was 
in Minneapolis, Minnesota, October 17 and 18, 1991.  

Characteristics addressed in the review of the federal programs 
were:

A.   FACILITATORS

ÀÀ Clear policy statement on assistive technology
ÀÀ Broad or mandatory coverage of individuals
ÀÀ Outreach requirements
ÀÀ Coverage of a wide range of assistive technology
ÀÀ Mandatory coverage of assistive technology support services
ÀÀ Requirements for an individualized program plan
ÀÀ Appeals process
ÀÀ Coordination of funding sources
ÀÀ Adequate and Reliable Funding
ÀÀ Primary payer
ÀÀ Training requirements
ÀÀ Consumer responsive
ÀÀ Mandated lead expert on assistive technology
ÀÀ State plan requirements on assistive technology
ÀÀ Appropriate level of state flexibility

B.   BARRIERS

ÀÀ Restrictive eligibility provisions
ÀÀ Limited or no outreach requirements
ÀÀ Restrictive use of medical necessity criteria
ÀÀ Prior authorization process
ÀÀ Limits on the use of assistive technology being financed 
     (location, purpose)
ÀÀ Limits on the type of assistive technology covered
ÀÀ No coverage of support services
ÀÀ Lack of informed professionals
ÀÀ No training requirements
ÀÀ Incentives for lowest cost assistive technology
ÀÀ Caps on the amount of coverage
ÀÀ Caps on the duration/scope of coverage
ÀÀ Last payer requirement
ÀÀ Cumbersome application process (individual, vendor)
ÀÀ Cumbersome reimbursement process
ÀÀ Limited program funding
ÀÀ Other administrative barriers.

4.   Information Sources

The examination of federal programs and policies used a variety 
of information sources, including the statutes, Congressional 
hearings and reports, federal regulations, policy statements 
issued by federal administering agencies, the "Catalogue of 
Federal Domestic Assistance," and various source books on federal 
programs.  Perspectives on facilitators, barriers, and 
implications for federal actions that could reduce barriers to 
financing, were obtained from the following sources:

.    Interviews with knowledgeable individuals at the respective 
     federal agencies;
.    Testimony at the NCD public forums on the financing of 
     assistive technology;
.    Discussions with researchers and advocates for effective 
     financing; and
.    The annotated bibliography on the financing of assistive 
     technology prepared following the NCD literature review 
     (NCD, 1991a).

Collectively, these sources provided a rich array of suggestions 
for federal  initiatives and reforms as well as information and 
perspectives on the  effectiveness of current federal policies 
and programs.  A list of the information sources used is included 
as Appendix A.

5.   Limitations

Two limitations were apparent early in the review process:

(1)  The significant lack of data on the extent to which 
     individual federal programs are currently financing 
     assistive technology; and

(2)  The disparities between program intent, as defined in 
     authorizing legislation and other official policy 
     statements, and program implementation.

One aspect of federal program review was intended to determine 
the numbers of individuals with disabilities receiving assistive 
technology through each of the public programs, the number of 
dollars being used to finance assistive technology, and, if 
possible, the quantities of the various assistive devices and 
services being financed.  This information was not available for 
any of the programs reviewed, with the exception of the 
Prosthetics and Sensory Aids Program of the Department of 
Veterans' Affairs (VA).

Incorporating an understanding of the disparities between 
official policy and federal program implementation presented a 
different challenge.  It is beyond the scope of this analysis to 
obtain comprehensive information on how each of the States uses 
the twenty-six federal programs and the reaction of their 
individual citizens to their State's implementation.  Therefore 
the analysis has made particular use of a questionnaire to 
identify the disparities within selected individual states.  
Additionally, the NCD consumer forums identified the gaps between 
federal policy and implementation at the state and local level.

The primary description of federal programs and their particular 
facilitators and barriers to financing assistive technology is 
based on information on federal policy goals and purposes as 
defined in legislation and regulations.  Differences between 
these stated goals and purposes and state/local implementation 
are highlighted as appropriate.

Discussions of state flexibility in program implementation are 
used to identify areas of state discretion, such as definitions 
of specific eligibility criteria, funding levels, and authorized 
services.  They are used primarily to highlight the scope of 
discretion authorized by federal statute or regulation.

6.   Products Of The Analysis

This report summarizes three major components of the analysis of 
federal programs:

(1)  An overview of the ways federal programs finance assistive 
     technology, the flexibility states have in implementing 
     programs, features that act as facilitators in the financing 
     of assistive technology, and those that act as barriers; 
(2)  A descriptive profile of each covered program; and
(3)  A discussion of the implications for federal action to 
     eliminate
     inappropriate barriers and to enhance access to the 
     financing of assistive technology for individuals with 
     disabilities.
SECTION III.  FEDERAL SUPPORT FOR THE FINANCING OF  ASSISTIVE 
TECHNOLOGY

Federal Program Characteristics:  Overview

The twenty-six programs included in the review reflect a broad 
spectrum of public policy goals, legislative history, program 
magnitude, target populations and eligibility requirements, 
mechanisms for financing assistive technology, and degree and 
scope of state flexibility.  An overview across the programs is 
helpful in understanding the context for the analysis of 
facilitators and barriers.

1.   Program Goals And Purposes
Most federal programs include a statement of their goals or 
purposes, found most frequently in the authorizing legislation as 
passed by the Congress and signed into law by the President.  For 
example, the description of the goals and purposes of the 
Technology-Related Assistance for Individuals with Disabilities 
Act of 1988 is found in P.L. 100-407, now 29 USC 2201-2271.  
Additional information on Congressional intent is found in the 
report accompanying the legislation.  The report on the 
Rehabilitation Act Amendments of 1986 (Senate Report 99-388), for 
example, includes the following amplification of the Act's 
purposes:

     The Committee views the Rehabilitation Act as a 
     comprehensive set of programs designed to meet the broad 
     range of needs of individuals with handicaps in becoming 
     integrated into the competitive workplace and the community 
     and in reaching their highest level of achievement ... .  
     The Committee definition [of supported employment] clarifies 
     that, for the purpose of the Rehabilitation Act, supported 
     employment may be considered an acceptable outcome for 
     employability.
     (Senate Committee on Labor and Human Resources).

Statements of this kind are used in the interpretation of policy 
goals in such activities as development of program regulations by 
federal agencies and the resolution of appeals on eligibility and 
service coverage by the courts.  Most of the programs include 
statements of goals or purposes that relate specifically to 
people with disabilities.  These include such goals as the 
promotion of independence and self-sufficiency (e.g., the 
Vocational Rehabilitation and Social Security work incentive 
programs);  access to health care (e.g., Medicare,
Medicaid, Maternal and Child Health, VA health service programs); 
rehabilitation (e.g., Vocational Rehabilitation, Medicaid); and 
equal access and opportunity (e.g., IDEA, the Americans with 
Disabilities Act, and Section 504). Such policies provide general 
support for the financing of assistive technology because of 
technology's significance to individuals with disabilities in 
reducing dependence and promoting self-sufficiency, maintaining 
or enhancing health status, rehabilitation, and as a major 
support to full participation as students, workers, and members 
of the community.

Other policy goals or purposes providing general support to 
effective financing of assistive technology include coordination 
(e.g., IDEA Part H - State Grants for Infants and Toddlers with 
Disabilities);  and improvements in the quality of services being 
provided (e.g., Carl D. Perkins Vocational and Applied Technology 
Act programs).

Statements of policy goals specific to assistive technology are 
found in a few federal programs, including statements as part of 
the authorizing legislation (e.g., the Technology-Related 
Assistance Act); and in regulation (e.g., regulations governing 
the Intermediate Care Facilities for people with Mental 
Retardation and related conditions (ICF/MR) program, an optional 
service under the Medicaid program.  Some programs -- including 
some without reference to the financing of assistive technology 
as a specific purpose or goal -- are covered by other policy 
statements specific to assistive technology.  For example, there 
is the Policy Directive on Rehabilitation Engineering from Nell 
Carney, Commissioner of the Rehabilitation Services 
Administration (RSA), U.S. Department of Education, November 16, 
1990, that reinforced the implementation of the Rehabilitation 
Act Amendments of 1986 and gave new emphasis to assistive 
technology in Rehabilitation Act programs.

Or other program guidance, such as within the Medicaid Home and 
Community Based Waiver program, an application format that 
includes assistive technology in its definition of appropriate 
services (i.e., environmental modifications and specialized 
medical equipment and supplies).

States are typically the target audience for these statements, as 
well as the recipients of the federal funds Congress appropriates 
to implement the policies  in most of the programs reviewed.

2.   Legislative History

The federal programs reviewed in this analysis range from old 
programs that have traditionally been used to finance assistive 
technology, such as the VA Prosthetics and Sensory Aids program, 
medical deductions in the federal tax code, and the durable 
medical equipment benefit under the Medicare program.  Recently 
enacted programs are the Technology-Related Assistance Act (1988) 
and the Americans With Disabilities Act (1990).  Still other 
programs that have been in place for several years but amended 
recently to include references to assistive technology are the 
Individuals with Disabilities Education Act of 1990, which added 
definitions of assistive technology services and devices to 
clarify its role in education and related services for children 
with disabilities, and the Carl D. Perkins Vocational and Applied 
Technology Act of 1990, which added requirements that states 
assure provision of assistive technology to students with 
disabilities.

3.   Program Magnitude

The federal programs that finance assistive technology vary 
greatly in their total magnitude -- both expenditures and numbers 
of individuals -- and in the expenditures specifically directed 
to assistive technology.  Table 1, Program Magnitude and State 
Flexibility (on next page) summarizes the magnitude of the 
federal programs reviewed. The greater the funding level for an 
individual federal program, the greater the potential exists for 
funding of assistive technology devices and services.  With the 
exception of the Technology Related Assistance Act (P.L. 
100-407), assistive technology funded devices and services are 
but one option for resource allocation from a menu of diverse 
programs' covered services.

4.   Target Populations and Eligibility Criteria

A few of the programs included in the review are targeted to a 
very broad population, including people who do not have 
disabilities, such as the federal tax code and the Medicaid 
program.  Others include specific components targeted to people 
with disabilities, such as the SSI program for individuals with 
disabilities and the Children with Special Health Care Needs 
component of the Maternal and Child Health (MCH) Block Grant.  
Some programs include people with disabilities as one of their 
defined target populations (e.g., Medicare and the Vocational 
Education program).  Another program requires that states address 
the needs of people with disabilities through state plan 
requirements (e.g., the Older Americans Act).  Not surprisingly, 
many of the
federal programs that are significant to the financing of 
assistive technology are targeted directly to individuals with 
disabilities, including programs authorized by the Individuals 
with Disabilities
                              TABLE 1



education Act, the Rehabilitation Act and the civil rights 
protections of the Americans with Disabilities Act and Section 
504 of the Rehabilitation Act.

The two focuses of target population and eligibility criteria 
used most frequently in these programs are age and level of 
income and resources.  Examples of age related targeting and 
eligibility include Part H of IDEA (infants and toddlers with 
disabilities from birth through age two), Part B of IDEA 
(children with disabilities ages three to twenty-one) and the 
Older Americans Act (individuals age sixty and over, regardless 
of disability status).  Programs targeted to low income 
individuals include Medicaid, SSI, and the MCH block grant 
program.  

A few programs include also policy language that suggests that 
special efforts should be made to reach low income members of the 
broader target population.  For example, the Older Americans Act 
requires that area agencies on aging assure that preference will 
be given to providing services to older persons with the greatest 
economic or social needs, with particular attention to low income 
minority older persons.

5.   Methods Used To Finance Assistive Technology

The federal programs reviewed for this analysis use a variety of 
methods to finance assistive technology.  These include direct 
provision or payment, usually to the provider, vendor or 
distributor;  financial assistance to the individual with the 
disability or family; and indirect or general support.  The 
typical direct financing method begins with determination of the 
individual's eligibility for the program, followed by a further 
determination that assistive technology -- either assistive 
device or assistive technology related service or both -- is 
needed by the individual and  can be paid for by the program.

There is no consistent standard of need across federal programs 
that guarantees an individual with a disability access to 
appropriate assistive technology services and devices.  For 
instance, several programs, including Medicare, Medicaid, and the 
VA, specify that the assistive technology must be medically 
necessary.  In the Rehabilitation Act, access to technology must 
relate to achieving employment potential.  Children covered by 
IDEA Part B have access to financing based on the educational 
necessity for the technology.  For example, children whose 
Individualized Education Plan indicates the need for assistive 
technology are entitled to receive the assistive technology from 
their local school district at no cost, as part of their free 
appropriate public education. 
The definition of assistive technology services and devices in 
the IDEA legislation and the related policy letter from the 
director of the federal Office of Special Education Programs make 
it clear that assistive technology can (and must) be paid for 
through IDEA funded programs, even though federal IDEA funding 
covers only a small percentage of the cost.

A third step in the process in some programs is that the 
assistive technology be provided by a certified vendor or 
provider.  For example, Medicaid rules specify that assistive 
devices and services paid for by the program can be obtained only 
from entities certified by the state Medicaid program.   Other 
examples of financial assistance include allowances for assistive 
technology expenditures in the federal tax code and some of the 
work incentive provisions for people with disabilities who 
receive Supplemental Security Income (SSI) or Social Security 
Disability Insurance (SSDI) benefits.  For example, the 
Impairment Related Work Expense (IRWE) program allows both SSI 
and SSDI recipients who work to deduct half of the cost of 
assistive technology and their other expenses that permit them to 
maintain employment and that are associated with their 
disability.  This is offset from the amount of their earnings for 
it would otherwise reduce their federal monthly payment.

Indirect support of financing includes linkages with programs 
that finance assistive technology directly, promotion of access 
to services and programs, and incentives to potential financiers 
of assistive technology.  The primary examples of such linkages 
are the relationships between SSI and Medicaid eligibility, and 
between SSDI and Medicare eligibility.

Promotion of access is exemplified by the Americans with 
Disabilities Act and Section 504 of the Rehabilitation Act of 
1973.  Both of these civil rights laws emphasize in their 
regulations that assistive technology must be provided as 
necessary to make reasonable accommodation in providing full 
access to people with disabilities, to employment, 
transportation, government funded services, and public 
accommodations.  Furthermore, Title IV of ADA requires that 
telephone services offered to the public in every state must 
include inter- and intrastate relay services that provide full 
telecommunications access to people with speech and hearing 
impairments.  Likewise, Section 508 of the Rehabilitation Act, 
added in 1986, requires federal agencies to provide workers 
equivalent access to electronic office equipment.  Large 
purchases of access-related equipment, especially computers, by 
the federal government will serve as a catalyst for the 
accelerated development, manufacturing and
marketing of accessible and adaptable office automation systems 
in the private sector.

Incentives to potential financiers are found in the federal tax 
code, including the Targeted Job Tax Credit program, which 
employers can use to finance job related assistive technology.  
The charitable contributions provision in the Tax Code is also an 
incentive for donations to charitable organizations that finance 
assistive technology for individuals.

6.   State Flexibility

For some federal programs, such as those administered by the 
Department of Veterans Affairs, Medicare, and SSDI benefits, 
analysis of state flexibility is not a critical variable.   
Although some regional differences may be observed, these are 
federal programs that finance assistive technology directly to 
individuals rather than provide funding to the states for such 
purposes.  Other federal programs are considered to be 
federal-state partnerships or, from the state perspective, 
state-federal.  Programs such as Medicaid, vocational 
rehabilitation (VR) programs authorized under Title I of the 
Rehabilitation Act, and Children with Special Health Care Needs, 
have considerable state flexibility.  For instance, although a 
core set of eleven Medicaid services is mandated, states have 
flexibility in the amount, scope and duration of coverage (e.g., 
number of days in the hospital).  States can also determine the 
specifics of eligibility requirements, optional services to be 
covered, including durable medical equipment, occupational, 
physical and speech/language therapy provision and provider 
qualifications.

States have great flexibility in many programs regarding their 
level of contribution.  Even in some programs with state match 
requirements, such as the Vocational Rehabilitation and Maternal 
Child Health Care (MCH) block grant programs, there is no federal 
mandate that the entire federal share allocated to the state be 
matched and therefore available to the residents in that state.

Some programs illustrate a mix of federal mandates and state 
flexibility;  e.g., the IDEA Part H program for infants and 
toddlers with disabilities includes stringent timelines, 
requirements for program components, and eligibility requirements 
in relation to age (i.e., birth through age two), as a condition 
of acceptance of federal Part H funds.  Also, infants and 
toddlers in states that
accept a fifth year of funding become entitled to services 
defined in the individualized family services plan.  At the same 
time, states have great flexibility in the scope and organization 
of services, their inclusion of infants and toddlers at risk of 
developing disabilities, and the use of fee schedules based on 
ability to pay.

Table 1 summarized the various kinds of state flexibility in 
program implementation found in the federal programs reviewed.  
There is also some indication that Congress has moved to limit 
state flexibility to some extent over the past few years.  
Examples include the expansion of mandatory coverage of low 
income women and children in the Medicaid program in OBRA 1989 
and OBRA 1990;  expansion of entitlement to services for children 
participating in the Medicaid Early Periodic Screening, Diagnosis 
and Treatment program to include the full range of Medicaid 
optional services, regardless of the state's individual Medicaid 
plan in OBRA 1990;  and reduction in flexibility in the 
expenditure of federal MCH block grant funds, coupled with new 
planning and reporting requirements in OBRA 1989.

Such actions would reverse the trend of the early 1980s toward 
the new  federalism, exemplified in particular by the 
consolidation of dozens of individual federal health and human 
service programs into seven block grants with maximum flexibility 
for the states in program expenditures, allocations among 
services and populations, and planning, and minimum federal 
requirements for block grant applications and reports on the use 
of federal funds.  At the present time it is too early to know if 
the 1990s will bring a resurgence of federal mandates on  how 
states may expend federal funds.

A recently announced position of the National Governors' 
Association (NGA) indicates that states are strongly opposed to 
new mandates, especially in the Medicaid program, and would 
prefer some recent enactments be rolled back.  For example, a 
news release describes requests to Congress "to delay the 
mandatory implementation of the 1990 package of Medicaid mandates 
for two years" (Feb., 1991).

In this broad overview of federal program characteristics, the 
analysis of coverage of assistive technology services and devices 
cuts across factors of targeted age and population groups, 
traditional notions of federal-state partnerships, all 
environments (home, school, work and community), and diverse 
approaches and definitions to document need. 

The greater the understanding of individual federal programs and 
the relationships between programs, the easier it is to chart an 
approach to assistive technology access that responds to 
individual and system needs.
SECTION IV.  PROFILES OF INDIVIDUAL FEDERAL PROGRAMS

The program profiles include a brief description of federal 
policy goals, target population and eligibility criteria, program 
magnitude, procedures for the financing of assistive technology, 
and the degree and scope of state flexibility in program 
implementation.  Additional information is provided as 
appropriate on such areas as case law that has refined program 
implementation and current federal initiatives, followed by 
perspectives on facilitators and barriers.

The descriptive information is based primarily on written sources 
on federal legislation and has been verified whenever possible 
with the respective federal agency.  The information on 
facilitators and barriers reflects multiple perspectives on 
program features and policies, including the perspectives of 
people with disabilities as well as advocates, researchers, state 
officials, and federal agency representatives.  Where found, lack 
of consensus is indicated.


I.   TITLE XVIII OF THE SOCIAL SECURITY ACT:  MEDICARE 

A.   Background

The Medicare program was established by Congress in 1965 with the 
enactment of title XVIII of the Social Security Act.  Medicare is 
a federal entitlement program which provides payment for certain 
medical services for three groups: (1) Social Security 
beneficiaries who have reached age 65, (2) working-age persons 
who are eligible for Social Security Disability Insurance (SSDI), 
and (3) persons with end-stage renal disease, the only 
disease-specific entitlement.  In 1990, Medicare covered 30.9 
million persons 65 years and over, and 3.3 million working-age 
persons with disabilities.

Medicare consists of two separate but complementary insurance 
programs, a Hospital Insurance program, known as Part A, and a 
Supplementary Medical Insurance program, known as Part B.  Part A 
covers hospitalization as well as services provided by skilled 
nursing facilities, home health agencies and hospices.  Part B 
covers a wide range of medical services and supplies including 
physician services, outpatient hospital services, comprehensive 
outpatient rehabilitation facilities, outpatient physical therapy 
and occupational therapy services, certain home health services, 
certain drugs and biologicals that cannot be self-administered, 
diagnostic x-ray and laboratory tests, ambulance
services, and purchase or rental of durable medical equipment, 
prosthetic devices, orthotic devices, and certain medical 
supplies.

The original intent of Congress was that Medicare would provide 
health insurance to protect the elderly from the substantial 
costs of acute health care services, which principally came from 
hospital care.  At that time, the majority of Americans who had 
any private health insurance were covered for hospitalization 
only.  The Medicare statute adopted a very restrictive definition 
of health care which emphasizes acute care hospitalization and 
physician services, even though a majority of Medicare 
beneficiaries have chronic health care conditions.  Medicare 
continues to exclude coverage for items or services which are not 
considered "reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a 
malformed body member."

Medicare is the single largest health insurance program in the 
country.  It accounted for $108.9 billion out of $585.3 billion 
in total personal health care expenditures in 1990 according to 
HCFA's Office of National Health Statistics. (Health Care 
Financing Administration, Office of National Health Statistics, 
1991).  Meanwhile, all of private health insurance contributed 
only $186.1 billion or less than one-third of total personal 
health care expenditures in 1990, among all self-insured 
employers and 1500 private health insurance companies.  Because 
of the size of Medicare, and the fact that it is administered 
through private health insurance companies, the Medicare program 
has a major influence on the policies and practices of private 
health insurance.  Because government is the largest third party 
payer for health care services, and Medicare represents almost 
two-thirds of Federal government expenditures for personal health 
care, there is tremendous pressure on Medicare to contain health 
care costs.

According to the Congressional Budget Office (CBO) baseline 
projections, Medicare payments go primarily to hospitals and 
physicians.  In 1990, 51.8 percent of total Medicare payments 
went to inpatient hospital care ($56.8 billion), 24.1 percent 
went to physicians ($26.4 billion) and 7.6 percent went to 
outpatient hospital services ($8.3 billion).  Meanwhile, DME 
suppliers received only $1.5 billion or 3.5 percent of Medicare 
Part B payments in 1990.  CBO estimates that Medicare 
expenditures for DME under Part B will expand to $2.7 billion by 
1996, accounting for only 3.2 percent of projected Part B 
outlays. (U.S. House of Representatives, Committee on Ways and 
Means, 1991).

Responsibility for administration of the Medicare program rests 
with the Health Care Financing Administration (HCFA) within the 
Department of Health and Human Services (DHHS).  HCFA contracts 
with private health insurers to administer Medicare.  Part A 
contractors are called fiscal intermediaries and Part B 
contractors are called Medicare carriers.  Blue Cross-Blue Shield 
companies serve as 41 out of 48 fiscal intermediaries for 
Medicare, and 26 out of 34 Medicare carriers throughout the 
country.  Medicare contractors have jurisdictions which 
correspond to regional, state-wide, or sub-state boundaries.  The 
fiscal intermediaries and carriers are responsible for: (1) 
determining the eligibility status of a Medicare beneficiary; (2) 
determining whether the services on submitted claims or bills are 
covered under Medicare; (3) determining the allowable charges 
based on the services provided; and (4) making correct payment to 
the beneficiary, physician, provider, or supplier of services.

Eligibility for Medicare depends on age and on disability status.  
Persons 65 and over are entitled to Part A of Medicare as a 
result of their Social Security contributions through a payroll 
tax on their earnings when they were employed.  Persons eligible 
for Part A are also eligible for Part B of Medicare if they pay a  
monthly premium of $29.90 in 1991 and are subject to a $100 
annual deductible, and a 20 percent coinsurance rate.  The 
Hospital Insurance (HI) Trust Fund (Part A) is financed primarily 
through the Social Security payroll (FICA) tax on Social 
Security-covered earnings which currently represents 1.45 percent 
of earnings each contributed by employee and employer.  The 
Supplemental Medical Insurance (SMI) Trust Fund (Part B) is 
voluntary and is financed partly from premiums paid by Part B 
enrollees and partly from general revenues.  Congress sets 
premium levels to generate approximately 25 percent of total Part 
B Trust Fund outlays with the rest financed by general revenues.
  
Although Medicare originally covered only persons aged 65 and 
over, the 1972 amendments to the Social Security Act (P.L. 
92-603) extended coverage to persons entitled to Social Security 
benefits because of their disability and to certain individuals 
with end-stage renal disease.  Persons over 18 years old with 
disabilities who are unable to work and are totally financially 
dependent on their parents may become eligible for SSDI if their 
parents are Social Security beneficiaries who have retired, died, 
or become disabled.  However, Medicare eligibility for persons 
under age 65 with disabilities requires a two-year waiting period 
between becoming eligible for Social Security Disability 
Insurance (SSDI) and becoming entitled to receive Medicare 
benefits.  The waiting period was imposed for cost-containment 
purposes and to avoid duplication of private
coverage, although it appears that as many as one-third of new 
SSDI beneficiaries are uninsured at some time during their 24 
month waiting period for Medicare.

B.   Financing Assistive Technology

Medicare makes a larger contribution towards DME than private 
health insurance but considerably less than out-of-pocket 
payments.  According to HCFA's Office of the Actuary, Medicare 
accounted for 17.8 percent of expenditures for DME in 1990 
compared to only 10.4 percent for private health insurance, while 
out-of-pocket payments accounted for 67.3 percent of expenditures 
for DME. (Health Care Financing Administration, Office of 
National Health Statistics, 1991)

Reflecting the acute care bias in Medicare's coverage criteria, 
most of the DME which Medicare pays for includes equipment which 
is required for breathing, ingestion, elimination, and 
ambulation.  A recent DHHS Fact Sheet provided the following 
break-down of Medicare expenditures for DME in 1990:

                           Expenditures
                     (in millions of dollars)

     DME & Supplies
          Inexpensive DME                   136  (6.9%)
          Frequently Maintained DME         74  (3.7%)
          Oxygen                            680 (34.4%)
          Rental DME                        346 (17.5%)
          ESRD Supplies                     3  (0.2%)
          ESRD Equipment                    25  (1.3%)

     Prosthetics and Orthotics              371 (18.8%)
     
     Parenteral and Enteral Feeding         340 (17.2%)

     TOTAL                                  1,975 (100%)

Based on these Medicare expenditures, oxygen and tube feeding 
account for over 50 percent of DME expenditures with prostheses 
and orthotics bringing the total up to 70.4 percent.  Rental DME 
(which is likely to be used
disproportionately by persons without permanent disabilities), 
brings the total up to 87.9 percent.  Only 3.7 percent goes for 
expensive equipment (over $150) which requires frequent 
maintenance, 6.9 percent goes for inexpensive DME (under $150) or 
equipment which is generally purchased by the Medicare 
beneficiary, and 1.5 percent goes for the life-supports of 
End-Stage Renal Disease.  

Medicare Coverage Criteria:  Medicare will pay for assistive 
technology if it meets certain Medicare coverage guidelines.  The 
primary statutory basis for Medicare coverage decisions appears 
in section 1862(a) of the Social Security Act, which prohibits 
payment under the Medicare program for any expenses incurred for 
services "which are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member."  Assistive technology 
which is to be covered by Medicare would have to meet three 
criteria: (1) impairment must be based on illness, injury, or a 
malformed body member; (2) the purpose of the device must be 
diagnosis, treatment, or improvement in functioning; and (3) the 
treatment must be "reasonable and necessary".  

The first criterion would eliminate persons from seeking 
treatment for conditions which were not caused by illness, 
injury, or a malformed body member.  Since all disabilities can 
be attributable to one of these causes, this requirement does not 
restrict coverage for DME.  The second criterion clarifies that 
the device can fulfill one or more specific purposes including 
diagnosis, treatment, or improvement in functioning.  The third 
criterion indicates that the device must be "reasonable and 
necessary". Equipment is considered "necessary" when it can be 
expected to make a meaningful contribution to the treatment of 
the patient's illness or injury or the improvement of one's 
malformed body member.  Equipment is considered "reasonable" if 
the expense of the item is proportionate to the expected 
therapeutic benefit.

In the Medicare Coverage Issues Manual, HCFA describes whether 
certain specific medical items, services, treatment procedures, 
or technologies can be paid for under Medicare.  This is followed 
by a DME Reference List which is designed to be used by Medicare 
carriers and intermediaries as a quick reference tool for 
determining the coverage status of certain pieces of DME (see 
Appendix A for DME Reference List from Medicare and Medicaid 
Guide, Section 27,221, pp. 9301-9308).  The DME reference list 
includes a brief explanation of why specific types of equipment 
are not covered.  Many items
are listed as "deny" because they are viewed as "comfort or 
convenience items" or "not primarily medical in nature".  HCFA 
cites the statutory authority of Section 1861(n) of the Social 
Security Act for this determination of "not primarily medical in 
nature".  However, this short section of the Social Security Act 
provides no definition of durable medical equipment.  Instead the 
Medicare statute describes "Durable Medical Equipment" by 
providing a list of only four types of DME.   The first two types 
of DME which are listed in the Medicare statute are iron lungs 
and oxygen tents which are practically never used any more.  The 
other two types of DME are hospital beds and wheelchairs.  While 
this outdated and incomplete list of DME reflects the types of 
DME that were common when the Medicare statute was passed in 
1965, it does not provide a reasonable basis for determining 
which types of DME should be covered by Medicare in the 1990s.  

In addition to rapid changes in medical technology, there has 
been a significant shift in the concept of health from an acute 
care model to a chronic care model.  In the acute care model, 
health is defined as the absence of disease or impairment, while 
in the chronic care model health is defined as managing chronic 
health conditions to maximize the capacity to participate as 
fully and independently as possible.  This evolution in the 
concept of health also reflects a shift in the disability 
paradigm from segregation and dependence to community integration 
and independent living.

HCFA Regulations for DME:
Although DME is not defined in the Medicare statute, HCFA has 
defined it in regulations (Medicare Part B Coverage, Section 
3144, Medicare and Medicaid Guide).  There are four 
characteristics which must all be met before assistive technology 
can be defined as "durable medical equipment" according to HCFA.  
One criterion is that the equipment "can withstand repeated use".  
A second criterion is that the device must be "primarily and 
customarily used to serve a medical purpose".  A third criterion 
is that the device is "generally not useful to a person in the 
absence of an illness or injury".  The fourth criterion is that 
the equipment is appropriate for use in the home.

On the basis of these four criteria for DME which HCFA has 
determined in regulations, many claims for assistive technology 
are denied by Medicare carriers.  These requirements arbitrarily 
exclude many types of assistive technology that meet the basic 
Medicare statutory requirements for Medicare coverage.  Secondly, 
it appears that current Medicare coverage policy is highly
inconsistent in what types of equipment Medicare will and will 
not pay for.  And thirdly, it appears that HCFA has created 
specific criteria which exclude many types of DME that meet the 
statutory requirements for Medicare coverage.


Problems with HCFA's Arbitrary Definition of DME:

A. Can withstand repeated use:
The requirement that DME can withstand repeated use was 
originally made because of its bearing on the rentability of 
equipment.  When Medicare began in 1965, all DME was arranged for 
on a rental basis.  For many types of DME which are normally 
purchased now, this characteristic is less important.  Moreover, 
the distinction between DME and disposable medical supplies is 
not problematic because Medicare covers many types of disposable 
medical supplies (such as catheters, ostomy supplies, and 
bandages anyway. 

B. Is primarily and customarily used to serve a medical purpose:
The second requirement that the device must be "primarily and 
customarily used to serve a medical purpose" is much more 
problematic for two reasons.  Instead of recognizing the three 
medical purposes of diagnosis, treatment, or improvement in 
function which are contained in the Medicare statute, the 
definition of DME which HCFA has adopted introduces a false 
dichotomy between medical purpose and functional purpose. 

HCFA has chosen to define what is a "medical purpose" and whether 
equipment is primarily used for that medical purpose.  Reflecting 
an historic acute care bias in the health care system, HCFA has 
narrowly defined medical purpose to mean the life sustaining 
functions of breathing, eating, elimination, and ambulation and 
the services which are performed by physicians.  This narrow 
interpretation of the meaning of "medical purpose" assumes that 
most people with disabilities are sick and require the expertise 
and supervision of a physician to be appropriately treated.  

One consequence of this arbitrary interpretation of "medical 
purpose" is that many types of assistive technology are not 
covered by Medicare even though they could enhance an 
individual's functioning by substituting for a malfunctioning 
body part.  HCFA contends that section 1861(n) of the Social 
Security Act does not permit coverage of every item that could be 
useful to a
person with a medical problem, even if the item is prescribed by 
a physician.   

A classic example of DME which HCFA has decided not to cover is 
an augmentative communication device which could enable a person 
with a speech disability to speak, but which HCFA views as a 
convenience item. Medicare will pay for an artificial larynx 
which replaces a surgically removed voice box, but will not pay 
for an augmentative communication device which substitutes for 
the function of malfunctioning vocal cords because speech is not 
a body part (see below). 

In contrast to augmentative communication devices, wheelchairs 
have always been covered as DME by Medicare because they enable a 
person who would otherwise be confined to a bed or chair to get 
around.  There appears to be some recognition that there are 
negative health consequences to being confined to a bed or chair.  
HCFA apparently does not think that there are negative health 
consequences to not being able to speak, given HCFA's acute care 
definition of health.  

HCFA has also denied coverage for assistive technology, like 
safety aids, which could prevent acute care needs, if it does not 
require the involvement of medical personnel and is not part of 
an active medical treatment plan.  This is illustrated below in 
the case of an extendable hand-rail system which would enable a 
person with a disability to climb stairs without falling.  

C. Generally is not useful to a person in the absence of illness 
or injury:

Another requirement for durable medical equipment is that it 
"generally is not useful to a person in the absence of illness or 
injury".  As a result, HCFA has excluded environmental control 
units from Medicare coverage on the grounds that they are a 
"convenience item".  Instead of recognizing how environmental 
control units can assist a person with a disability to control 
their environment, HCFA has held that they do not meet the 
requirement that they are useful only to a person with an illness 
or injury even if they have "some remote medically related use" 
for a person with an illness or injury.  In a frequently cited 
example of "Equipment Presumptively Nonmedical" from HCFA's 
Medicare Carriers Manual (Section 2100.1(B)(2), HCFA explains 
that Medicare would not pay for an air conditioner for a cardiac 
patient who needs an air conditioner to lower room temperature 
because an air conditioner could also be used by a person without 
a medical condition. "(I)n the case of a cardiac patient, an air
conditioner might possibly be used to lower room temperature to 
reduce fluid loss in the patient and to restore an environment 
conducive to maintenance of the proper fluid balance.  
Nevertheless, because the primary and customary use of an air 
conditioner is a nonmedical one, the air conditioner cannot be 
deemed to be medical equipment for which payment can be made."  
This rationale, perhaps more than any other, belies the 
unwillingness of Medicare to actually consider whether a specific 
service or device would have a beneficial therapeutic effect on 
an individual Medicare beneficiary.  By denying that 
thermo-regulation is a medical need, HCFA invites specialized 
equipment to be marketed for this purpose to replace the easy 
adaptation of a lower cost air conditioner.  This section of the 
Medical Carriers Manual which is cited routinely to deny coverage 
for DME today was last revised in 1978.

Medicare ignores the difference between a convenience item for a 
person without a disability and what is a functional necessity 
for fulfilling a medical purpose for a person with a disability.  
For example, one type of assistive technology is a 
voice-activated switch (called "Butler in the Box") which could 
enable a person who is quadriplegic due to a spinal cord injury 
to meet his or her ADL needs independently in his or her own 
home.  Medicare would tend to treat this voice-activated switch 
as a convenience item for the person with a spinal cord injury 
because it would be a convenience item for a person without 
functional limitations.

D. Is appropriate for use in the home:
This criterion has been interpreted by HCFA as a way of limiting 
coverage for assistive technology that Medicare beneficiaries may 
require to function both in and outside their home.  HCFA 
regulations require that Medicare will only cover equipment which 
is needed within the home.  While Medicare will pay for a manual 
wheelchair for a person who would otherwise be confined to a bed 
or chair, Medicare will only pay for a power wheelchair for a 
person who cannot operate a manual chair in his or her own home.
Many persons who require power-wheel chairs to move about in the 
community are denied coverage for power wheel chairs unless they 
also need them in their homes.  This regulation fails to 
recognize that many people who cannot walk are not home-bound and 
that they have mobility needs in the community as independent 
participating members of society.  If the person is not 
home-bound, there is no reason for health related assistive 
technology to be home-bound.  

Another example of arbitrary barriers being imposed by HCFA 
regulations
involves eligibility for portable oxygen equipment.  While no one 
would suggest that dependence on a respirator or ventilator is 
not medically necessary, HCFA has recently implemented a 
regulation since December 1, 1991, that requires a physician to 
document the need for portable oxygen in the home.  This is 
designed to ensure that Medicare does not pay for portable oxygen 
unless the physician can explain the medical therapeutic purpose 
to be served which cannot be met by a stationary system, e.g. a 
patient's need to ambulate beyond 50 feet of tubing of the 
stationary equipment.     

Problems with Medicare's definition of prosthetic devices and 
orthotics

The Medicare statute provides an arbitrary definition of 
prosthetic devices as "devices which replace all or part of an 
internal body organ" (Sec. 1861(s)(8).  This definition also 
reflects the acute care bias in the health care system in 1965 
when Medicare was passed.  HCFA has used this definition of 
prosthetic devices to deny coverage for certain devices which 
enhance the functioning of a malfunctioning body part if it has 
not been removed from the body.  This latter distinction may be 
relevant to the role that a physician must play in removing a 
malformed or malfunctioning body part, but it is irrelevant to 
the use of many types of prostheses which can improve functioning 
without physically replacing the malformed or malfunctioning body 
part.

The National Council on Disability (NCD) was pleased that the 
Director of Medicare's Office of Coverage and Eligibility Policy, 
Robert E. Wren, indicated in a letter to George H. Oberle, 
Chairman of NCD's Committee on Technology, received on March 3, 
1992, that HCFA would pursue the possibility of implementing one 
of NCD's initial recommendations to re-interpret the meaning of 
replacement of a body organ in the Medicare definition of covered 
prosthetic device.  NCD had recommended that HCFA interpret the 
Medicare statute to cover prosthetic devices that reflect 1990's 
best practice and state of the art by including "improvement in 
the function of a malfunctioning body organ or substitute for a 
neurological dysfunction."
 
As with DME, the Medicare statute does not provide a definition 
of orthotic devices but offers instead a representative list 
including leg, arm, back, and neck braces, and artificial legs, 
arms, and eyes (section 1861(s)(9) under the description of 
"medical and other health services".  In a separate section on 
"Exclusions from Coverage", the Medicare statute lists the 
following examples: "personal comfort items", eyeglasses, hearing 
aids, and orthopedic shoes
(section 1862(a).

Special Exception Items
HCFA includes a section in the Medicare Carriers Manual called 
"Special Exception Items" which explains that "specified items of 
equipment may be covered under certain conditions even though 
they do not meet the definition of DME" because they are not 
primarily and customarily used to serve a medical purpose and/or 
are generally useful in the absence of illness or injury.  
According to the Medicare Carriers Manual, "These items would be 
covered when it is clearly established that they serve a 
therapeutic purpose in an individual case..."  However, HCFA has 
interpreted these exceptions as applying only to gel pads and 
heat lamps.  In a qualifying note, HCFA insists that "(T)he above 
items represent special exceptions and no extension of coverage 
to other items should be inferred."  The last time this section 
was revised was in 1975!

Medicare Carriers determine what is "reasonable and necessary":

It is the responsibility of Medicare carriers to decide whether 
specific claims are "reasonable and necessary" according to 
Medicare guidelines.  These determinations are supposedly based 
on the medical documentation supplied by a physician and by 
rehabilitation professionals which contain information on: (1) 
medical diagnosis, (2) reason the equipment is needed, (3) 
patient's prognosis, and the (4) estimate of the duration of 
need.  Where national policies exist, the Medicare carriers are 
obligated to enforce those policies.  In the absence of national 
policy, however, individual Medicare carriers have some 
discretion in determining what is "reasonable and necessary" in 
consultation with its medical staff, and with HCFA, when 
appropriate, based on the law, regulations, rulings, and general 
program instructions.

DME claims are more complex to process than other types of claims 
for physician or laboratory services because of the labor 
intensive nature of reviewing the documentation of medical 
necessity.  Moreover, claims for DME and prosthetics, orthotics, 
and medical supplies (referred to as DMEPOS) represent only about 
5 percent of most Medicare carriers' workload (cited in HCFA 
Proposed Rule for Carrier Jurisdiction for Claims for DME, 
Prosthetics, Orthotics and Supplies, and Other Issues Involving 
Suppliers, August 23, 1991, p. A15).  According to HCFA, "Only a 
few large carriers have the claims volume to justify establishing 
special processing units or undertaking the
extensive training needed to develop expertise in pricing claims 
and establishing comprehensive medical review guidelines.  Most 
carriers find it inefficient to devote significant resources to 
the relatively few claims they process."  

As a result, Medicare carriers typically use the Medicare 
guidelines as an excuse for not considering whether equipment 
serves a "therapeutic purpose in an individual case".  Even 
though physicians are asked to provide medical documentation of 
medical necessity, the Medicare carrier may dismiss a claim on 
the basis of certain types of equipment being "presumptively 
non-medical".  These may include equipment which basically serves 
comfort and convenience functions such as elevators, stairway 
elevators, physical fitness equipment, self-help devices (e.g. 
safety grab bars) and training equipment (e.g. speech teaching 
machines).  

Case Study: Extendable Handrail as DME

To examine the limitations of the Medicare program, researchers 
focused on a case in Minnesota which came to our attention during 
one of the NCD regional forums.  This case revealed many of the 
obstacles to coverage based on an acute care oriented definition 
of medical necessity.  (See Appendix B for record of the case 
concerning an extendable handrail system manufactured by the St. 
Croix Railing Company).

The St. Croix Railing Company in Minnesota developed an 
extendable handrail device to provide support and balance to a 
person who has difficulty walking up a stairway.  The extendable 
handrail device pivots out from the wall to within 22 inches of a 
fixed hand rail on the opposite side creating a "walker like" 
dual hand rail system that enables persons with diminished 
physical capacity to use stairs more frequently and without fear 
of falling.  The total cost of the device for purchase and 
installation is approximately $1400 for which Medicare would be 
expected to pay 80% ($1120).  The extendable hand rail can be 
very useful to frail elderly persons as well as to persons with 
early multiple sclerosis, muscular dystrophy, arthritis, stroke, 
trauma, and other physical disabilities.  This system was 
developed with the assistance of two grants from the Department 
of Health and Human Services and has been approved for use by the 
Veterans Administration and has been used by Workers 
Compensation.
                         [Insert Photo]
     
As the distributor for the extendable handrail system, Becklund 
Health Care
Supplies, Inc. has tried to get Medicare to pay for the purchase 
and installation of the extendable hand-rail device in the home 
of a Medicare beneficiary who has had difficulty climbing stairs.  
The Medicare beneficiary has osteoarthritis, and has a steel rod 
in her leg to the hip that makes it impossible to bend the knee 
without a support.  She lives alone in the two-story home which 
she has lived in for 22 years with the only bathroom and bedroom 
on the second floor.  The Medicare beneficiary needs the 
extendable handrail device to transfer between floors which is 
necessary to carry on activities of daily living.  In addition, 
her treating physicians say she needs the handrail system to 
strengthen her legs, and the physical therapist explained that 
the extendable handrail was needed to enable the Medicare 
beneficiary to get exercise which she needs to reduce 
hypertension and to build cardiac vascular strength.

The Medicare carrier has continued to ignore the medical and 
rehabilitation potential of the extendable handrail system for 
this specific Medicare beneficiary because HCFA's general 
guidelines for DME suggest that an extendable hand rail is a 
comfort or convenience item and therefore does not serve a 
medical purpose. (cite Robert Wren's letter received November 
1989 in Appendix).  Interestingly, Medicare covers such assistive 
technology as canes, crutches, walkers, and wheelchairs if a 
Medicare beneficiary has a condition which impairs ambulation, 
but is denying coverage for an Extendable Handrail which promotes 
mobility and independence at home.

Instead of assessing the claim based on the extensive medical 
documentation provided by the Medicare beneficiary's physicians 
and physical therapist, the Medicare carrier has persisted in its 
view that an extendable handrail is more like safety grab bars or 
a stairway elevator which is presumptively non-medical equipment 
than it is like a walker which is covered by Medicare.
 
After over a year of rejections and appeals, the Medicare carrier 
finally admitted that they had misplaced the medical records but 
they continue to reject the claim which is now scheduled for an 
Administrative Law Judge review.  The Medicare carrier claims 
that their hands are tied because of the HCFA guidelines, while  
HCFA claims that the decision is up to the Medicare 
carrier.(include letter in Appendix).

This case reveals several substantive policy issues:  One is that 
the Medicare carrier did not complete an individual analysis of 
medical necessity to determine the therapeutic purpose of a piece 
of equipment because it was judged to be
disqualified by HCFA's regulatory guidelines for non-medical 
equipment.  Second, Medicare is unwilling to recognize that the 
extendable handrail has both practical and therapeutic purposes 
that are useful for both comfort and safety and for a medical and 
rehabilitation needs.  Third, Medicare is non-responsive to the 
needs of this Medicare beneficiary for assistance with changing 
elevation levels which permit her to maintain independence and 
continue to reside in her home and carry on with activities of 
daily living.  Medicare appears oblivious to the fact that 
keeping people autonomous in their own homes is less expensive 
than keeping them in nursing homes.  Fourth, instead of assessing 
the medical purposes for a person's need, the function of the 
Medicare carrier seems to be to find a precedent that can be 
cited to justify denial of equipment as non-medical in nature.  
Fifth, the appeal process can be dragged out by the Medicare 
carrier over a very long period of time without being publicly 
accountable for misplacing records or for contracting with a 
lawyer who the Medicare carrier uses for all of their so-called 
Fair Hearings.  Sixth, the Medicare regional office provides no 
oversight to inappropriate claims processing or other 
questionable hurdles at the Medicare carrier level.

HCFA coverage criteria are inconsistently applied:
HCFA continues to maintain a false dichotomy between medical 
purpose and functional purpose which allows it to limit coverage 
for certain types of DME that do affect health.  Some types of 
DME which are viewed as medically necessary do not in fact cure a 
condition but are considered necessary only because they improve 
function.  For example, a wheelchair is considered "presumptively 
medical" by HCFA because it improves the "function" of nonworking 
body parts even though it will not affect the course of a 
person's cerebral palsy, stroke or ALS.  The Medicare standard is 
supposed to be that equipment is necessary when it can be 
expected to make a meaningful contribution to the treatment of 
the patient's illness or injury or to the improvement of his 
malformed body member.  However, this standard is often applied 
arbitrarily.  

If gangrene requires amputation of a limb, Medicare would pay for 
a prosthesis even though the prosthesis would have no relation to 
the illness or disease, and the body part was not malformed.  In 
addition, Medicare covers other services such as pain medication, 
palliative care, and occupational therapy which also do not cure 
conditions but promote function.  However, Medicare will not pay 
for many types of assistive technology which can improve function 
without replacing a malformed body part.

Medicare refuses to cover augmentative communication devices even 
though they meet all four of HCFA's criteria for DME.  Clearly, 
they can withstand repeated use.  Secondly, they are used 
exclusively to serve a medical purpose: to improve the functional 
abilities of a person with a significant communication 
disability.  HCFA may argue that the content of the speech 
determines whether it should be regarded as "medical", but this 
excuse has been thoroughly exhausted under Medicaid.  Thirdly, 
augmentative communication devices serve no purpose for people 
who do not have a significant communication disability.  There is 
no reason why a person without a speech disability would consider 
using an augmentative communication device.  And fourthly, they 
are appropriate for use in the home.  

The reason that HCFA offers to deny coverage for augmentative 
communication devices is that speech is a "convenience" rather 
than a medical necessity.  This can be challenged on the grounds 
that speech can facilitate communication with one's physician.  
One can also suggest that enabling a person to speak can increase 
a sense of well-being, reduce frustration, and increase 
self-sufficiency all of which are likely to have a positive 
impact on one's health.  One can also go back to the Medicare 
statute and see that an augmentative communication device is 
designed to improve the functional abilities of a person with a 
severe communication disability resulting from an illness, 
injury, or malfunctioning of a body member.  Although the 
augmentative communication device does not replace the body 
member, it certainly substitutes for the function of a body organ 
which is what a prosthesis is. 

Many types of durable medical equipment which Medicare has always 
covered do not in fact treat conditions but only increase 
function.  This is true of limb prostheses as well as of 
wheelchairs.  Some mobility aids, like scooters, that Medicare 
covers as DME, could be regarded as convenience items for people 
without disabilities, but Medicare recognizes that they are more 
than convenience items for persons who cannot walk.  A wheelchair 
does not replace legs, but it replaces the function of legs by 
enabling a person without control of his or her legs to move.  If 
Medicare was consistent in holding that the ability to speak is a 
convenience, why would it pay for an artificial larynx even if it 
met the definition of a prosthesis?  Sound public policy cannot 
allow HCFA to continue to treat speech as a medical necessity 
when the vocal cords have been removed while treating speech as a 
convenience when the vocal cords do not work due to neurological 
reasons.

HCFA Initiatives

Although DME costs are less than 2 percent of total Medicare 
expenditures, HCFA has focused on cost containment strategies in 
the DME area.  These initiatives have been undertaken in response 
to complaints that DME suppliers have developed marketing and 
billing strategies to maximize profits and have not always 
provided beneficiaries with quality items and service.  Many of 
these complaints involve taking advantage of the "point of sale" 
system which HCFA created through which DME vendors have 
incentives to structure their business so that they operate 
within the area of a carrier with the most favorable 
interpretation rules, utilization screens, local medical review 
policy, or pricing for their products.  OBRA 1990 has authorized 
HCFA to based reimbursement on the rates established where the 
Medicare beneficiary resides. 

Supplier standards

Most of the 48,000 suppliers of durable medical equipment who 
Medicare beneficiaries depend on for life-saving and functional 
enhancing equipment are not subject to state licensure laws, 
quality assurance standards, or other similar criteria typically 
required of health organizations and professionals.  Medicare 
carriers have issued provider numbers to regulate who would be 
eligible to bill Medicare, but these provider numbers have not 
been allocated on the basis of any uniform national criteria to 
ensure appropriate business practices or quality standards for 
the DME.  According to HCFA, many DME suppliers actually perform 
no supplier functions but contract with other suppliers to 
perform their marketing, order taking, and servicing, in effect 
"buying" Medicare claims at face value and inflating the amounts 
they bill to Medicare in order to make a profit.  On the other 
hand, some centralized providers of specialized equipment have 
been unable to bill Medicare when they could not obtain a 
provider number because they did not have a local office in a 
specific Medicare carrier's jurisdiction.  

On November 6, 1991, HCFA issued a proposed rule (Federal 
Register, Vol. 56, No. 215m po. 55612) regarding DME claims 
payments to initiate a national system based on minimum standards 
for suppliers that is supposed to reduce fraud and abuse.  Before 
a billing number could be issued, DME suppliers would have to 
disclose the identity of any person who has an ownership or 
control interest in the DME supplier and in any health care 
provider receiving Medicare reimbursement.  This is designed to 
identify conflicts of interest
between DME suppliers and providers of services and among DME 
suppliers that may affect how they operate.  In addition, DME 
suppliers would be required to maintain a complaint log 
describing all complaints regarding delivery of Medicare covered 
items to Medicare beneficiaries, and keep a record of any 
warranties honored, repairs to rented equipment, and acceptance 
of returns of substandard and unsuitable items from Medicare 
beneficiaries.  These records would be reviewed periodically by 
Medicare carriers to determine whether the DME vendors should be 
allowed to re-enroll every 2 or 3 years.  The DME trade 
associations, including the National Association of Medical 
Equipment Suppliers (NAMES), the Home Care Coalition of the 
Health Industry Distributors Association (HIDA), and the Health 
Industry Manufacturers Association (HIMA) have taken a strong 
public stand against potentially fraudulent and abusive practices 
in the home medical equipment (HME) industry which can tarnish 
the reputation of their industry.  HIDA held a consensus 
conference in May 1991 to develop recommendations for DME 
supplier standards for participation in the Medicare program.
  
Certificates of medical necessity

To reduce unnecessary payments for DME, Congress authorized HCFA 
in OBRA' 90 to prohibit DME suppliers from distributing to 
physicians completed or partially completed certificates of 
medical necessity forms (CMNs) that document a patient's medical 
need for specific items of equipment.  Previously, physicians 
were allowed to sign the CMN after DME suppliers, who are more 
familiar with the intricacies of Medicare carrier billing 
requirements, had filled out the form.  Medicare carriers are 
supposed to review CMNs to determine whether a covered item is 
reasonable and necessary for the diagnosis or treatment of 
illness or injury or to improve functioning.  DME suppliers are 
concerned that requiring physicians to complete the new 
certificate of medical necessity will increase unnecessarily the 
physician paperwork burden and potentially disrupt Medicare 
beneficiaries' access to quality home medical equipment products 
and services.  DME suppliers want to be allowed to continue 
writing the appropriate Health Care Products Coding System 
(HCPCS) code directly on the CMN for those items of equipment 
ordered and to include the names of the items of equipment that 
correlate with the HCPCS code.  HCFA has begun requiring 
physicians to complete the CMNs for types of equipment that HCFA 
has identified as "abused or overutilized" including: TENS units, 
power operated vehicles, seat lift chairs, air fluidized beds, 
paraffin baths, and decubitus care pads/mattresses.

Previous investigations by the Office of Inspector General (OIG) 
have undercovered various forms of "fraud and abuse" by DME 
suppliers who had succeeded in marketing various types of DME to 
Medicare beneficiaries.  One type of fraud is advertising that 
Medicare beneficiaries can get Medicare to pay for certain types 
of DME at no cost to the Medicare beneficiary.  Physicians 
reported being pressured to sign the CMN in order to avoid losing 
the patient.

In its 1989 study of "Medicare Coverage of Power-Operated 
Vehicles, the Office of Inspector General (OIG) was concerned 
that more than half of its random sample of Medicare 
beneficiaries who used power-operated vehicles (POVs) that 
Medicare paid for in 1986 reported that they learned about POVs 
through television and other advertising, while thirty-seven 
percent learned about POVs from family, friends, and neighbors.  
Only 6 percent said they learned about POVs from a doctor or 
other medical personnel.  Moreover, three quarters of these 
Medicare beneficiaries said it was their own or their family's 
ideas, not that of a health care professional, to obtain a POV.  
(Office of Inspector General, Medicare Coverage of Power-Operated 
Vehicles, July 1989).

This finding was interpreted by the OIG as an indication that the 
POVs were not medically necessary, rather than that physicians 
are not generally familiar with the most useful types of DME to 
overcome functional limitations.  The OIG reinforced its 
interpretation that the demand for POVs was illegitimately 
generated by aggressive supplier marketing by reporting that 
one-third of the beneficiaries claim they were told they would 
not have to pay anything for the POV.  This, of course, is a 
direct violation of Medicare payment rules where Medicare is 
suppose to pay 80 percent of allowable charges, and suggests that 
the reimbursement rate which Medicare paid in 1986 may have been 
inflated to cover the 20 percent coinsurance which the supplier 
is legally obligated to collect from the Medicare beneficiary.  
Despite this claim, the OIG report actually provided no evidence 
that the POV beneficiaries did not pay the 20 percent 
coinsurance.  Nevertheless, physicians confirmed that they 
generally played a passive role in prescribing POVs often signing 
the authorization after the POVs were delivered in one-third of 
the cases, and having little knowledge of Medicare coverage 
guidelines.  

On the basis of its random sample, OIG estimated that Medicare 
should not have paid for a majority of the POVs it paid for in 
1986.  This was primarily because sixty-two percent of the POV 
beneficiaries reported that they could
operate a wheelchair manually when they obtained their POV, or 
they were using their POV exclusively outside their home in 
violation of the Medicare coverage requirements.  

To reduce inappropriate payments for POVs, the OIG recommended 
that Medicare carriers use medical staff to review each submitted 
POV claim for medical necessity, allow only certain specialists 
to authorize these claims, prohibit payment for DME unless 
suppliers receive a written order from a physician before the 
delivery of the item to the patient, and ensure that payments are 
made only for beneficiaries whose medical and/or physical 
conditions render them unable to use a wheelchair manually and 
who need a POV for indoor use in accordance with Medicare 
guidelines.  HCFA questioned the OIG's estimate of the actual 
amount of inappropriate expenditures for power-operated vehicles, 
but shifted the blame from the Medicare carriers to the 
physicians who had certified that the equipment was medically 
necessary.  This reinforces the acute care medical model.

The General Accounting Office (GAO) has recently recommended that 
physicians be required to provide a narrative justification for 
the DME.  In the few Medicare carriers who they studied, GAO 
researchers found a sharp drop in payments for three types of DME 
when the Medicare carrier required a narrative justification from 
the physician.  (General Accounting Office, Durable Medical 
Equipment:Specific HCFA Criteria and Standard Forms Could Reduce 
Medicare Payments, June 1992).  The study focused on TENS 
devices, power-operated vehicles (POVs), and seat-lift chairs.

HCFA is concerned that narrative justifications from physicians 
may be difficult to process in a system that is moving to 
electronic billing.  Meanwhile, DME vendors are concerned that 
requiring physicians to fill out narrative justifications would 
delay the process of claims submission and discourage physicians 
from prescribing medically necessary DME.  The National Council 
on Disability (NCD) is concerned that many physicians know very 
little about DME.

GAO focused entirely on whether the criteria for medical 
necessity and the documentation requirements for medical 
necessity reduced Medicare payments for DME.  While payments 
dropped precipitously, it was not clear from this study whether 
this occurred chiefly because of a greater rate of denials or 
because of a smaller number of submissions.  More importantly, 
GAO did not
look at whether the criteria of medical necessity prevented 
Medicare beneficiaries from receiving the DME that they needed.  
Finding that Medicare carriers differed in the way they decided 
what DME is medically necessary, GAO estimated that a substantial 
amount of Medicare payments could have been avoided.  What GAO 
did not ask but is the major focus of this Report is whether the 
Medicare criteria for medical necessity are in fact appropriate 
in relation to the Medicare beneficiaries' health care needs.

Consolidation of DME claims processing into four regional DME 
Medicare carriers

HCFA is planning to consolidate all DME claims processing into 
four regional DME Medicare carriers.  On the basis of a Request 
for Proposal which is due in mid-July 1992, the four regional DME 
carriers will be announced in the fall of 1992 and become 
operational in the summer of 1993. 

Consolidation is expected to permit the development of a more 
specialized capacity to process DME claims, and it is also 
expected to create greater uniformity than exists now among the 
34 private insurers who act as Medicare Part B carriers.  
However, this HCFA initiative appears to be developed primarily 
as a strategy to reduce perceived "fraud and abuse" in the 
Medicare DME program.  There has been very little recognition of 
the problems which HCFA's arbitrary definitions of medical 
necessity cause for Medicare beneficiaries.

In the development of standardized medical review policy, 
pricing, and utilization screens, it is imperative that HCFA 
encourage input from Medicare beneficiaries as well as DME 
vendors on the appropriateness of medical necessity criteria 
which will be used by the regional DME carriers.  It would be a 
huge mistake to limit input on utilization screens, medical 
review guidelines, and medical policy to Medicare carrier medical 
directors and medical review staff.

C.   State Flexibility

State government has no role in the administration of Medicare.  
As a federal entitlement to health care, HCFA provides uniform 
standards for administration.  Medicare fiscal intermediaries and 
carriers are charged with the responsibility to assure that 
payments are made only for services that are
covered under Medicare Part A or Part B.  However, since medical 
practice patterns and prices vary throughout the country, the 
Medicare program relies on decentralized decision-making by 
Medicare fiscal intermediaries and carriers to decide when a 
health care technology or service is covered under Medicare. 

The decentralized administration of Medicare through fiscal 
intermediaries and carriers, is sensitive to local variations in 
price and practice patterns.  It also provides some significant 
discretion to Medicare carriers in interpreting standards of 
medical necessity.  While the statutory definition excludes 
coverage for comfort items, the Medicare statute does not make 
the judgment whether a specific device is a convenience or 
medical necessity for a specific person.  

Many items are denied routinely because either they are not 
primarily medical in nature (e.g. they are deemed to be 
educational, environmental control, hygienic, self-help, or 
convenience/comfort items), or they are non-reusable supplies, or 
they are inappropriate for home use.  Sensory and communication 
aids are notable because of their absence from the inventory of 
commonly covered products as are environmental control units, and 
environmental modifications.  The list is only a set of 
guidelines for Medicare carriers and is not legally enforceable.  
In fact, there is room for interpretation of coverage by each 
carrier.

Where a national coverage decision does not exist, Medicare 
contractors have the authority to decide whether the service in 
question appears to be reasonable and necessary for a specific 
individual. Even when a claim for a new, or otherwise 
questionable service is received, the contractor is authorized to 
make reasonable and necessary decisions with respect to the 
service, in the absence of applicable national policy.  These 
decisions are usually made in consultation with the contractor's 
own medical staff and local medical specialty groups.  In fact, 
coverage decisions made by the same contractor may appear to vary 
from claim to claim reflecting relevant differences in the 
circumstances in which the service is furnished or the need of 
the particular beneficiary for that service.  

National Coverage Decisions:
If a contractor cannot resolve a coverage question 
satisfactorily, or believes a national coverage decision may be 
necessary, the issue is referred to HCFA central office through a 
HCFA regional office.  Another source of contractor
referrals is the Coverage/Payment Technical Advisory Group (TAG) 
which is made up of medical directors and other officers of the 
carriers and intermediaries, which meets every six to eight weeks 
with HCFA staff to discuss its experience with various coverage 
and payment issues.  The Bureau of Eligibility, Reimbursement and 
Coverage (BERC) within HCFA may decide to initiate the process 
for a national coverage decision if one or more of the following 
factors is present:

(1)  The service is likely to be used in more than one region of 
     the country.

(2)  The service is likely to represent a significant expense to 
     the Medicare program.

(3)  The service has the potential for rapid diffusion and 
     application.

(4)  There is substantial disagreement among experts regarding 
     the safety, effectiveness, or appropriateness involved in 
     the use of a service.

(5)  The service represents a significant advance in medical 
     science.

(6)  The service represents a new product, that is, a device, 
     drug, or procedure for which there is no similar technology 
     already covered under Medicare.

(7)  The service has been subject to inconsistent coverage 
     decisions by contractors or regional offices and a conflict 
     can only be resolved by a national decision.

(8)  The service that was commonly accepted by the medical 
     profession has become outmoded or otherwise not in the 
     public's interest.

Approximately two hundred national Medicare coverage decisions 
have been made on individual health care technologies since the 
Medicare program was established in 1965.  

When confronted with inconsistent coverage decisions, HCFA 
representatives have on occasion warned that a national decision 
on certain types of assistive technology, such as augmentative 
communication devices, would eliminate the discretion that some 
Medicare contractors have shown toward this assistive
technology.  National coverage decisions would be binding on 
Medicare carriers.  To the extent that various types of assistive 
technology are already viewed as excluded by Medicare statute, a 
national coverage decision by HCFA would not be able to override 
these statutory constraints.  On the other hand, HCFA has imposed 
its own interpretations on the definitions of DME and prosthetic 
devices.
   
There are various steps involved in making a national coverage 
decision.  HCFA has an internal advisory organization composed of 
physicians and other health professionals in HCFA's Central 
Office and counterparts from the Public Health Service called the 
HCFA Physicians' Panel.  This organization meets periodically in 
closed session to consider whether specific coverage decisions 
should be referred to the Public Health Service for an Inquiry or 
a full Assessment. 

Inquiries provide information to HCFA while Assessments provide 
recommendations to HCFA for a coverage decision.  On the basis of 
this information, recommendations, and any other material that 
HCFA deems appropriate, HCFA decides whether to issue a national 
coverage decision which is then included in the Issuances in the 
Coverage Issues Manual and published in the Federal Register.    

Health Care Technology:
HCFA has developed a complex process for approving health care 
technology for Medicare coverage.  Since medical technology is 
the leading contributor to the rise of health care costs 
throughout the health care system, there are some important links 
between HCFA and the Office of Health Technology Assessment 
(OHTA), the Food and Drug Administration (FDA), the National 
Institutes of Health (NIH), and the Centers for Disease Control 
(CDC) in the Public Health Service which have an important role 
in evaluating: (1) safety and effectiveness of medical services, 
(2) experimental or investigational nature of new services, and 
(3) appropriateness of specific services.

While many types of medical technology should be subject to this 
review process, it appears that many types of assistive 
technology do not raise issues of safety or effectiveness.  
Rather, these types of assistive technology raise questions about 
whether they fall within a reasonable interpretation of the 
meaning medical purpose. 

Interestingly, HCFA reports that as many as 65.8 percent of 
Medicare carrier decisions in 1990 which were appealed to 
conclusion are eventually reversed (see Table 48 in 1991 HCFA 
Statistics, p. 41.)  In FY 1991, 63.6% of appeals at the review 
stage, 58.8% of appeals at the fair hearing stage, and 67.0% of 
appeals at the Administrative Law Judge stage, reverse the 
decisions of the Medicare carrier and result in decisions 
favorable to the consumer (Carrier Appeals Report, Fiscal Year 
1991).  However, the number of appeals is a tiny fraction of the 
total number of denials.  The problem is that most people whose 
claims are denied do not have the knowledge or resources to make 
an appeal and therefore do not receive a favorable judgment.  

Payment Policy:  HCFA has developed payment policies for 
different types of DME which attempt to control costs, provide 
access to appropriate equipment, and address the maintenance, 
repair, and replacement needs associated with using DME.  

Medicare payment policy for different types of health care 
services is specified in the Medicare statute (section 1834(a).  
Prior to 1987, DME and prosthetics and orthotics were reimbursed 
on a reasonable charge basis reflecting the average charges in a 
geographical area.  OBRA 1987 eliminated reasonable charge 
reimbursement and replaced it with a fee schedule for all 
suppliers, effective January 1, 1989.  DME is divided into six 
categories (referred to as the six point plan) which stipulate 
the method by which equipment may be acquired (rental, purchase 
or either) and specified how fee schedule payments are to be 
calculated for each category.  Under the fee schedule, payment 
for all affected items is in the amount of a single fee, 
calculated for each item for each carrier area.  Subsequent fee 
increases are limited to annual adjustments based on the Consumer 
Price Index-Urban.  This was revised by OBRA '90 so that 
increases are now based on a factor called a covered item update.
(See Chart 1: Medicare Reimbursement for Durable Medical 
Equipment, pp. 166-167 in 1992 Green Book).

In addition, HCFA is proposing to centralize the processing of 
claims for DMEPOS to four designated Medicare carriers throughout 
the country and to require fees to be based on the location of 
the Medicare beneficiary rather than the point of sale.  Although 
centralization is being introduced to reduce fraudulent and 
abusive marketing practices, it remains to be seen whether these 
changes will reinforce a narrow interpretation of the necessary 
and reasonable standards or allow for a broader interpretation 
based on a more knowledgeable
review of DME claims.  Centralization will provide economies of 
scale in processing DMEPOS claims that will permit greater 
expertise in establishing comprehensive medical review guidelines 
and expertise in processing claims.  In its proposed regulations, 
HCFA indicates that its contracts with regional carriers for 
processing DMEPOS claims will have utilization screens, medical 
review guidelines and medical policy for the most frequently used 
codes in order to enhance consistent claims processing among 
regional carriers.

Medicare providers and suppliers can accept assignment and bill 
Medicare directly or collect the entire bill from the Medicare 
beneficiary.  If assignment is accepted, the provider or supplier 
is obligated to accept the allowable charges that Medicare will 
reimburse for and only bill the Medicare beneficiary for a 20 
percent copayment based on the allowable charge.  HCFA reports 
that 81.1 percent of Part B claims were assigned in 1990.  

Historically, DME suppliers have been geared more for long term 
rental of equipment rather than sales.  In the original Medicare 
legislation of 1965, Medicare Part B only covered rental of 
equipment.  The provisions including purchase of equipment as an 
option, whether through a lump-sum or a lease-purchase 
arrangement, were added with the Social Security Amendments of 
1967.  DME suppliers have preferred rental arrangements because 
their repair and maintenance costs could be built into the rental 
costs which simplified their administrative paperwork.  Long term 
rental of DME has also been more profitable to a supplier 
because, over the course of the rental period, the supplier could 
receive more than the total value of the equipment.

To counter this tendency, HCFA has revised its rental/purchase 
guidelines.  Since 1989, Medicare is using a six-point 
reimbursement policy for durable medical equipment which was 
established by the Omnibus Budget Reconciliation Act (OBRA) of 
1987 (P.L. 100-203).  This Medicare Part B reimbursement policy 
applies different payment policies to different classifications 
of DME, prosthetics, and orthotics.  The six classifications of 
medical equipment are: 

.    Inexpensive or other routinely purchased DME:  This category 
     includes items such as canes, walkers, commodes, crutches or 
     other equipment which do not cost more than $150.  In 
     addition, this category includes equipment which is acquired 
     by purchase at least 75 percent of the time.  Items in this 
     category can be rented or purchased.
     
.    Equipment requiring frequent and substantial servicing. 
     Items in this category include intermittent positive 
     pressure breathing equipment, volume ventilators, suction 
     pumps, and CPAP machines.  Items in this category can only 
     be rented with maintenance and servicing included in the 
     rental payment.

.    Customized equipment. These are items which are constructed 
     or substantially modified to meet the unique needs of an 
     individual person.  The items can be covered on a purchase 
     basis only, and there are no guidelines which Medicare 
     carriers must use in determining prices for customized 
     equipment.  Medicare will also pay for maintenance and 
     servicing not covered by the manufacturer's warranty.  

.    Prosthetic and orthotic devices. Such items include urinary 
     and colostomy equipment, transcutaneous electrical nerve 
     simulators (TENS Units), braces, prosthetic limbs, and 
     artificial eyes.]  Items in this category are covered on a 
     purchase basis only with the exception of TENS Units.  A 
     trial rental period of two months is required on a TENS Unit 
     before converting to a purchase.  

.    Capped rental items.  Items in this category include 
     hospital beds, pressure pads, and wheelchairs, including 
     electric wheelchairs effective with dates of service May 1, 
     1991 and after.  Prior to May 1, 1991, these items could 
     only be considered as rental items. Medicare would pay for 
     up to 15 months of continuous rentals for medically 
     necessary items.  After 15 months of continuous rentals, 
     suppliers retained title to the equipment but were required 
     to provide the item to the patient without charge until 
     medical need ended.
     Since May 1, 1991, the patient must be offered the option of 
     purchasing the item in the 10th rental month or, in the case 
     of electric wheelchairs, the patient must be offered the 
     option to purchase in the initial month as well as in the 
     10th month of rental.  If purchased, title to the equipment 
     transfers to the patient.  If rented, title remains with the 
     supplier but the supplier must continue to furnish the 
     equipment without charge until medical need ends.  The 
     Medicare patient, not the supplier or the Medicare carrier 
     makes the decision to rent or purchase the item.

.    Oxygen and oxygen equipment. Rental for equipment is 
     included in the
     monthly purchase of oxygen.

Replacement of equipment which the beneficiary owns or which is a 
capped rental item is covered in cases of loss or irreparable 
damage or wear and when required because of a change in the 
beneficiary's condition.  Medicare does not cover replacement of 
rented equipment except capped rental items.

Maintenance and servicing of purchased equipment is covered in 
the following classes: inexpensive or routinely purchased, 
customized items, other prosthetic and orthotic devices, and 
capped rental items.  Maintenance and servicing of purchased 
items that require frequent and substantial servicing, or oxygen 
equipment is not covered.  Payment may not be made for 
maintenance and servicing of rented equipment other than the 
maintenance and servicing fee established for capped rental 
items.

Payment for replacement of rental cap items and items requiring 
frequent and substantial servicing is based on a reasonable 
lifetime of five years.  With OBRA 1990, Medicare will phase in 
national limits on fees for all DME except customized equipment.  
In addition, prosthetics and orthotics will be subject to 
regional limits rather than national fee limits.

D.   Current Policy Issues

HCFA has focused on fraud and abuse in the DME industry as a way 
to contain health care costs.  There has been no recognition that 
HCFA's regulations for DME have severely limited access to 
assistive technology that could improve the health, safety, and 
ADL needs of persons with disabilities.  Among the public policy 
issues which need to be reexamined is whether Medicare should 
continue denying coverage for health related assistive technology 
which promotes functional improvement.  Many of these devices are 
currently excluded as so-called "comfort" or "convenience" items 
by HCFA regulations because of an acute care definition of 
medical purpose, and requirements that equipment must be 
primarily and customarily used by persons who ill or injured, and 
that the equipment must be needed in the home to be covered by 
Medicare.

HCFA has developed strategies to reduce fraud and abuse through 
national standards for supplier numbers and regionalization of 
DME carriers.  While this may lead to greater uniformity in 
standards, it is not clear how it will lead to
the development of more appropriate standards.  So far, the 
regionalization process is being handled through HCFA staff and 
Medicare Medical Directors with no opportunity for input by 
Medicare beneficiaries and the organizations which represent them 
or DME vendors.

HCFA is trying to continue using physicians as gatekeepers to the 
Medicare system by requiring them to completely fill out the 
Certificate of Medical Necessity, etc.  This strategy which may 
be reasonable for medical services which physicians have 
expertise in, does not make sense for most forms of assistive 
technology.  HCFA should consider to what extent physicians are 
appropriate gatekeepers for most forms of assistive technology 
based on their expertise in assessing needs and their knowledge 
about best practices in assistive technology.  HCFA should learn 
how other countries such as Canada (and Sweden) finance technical 
aids for persons with disabilities through their health care 
system where rehabilitation professionals play a critical role as 
authorizers of many forms of assistive technology.  

HCFA is trying to contain health care costs but has not looked at 
the impact of assistive technology on the health consequences for 
persons with disabilities.  For example, is it really 
cost-effective to not pay for safety bars in the bathroom when 
Medicare pays for the preventable health care that occurs when 
falls occur at home?  Requiring DME to be "not useful to a person 
in the absence of an illness or injury" ensures that the 
equipment is likely to be highly stigmatized and the price is 
unnecessarily costly.  This may conflict with HCFA's emphasis on 
cost containment.

E.   Facilitators

All Medicare beneficiaries are eligible for Medicare covered 
services which are found to be necessary and reasonable.  Many 
types of assistive technology can be covered by Medicare if they 
are integrated within a larger treatment plan that is supervised 
by a physician.

Medicare will pay for the maintenance, repair, replacement, and 
training for use of assistive technology which is covered by 
Medicare.

Medicare requires a trial period for two months for certain types 
of assistive technology, like Transcutaneous electrical nerve 
stimulation (TENS) Units so that the Medicare beneficiary can 
experience the functional advantages of this
device over other alternatives before deciding to purchase the 
equipment.

Although the primary consideration in determining coverage under 
Medicare is the medical need in the home, equipment may be used 
outside the home.

Medicare generally accords greater weight to the medical opinion 
of an attending physician (called the treating doctor rule) than 
the medical judgment of an employee of the Medicare carrier who 
does not actually see the Medicare beneficiary.

F.   Barriers

HCFA has historically resisted broadening its interpretation of 
Medicare's definition of DME and prosthetic devices to include 
many forms of assistive technology which could promote functional 
capacity and independence.  Medicare was created with a very 
restrictive view of medical purpose for DME which focuses 
primarily on ambulation, respiration, ingestion and elimination.  
As a result, most of the DME which is covered by Medicare relates 
to one of these four functions.  Medicare does not generally pay 
for DME that is not directly related to reducing acute health 
care needs.

Physicians and other Medicare providers are often not 
sufficiently knowledgeable about Medicare's documentation 
requirements to demonstrate how assistive technology is medically 
necessary.  The ultimate determination of whether Medicare will 
pay for assistive technology often depends on whether the 
prescription for the device is integrated into a larger medical 
treatment plan.  This reflects the acute care legacy of Medicare 
which existed when Medicare was created in 1965.

Persons who are eligible for both Medicare and Medicaid often 
have less access to assistive technology than persons who are 
eligible for only Medicaid.  This occurs when Medicaid refuses to 
conduct a prior approval review before sending the claim to 
Medicare for a determination of the Medicare contribution to the 
cost of the device; instead Medicaid decides to pay only 20 
percent of the allowable charge rate that Medicare uses, leaving 
the individual to pay the difference between Medicare's allowable 
charge rate and the actual price of the equipment.  In the 
absence of Medicare, Medicaid would likely cover the full cost of 
the equipment if it was determined that the individual was 
eligible for it.  The solution to this penalty for "dually 
eligible persons" which is often referred
to as the "cross-over" problem has already been found for the 
Medicaid programs in California and Maine pursuant to court 
orders in Charpentier v. Kizer (US Dist Court ED Cal) and Vigue 
v. Ives (US Dist Court Me).  This solution should be required of 
all Medicaid programs without additional lawsuits.  The solution 
is for Medicaid to proceed with prior approval for dual enrollees 
and to pay the full cost of the equipment which an individual is 
eligible for minus the contribution which Medicare makes as the 
primary payer.

Medicare does not cover SSDI beneficiaries during the two year 
waiting period when they are most likely to need appropriate 
rehabilitation and assistive technology.

G.   Suggestions for Reform

FEDERAL LEVEL:

Definition of medical necessity

Medicare should expand the definition of medical necessity from 
what is needed for acute care to all services which promote 
"health, safety, and Activities of Daily Living (ADL) needs".  
This approach is more consistent with the statutory purposes that 
Congress intended for Medicare than the restrictive regulations 
that HCFA has developed for DME.  This proposed definition would 
not cover all assistive technology that increases function caused 
by a medical condition.  But it would appropriately extend 
Medicare coverage to environmental control devices, safety 
equipment, self-help equipment for ADL needs, and communication 
devices.  The latter would be covered to the extent that 
communication devices affect communication with medical 
personnel, would increase an individual's response to an 
emergency situation, and could reduce or prevent depression 
resulting from a frustration to communicate with others.

The definition of medical necessity should also eliminate the 
home-based definition of need although locus would be taken into 
account as one determinant of purpose.  If a device is used 
exclusively in the workplace, it would be regarded as having a 
vocational purpose rather than a medical purpose, even if it 
involves life-supports (e.g. oxygen mask for coal miners) and 
would not be covered by health insurance.  On the other hand, if 
the device is used in both the workplace and home (like a 
wheelchair is likely to be) it
would be regarded as having a medical purpose in both places and 
would be eligible for health insurance coverage.  Finally, if a 
device is used exclusively in the home but does not affect 
health, safety, or ADL needs (even though it can increase 
function which has been limited by a medical condition) it would 
not be regarded as having a medical purpose and would not be 
eligible for health insurance coverage (e.g. closed caption TV).

EXECUTIVE 
.    Revise HCFA regulations and policy guidelines regarding DME 
     to broaden "medical purpose" to include services which 
     promote "health, safety, and ADL needs";

.    Eliminate the Medicare requirement that equipment or devices 
     which are regarded as medically necessary must be useful 
     only to a person with an illness or injury;

.    Eliminate requirement that need for DME must be based 
     exclusively on need within one's home;

.    Interpret the Medicare statutory definition of prostheses to 
     mean devices which improve the function of a malfunctioning 
     body organ or substitute for a neurological dysfunction 
     regardless of whether the device replaces or substitutes for 
     a missing or malfunctioning body part.

.    Expand the Special Exception section to include all devices 
     which serve a therapeutic purpose in an individual case. 
     Eliminate the requirement that the device is part of a 
     patient's active plan of care under the supervision of a 
     physician.

.    Seek input from Medicaid beneficiaries with disabilities and 
     DME vendors in the development of medical review guidelines, 
     utilization screens, and medical policy for regionalized DME 
     carriers.

.    Examine different models in other countries for financing 
     assistive technology through the health care system in order 
     to identify better ways to authorize service, etc.

.    Develop a systematic process for publicizing the conditions 
     under which various types of assistive technology are 
     considered to be medically
     necessary for specific individuals by certain Medicare 
     carriers.  This dissemination process will create precedents 
     which build an expanded "institutional memory" among 
     Medicare carriers which currently classify most types of 
     assistive technology as "convenience" items;

.    Develop the capacity of Medicare Part B claims reviewers to 
     make better decisions about the medical necessity of 
     assistive technology;

.    Provide outreach and technical assistance to physicians and 
     other specialty Medicare providers to increase their 
     awareness of the documentation requirements of medical 
     necessity for assistive technology;

.    Develop appropriate quality assurance mechanisms to contain 
     abuse without denying access to basic health related 
     services;

.    Study the cost-effectiveness of expanding Medicare coverage 
     for assistive technology as prevention services to reduce 
     the secondary disabilities of Medicare beneficiaries with 
     disabilities.  In addition,  assistive technology can reduce 
     the incidence of primary disabilities among family members 
     (many of whom are also Medicare beneficiaries) who often 
     provide necessary personal assistance.

LEGISLATIVE
.    Amend the Medicare statute to cover assistive technology 
     which promotes "the health, safety, and ability of the 
     individual to meet ADL needs as independently as possible". 

.    Require Medicare to create a separate track for authorizing 
     assistive technology.

.    Hold Medicare responsible for the cost of nursing home care 
     which could have been avoided if Medicare covered assistive 
     technology which enabled Medicare beneficiaries to function 
     more independently in their own home.

STATE LEVEL:
.    There are no recommendations for State level changes in the 
     Federally-administered Medicare program.  However, states 
     should adjust their Medicaid policies to avoid penalizing 
     persons who are dually eligible for
     Medicare and Medicaid.  Medicaid should make a prior 
     approval determination before sending the claim to Medicare 
     for partial reimbursement.


II.  TITLE XIX OF THE SOCIAL SECURITY ACT:  MEDICAL ASSISTANCE 
     (MEDICAID) 

.    Mandatory And Optional Services
.    Early Periodic Screening, Diagnosis And Treatment (EPSDT)
.    Intermediate Care Facilities For Persons With Mental 
     Retardation And Related Conditions (ICF/MR)
.    Section 2176 Waivers (Home and Community Based Services;  
     Model 200)
.    Community Supported Living Arrangements Program.

[42 USC Section 1396 et seq.; 42 CFR 430-456]

Background
Title XIX of the Social Security Act contains the statutory 
authority for Medicaid, the federal-state Medical Assistance 
program, initially authorized under the Social Security Act 
Amendments of 1965 (P.L. 89-97).  The statutory purposes of the 
Medicaid program, as enacted in 1965, are to enable each state, 
"as far as practicable under the conditions in such State, to 
furnish (1) medical assistance on behalf of families with 
dependent children and of aged, blind, or disabled individuals, 
whose income and resources are insufficient to meet the costs of 
necessary medical services, and (2) rehabilitation and other 
services to help such families and individuals attain or retain 
capability for independence or self care" [42 USC Section 1396].

Medicaid funding is shared between the federal government and the 
states, with federal shares ranging from 50 to 83 percent, 
depending on federally established annual average per capita 
income.  The average federal share is 57 percent.  Total federal 
Medicaid expenditures in FY 1990 were $41.1 billion, covering 
services to an estimated 25,529,000 individuals.  This number is 
projected to increase to 27,333,000 in FY 1991 and the federal 
expenditures are projected to exceed $54 billion.

Medicaid also is an entitlement program, i.e., services meeting 
state and federal
requirements (other than demonstration and waiver programs) must 
be provided to eligible individuals without regard to state or 
federal appropriation levels.

States must choose to participate in the Medicaid program.  They 
do so by submitting a state medical assistance plan to the Health 
Care Financing Administration, U.S. Department of Health and 
Human Services, that meets criteria established by the federal 
government [42 USC Section 1396a(a)].  At this time, all states 
participate in the Medicaid program.

The state plan must identify the services, both mandatory and 
optional, that will be part of the state's Medicaid program (see 
below); assure that the Medicaid program is administered on a 
statewide basis, must specify the amount, duration and scope of 
each service it provides in order to reasonably achieve the 
purpose of the program;  that services available to any 
categorically needy beneficiary in the State must be equal in 
amount, duration and scope to any other categorically needy 
beneficiary in the state; that persons eligible for services have 
freedom of choice in the selection of service provider, and that 
it provide an opportunity for individuals to challenge the denial 
of eligibility or coverage or the failure to make a decision in a 
timely manner; and designate a single state agency which will be 
responsible for administration of the program.  The state plan 
also must provide assurances regarding the state's financial 
contribution to the program.

Eligibility for the Medicaid program is based on means tests as 
defined by the individual states.  There are three basic types of 
eligibility:  (1) mandatory eligibility for the categorically 
needy, i.e., those whose eligibility is linked to their 
eligibility for programs such as Supplemental Security Income 
(SSI) or Aid to Families with Dependent Children (AFDC), which is 
required; (2) optional eligibility for certain other groups who 
do not receive cash assistance but who would otherwise be 
eligible; and (3) optional eligibility for the medically needy, 
those who, except for income and resources, fall into one of the 
categories covered by the state (i.e., aged, blind, disabled, 
families with dependent children, pregnant women and children); 
and whose income and/or resource are in excess of the standards 
for categorically needy coverage, and who become eligible by a 
spend down process.

To ensure broader coverage of low income pregnant women and 
children, Congress began decoupling Medicaid eligibility from 
welfare in 1987.  OBRA 1990 required states, effective July 1, 
1991, to provide prenatal care and child health care for pregnant 
women and children up to 6 years of age at 133
percent of federal poverty level.  OBRA 1990 also allows states 
to expand this coverage up to 185 percent of the federal poverty 
level.

Although states must make payments on behalf of the categorically 
needy, they have considerable flexibility in the specific means 
criteria (income and resources levels) that they use, especially 
for AFDC recipients.  Coverage of the medically needy is based on 
limits of income and resources to qualify as medically needy, the 
so-called spend down requirements, as defined by the states 
within federal guidelines.  Coverage of children under age 18, 
who require the level of care provided in a Medicaid-certified 
institution and whose parents' income and resources exceed SSI 
eligibility standards, is also a state option under TEFRA 134 
(see third paragraph of Section C, State Flexibility, for more on 
TEFRA 134). 

P.L. 101-239 also mandated expansion of the EPSDT program, as 
described below.  OBRA 1990 (P.L. 101-508) also added phased-in 
mandatory coverage of children up to 100 percent of the federal 
poverty level; states must cover children up to age 19 by the 
year 2003, beginning at age 7 as of July 1, 1991.  The mandatory 
and optional services of the Medicaid program as they relate to 
the financing of assistive technology are described in the 
following section.

1.   MEDICAID MANDATORY AND OPTIONAL SERVICES

A.   Background

Federal statute and regulation define eleven services that states 
are required to provide to categorically needy individuals as a 
condition of participation in the Medicaid program.  The 
following services must be made available to the categorically 
needy, and if included in the state plan, optional groups of the 
categorically needy:

.    inpatient hospital care;
.    outpatient hospital care
.    laboratory & x-ray services;
     skilled nursing facility services for persons age 21 and 
     over;
.    family planning services and supplies to women of 
     childbearing age;
.    physicians' services;
.    nurse midwife services;
.    home health services, including medical supplies and 
     equipment for
     persons age 21 and over;
.    early, periodic screening, diagnosis and treatment for 
     individuals under age 21;
.    rural health clinic services;
.    services to pregnant women;
.    certified pediatric and certified family nurse 
     practitioners;
.    federally qualified health centers.

The last two mandatory services were added by the Omnibus Budget 
and Reconciliation Act of 1989 (P.L. 101-239).

There are also over thirty optional services that states may 
choose to provide through their Medicaid program, including 
rehabilitation services; prosthetic devices; durable medical 
equipment; occupational, physical, and speech-language therapies; 
personal care services; targeted case management; and 
intermediate care facility services, including services in an 
institution for people with mental retardation and related 
conditions (ICF/MR).

States exercise great flexibility, however, in the amount, scope 
and duration of both mandatory and optional services that are 
covered by their state Medicaid plan; for example, a state may 
choose to cover only a limited number of visits by a therapist, 
or place a dollar cap on the service provided.

B.   Financing Assistive Technology

Medicaid rules provide states with many options in financing 
assistive technology.  Among the mandatory services, for example, 
states can finance durable medical equipment as part of the 
mandatory home health services benefit.  As described below, the 
EPSDT program can be used extensively to finance technology for 
children up to 21 years of age.  A provision added in 1988 (P.L. 
100-360) clarified that Medicaid can be used for the cost of 
related services in a school aged child's individualized 
educational program (IEP) under Part B of IDEA and in an infant 
or toddler's individualized family services plan (IFSP) under 
Part H of IDEA.

Assistive technology is a covered expense under the following 
optional Medicaid services:  prosthetic devices, physical 
therapy, occupational therapy, speech, hearing and language 
therapy, rehabilitation services, eyeglasses, preventive 
services, ICF/MR and CSLA (for profiles of these last two 
Medicaid
options, see 3. ICF/MR and 5. CSLA below).

Assistive technology provided to Medicaid eligible individuals 
typically requires prior medical approval, must be medically 
necessary as defined by the individual state, and can be obtained 
only from vendors and providers licensed by the state Medicaid 
agency, within federally specified guidelines.

C.   State Flexibility

States have great flexibility in the design of their Medicaid 
programs, especially in five areas:  (1) eligibility, (2) 
optional services, (3) amount, scope and duration of covered 
services, (4) use of Medicaid waivers, and (5) reimbursement 
methodologies.  Because of this flexibility, no two states have 
the same program.  As mentioned above, states can choose to limit 
Medicaid eligibility only to the categorically needy.  Within 
that option states can influence eligibility by setting very low 
income and resource criteria for eligibility into the AFDC 
program which, in turn, determines eligibility for Medicaid for 
this portion of the categorically needy population.

In general, SSI recipients on the basis of age, blindness or 
other permanent disability are categorically eligible for 
Medicaid;  however, federal law permits states to use more 
restrictive criteria in relation to income and resources in 
determining their Medicaid eligibility.  This so-called 209(b) 
provision is used by fourteen states (Connecticut, Hawaii, 
Illinois, Indiana, Minnesota, Missouri, Nebraska, New Hampshire, 
North Carolina, North Dakota, Ohio, Oklahoma, Utah and Virginia).

A major eligibility option affecting children with disabilities 
is the so-called Katie Beckett or TEFRA 134 option, because of 
its origin in the Tax Equity and Fiscal Responsibility Act 
(TEFRA) of 1982 (P.L. 97-248).  Under this provision, states may 
choose to make non-institutionalized children with disabilities 
eligible for Medicaid who would be eligible if they were 
institutionalized for more than thirty days.  This provision 
allows the waiver of deeming parental income and resources so 
that children with severe disabilities in middle income families 
can receive Medicaid services.  The most recent information from 
the National Governor's Association is that only nineteen states 
have chosen this option.

Medicaid allows states the further option of expanding their 
Medicaid programs
to include groups of persons who may meet the family 
characteristics criteria of the categorically needy programs, but 
who cannot meet the strict financial limits on income and 
resources imposed by those programs (i.e., SSI or AFDC).  Because 
these people are viewed as having excess income, federal law 
allows states to impose a spend down.  I.e., the medically needy 
may be required to incur some medical costs prior to becoming 
eligible for Medicaid.

In addition, states have the option of offering different 
optional Medicaid services and different amount, scope and 
duration of the same services to the medically needy than they do 
to the categorically needy.  States have almost unlimited options 
in the selection and definition of their Medicaid services.  
Although federal legislation and regulations require that 
coverage of services as to amount, duration and scope must be 
sufficient to reasonably achieve its purpose, in practice state 
are permitted considerable discretion in setting these limits.  
Waivers of comparability, state wideness and freedom of choice 
are also used by states to shape their individual Medicaid 
programs.  Although some federal waiver requirements place limits 
on eligible populations, states generally have considerable 
latitude in their waiver designs, and in their choice of waivers 
to apply for.

States also have considerable freedom to develop their own 
methods and standards for reimbursement of Medicaid services, 
including the specific rates of payment for different types of 
service.  Under Medicaid law, providers must accept the Medicaid 
reimbursement as payment in full.

D.   Current Policy Issues 

Recent legislation, in particular the Omnibus Budget and 
Reconciliation Act of 1989 (OBRA 1989 - P.L. 101-239) and OBRA  
1990 (P.L. 101-508), has reduced state flexibility to some 
extent.  In addition to stronger mandates on Medicaid eligibility 
of low income women and children, OBRA 1990 included provisions 
to clarify that Medicaid home health services can be financed in 
settings other than the individual's home (e.g., at school) 
beginning in 1994; codifying the regulatory definition of 
optional rehabilitation services, including services in 
facilities, homes or other settings for maximum reduction of 
physical disability and restoration to the best possible function 
level; and authorization of the Community Supported Living 
Arrangements program (see below).

Regarding limits on coverage of private duty nursing services, 
the Health Care
Financing Administration (HCFA) issued a policy clarification 
directing state Medicaid directors to apply a court decision 
(Detsel v. Sullivan, 895 F.2d 58, 2d Cir. 1990) on the issue.  
This decision clarified that the state could not use an at home 
only limitation on private duty nursing services.  A class action 
has been filed (Skubel v. Sullivan) to extend the decision in 
Detsel to Medicaid home health care nurses.

As described in the overview of findings, states have raised 
concerns about mandates that will increase their Medicaid costs.  
For example, the National Governors' Association has offered 
proposals to reduce or delay mandates in expanded eligibility for 
low income women and children, expansion of the EPSDT program, 
and state responsibility for some low income people's Medicare 
co-payments.

On September 12, 1991, HCFA promulgated an interim final rule 
which has potentially devastating effects on state Medicaid 
services, including those to children and adults with disability 
and their families (Federal Register, Sept. 12, 1991, pp. 46380 
et seq.).

The rule defines the conditions under which state expenditures 
for Medicaid services would qualify for federal matching funds 
(federal financial participation, FFP).  The rule prohibits the 
use of provider voluntary contributions and severely restricts 
the use of certain state-imposed, provider specific taxes as 
allowable expenditures for the purpose of claiming federal 
Medicaid matching funds.  The rule also implies that certain 
intergovernmental transfers may be illegal, such as those used in 
state home and community based services and early intervention 
programs.  The rule is effective January 1, 1992.

There is concern that the rule also would prohibit the use of 
local government tax dollars or funds from other state agencies 
as state match, which will significantly increase fiscal 
pressures in most state Medicaid programs. As a result of the 
outcry over the proposed rule by numerous parties, the House 
Subcommittee on Health and the Environment conducted two hearings 
on the issue. Subsequently, the House passed legislation to 
rescind the rule.  While debating the House Bill (H.R. 3595) the 
Senate substituted legislation reflecting a final hour compromise 
reached between the National Governors' Association and the White 
House to cap the state provider tax share of state Medicaid 
matching funds at 25 percent.

E.   Facilitators

There are several policy statements in Medicaid law and 
regulation that strongly support access to financing.  Broad 
support is contained in the definition of rehabilitation as one 
of the two central purposes of the program.  States also must 
provide assurances in their state Medicaid plan that each service 
is "sufficient in amount, duration and scope to reasonably 
achieve its purpose" (42 CFR 440.230(b)) and that they will 
"provide such safeguards as may be necessary to assure that 
eligibility for care and services under the plan will be 
determined, and such care and services will be provided in a 
manner consistent with simplicity of administration and the best 
interests of the recipients" [42 USC Section 1396a(a)(19)].

States also are not permitted to "arbitrarily deny or reduce the 
amount, duration, and scope of a required service ... to an 
otherwise eligible recipient solely because of the diagnosis, 
type of illness or condition" [42 CFR 440.230(c)]. 

Although this requirement states that it is applicable only to 
required services, it has been applied to optional services as 
well.  In combination, these provisions lay a foundation for 
access to assistive technology that will meet the medical needs 
of Medicaid eligible individuals with disabilities, including 
promotion of greater independence or self care.  Another 
facilitator is the potentially broad scope of assistive 
technology coverage that is possible under the Medicaid program, 
including supportive services and therapies as well as assistive 
devices.  Medicaid is also a federal entitlement program, i.e., 
not subject to a closed-end federal appropriation.  Medicaid is 
also targeted to needy individuals because of their low income 
and lack of resources, and can be targeted to those who are needy 
specifically because of their expenditures for health care, under 
the optional medically needy category or use of the TEFRA option.

F.   Barriers

The primary barriers are found in state implementation of the 
program. Such barriers include:  use of medical necessity and 
related prior approval or authorization requirements;  limits 
placed on cost, amount, scope and duration of assistive 
technology, and State decisions not to include coverage of those 
optional services that provide coverage for assistive technology.
  
Overall, there has been little emphasis in most states on 
rehabilitation as one of the two primary purposes of the Medicaid 
program.  This is compounded by (1) a lack of knowledge of 
assistive technology and its significance in improving health 
status among professionals preparing and reviewing documentation 
of medical necessity, and (2) pressures for Medicaid cost 
containment.  Assistive technology often is seen as a convenience 
rather than medically necessary.

Another barrier at the state level is state limits on 
eligibility.  At the present time, thirteen states do not cover 
the medically needy population.  Thirteen states (not necessarily 
the same thirteen) exercise the 209(b) option to limit Medicaid 
eligibility to some SSI recipients with disabilities and only 
nineteen states are known to have opted to expand eligibility 
permitted by TEFRA.  Nationally, there is evidence that more than 
37 million Americans are without Medicaid or other health care 
coverage, many because their low earnings are marginally over 
state and federal limits for Medicaid eligibility.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE
.    Reinforce rehabilitation as one of the two policy goals by 
     adding a definition of medical necessity that includes 
     rehabilitation, independence, self-care and long-range 
     benefits;
.    Issue specific policy guidance on assistive technology, 
     including definitions (preferably those found in the 
     Technology-Related Assistance Act, as part of the move to 
     establish a uniform definition across federal programs);
.    Clarify the various ways that assistive technology can and 
     should be financed through Medicaid;
.    Collect/analyze data on the effects of amount, scope and 
     duration limits, including access to assistive technology;
.    Enforce prohibitions on diagnosis-based service eligibility 
     criteria and inappropriate amount, scope and duration 
     limits;
.    Support research and technical assistance on using Medicaid 
     for assistive technology.

LEGISLATIVE
.    Shift at least one major assistive technology related 
     service from optional to mandatory -- either physical 
     therapy/occupational therapy/speech and
     hearing therapy or prosthetics and orthotics;
.    Add a definition of medical necessity that includes 
     rehabilitation and long-range benefits;
.    Eliminate the 209(b) option;
.    Clarify (with a technical amendment, if necessary) that 
     private duty nursing, home health and personal care 
     assistance can be in multiple locations;
.    Add a prevention component; recognize the importance of 
     secondary disability and prevention of illness through 
     assistive technology.
.    Mandate the TEFRA 134 option.

STATE LEVEL:
.    Review use of medical necessity, prior authorization, and 
     amount/scope/duration limits in relation to rehabilitation, 
     long-range benefits, assistive technology effectiveness;
.    Provide information/technical assistance to reviewers on 
     assistive technology;
.    Include knowledge of assistive technology in standards for 
     providers, especially therapists, case managers, 
     rehabilitation services, personal care attendants, and home 
     health vendors.
2.   THE EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT 
     PROGRAM (EPSDT)

A.   Background 

EPSDT was added to the Medicaid program as a mandatory service in 
the Medicaid amendments of 1967 (P.L. 90-248).  The purpose of 
the program is to identify health problems facing young 
low-income children from birth to 21 years of age so that early 
intervention can prevent illness or more serious difficulties; to 
provide treatment and other measures to correct or ameliorate any 
physical or mental "defects" or chronic conditions discovered; 
and to promote utilization of EPSDT services through outreach and 
assistance in using available programs (e.g., through arranging 
transportation).  All states must include EPSDT as a covered 
service.

EPSDT screening, as a result of OBRA '89, must include a health 
and developmental history, a comprehensive unclothed physical 
exam, vision, hearing, and dental screening services. States must 
establish periodicity  schedules that set out the frequency of 
screening and that meet reasonable standards of medical and 
dental practice.

OBRA 1989 (P.L. 101-239) significantly expanded the EPSDT benefit 
by requiring that any Medicaid service listed in Section 1905(a) 
of the Act for which federal reimbursement is available (most 
Medicaid mandated and optional services) -- and that is medically 
necessary to treat or ameliorate a condition, physical or mental 
illness, or a condition identified through the screening process 
-- must be provided to EPSDT participants regardless of whether 
or not such services are covered under the state plan. Such 
services must be provided without regard to the limits on amount, 
duration and scope in the state plan.

Previously, states were required to provide only diagnostic and 
treatment services for defects in vision and hearing, including 
eyeglasses and hearing aids; dental care needed for relief of 
pain and infection, restoration of teeth and maintenance of 
dental health; and immunizations.  The number of low income 
children eligible for Medicaid will increase due to Medicaid 
amendments in OBRA 1990 (P.L. 101-508) which require states not 
already doing so to phase in coverage of children age 7 - 19 
years up to 100 percent of the federal poverty level by the year 
2003.  More children are expected on the SSI rolls as a result of 
the U.S. Supreme Court decision in Zebley v. Sullivan which
expanded the definition of disability for low-income children 
with disabilities. In addition, OBRA '89 requires states to 
phase-in up to 80 percent enrollment of all Medicaid eligible 
children in EPSDT by 1995.

B.   Financing Assistive Technology

Although there are no specific references to assistive technology 
in the regulations governing EPSDT, eligible children in need of 
assistive technology are now entitled to whatever Medicaid 
financed services are medically necessary (e.g., medical 
equipment, rehabilitation, physical therapy, etc.) regardless of 
their state's individual Medicaid plan and state limits on 
amount, scope and duration.  Items covered include but are not 
limited to eyeglasses, hearing aids, wheelchairs, braces, 
augmentative communication devices, environmental controls, etc.

C.   State Flexibility

States continue to have flexibility in some aspects of the EPSDT 
program, in particular the inclusion of the medically needy.  The 
amendments described above, however, have placed significant 
limits on state flexibility in EPSDT services, in the interest of 
improved health care for low income children, regardless of their 
state of residence.  Federal EPSDT guidelines do, however, permit 
states to place appropriate limits on EPSDT services based on 
medical necessity.

D.   Current Policy Issues

States are currently awaiting further guidance from HCFA 
regarding limits they can impose in their definition of medical 
necessity, i.e, in the definition of settings where services may 
be covered.  Proposed regulations are not expected before spring 
1992.

E.   Facilitators

The primary facilitator is the provision that requires states to 
provide services based on individual need and state-defined 
medical necessity without regard to their individual state plan 
Medicaid program limitations.  Access to financing also will be 
improved for low income children in states which must now phase 
in coverage to 100 percent of poverty level.
F.   Barriers

The primary barriers are the lack of knowledge of assistive 
technology among the professionals participating in the EPSDT 
program compounded by families' lack of awareness of the program.  
A significant potential barrier are state limits imposed in the 
name of medical necessity, such as a requirement that services 
are covered only when provided in a clinic!   Access is also 
limited in states which do not cover the medically needy 
population.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE
.    Enforce the new provisions; resist pressures to back down on 
     implementation;
.    Clarify the medical necessity definition as described above 
     for the basic Medicaid program.

STATE LEVEL:
.    Promote knowledge development/dissemination on assistive 
     technology
.    Monitor follow-up on individual care plans, including access 
     to assistive  technology;
.    Promote collaboration with Part H and Part B of IDEA 
     (Individuals With Disabilities Education Act) and the 
     Children with Special Health Care Needs/MCH Block Grant 
     programs and Head Start.

3.   INTERMEDIATE CARE FACILITIES FOR PEOPLE WITH MENTAL 
     RETARDATION AND RELATED CONDITIONS (ICF/MR)

A.   Background

The ICF/MR program is an optional Medicaid service enacted by 
Congress in 1971.  All states currently provide ICF/MR services.  
Medicaid certified ICF/MR facilities must serve a minimum of four 
individuals, must provide active treatment and meet over 200 
federal standards for certification, and must provide services 
only to people with mental retardation or related conditions who 
are in need of active treatment and who require 24-hour 
supervision.  

Related conditions includes developmental disabilities which is 
defined to mean an individual within the term "mental retardation 
and related conditions" as set forth in regulations in effect on 
July 1, 1990, and is as follows:

     "The term "developmental disability" means a severe, chronic 
     disability of a person which -- (A) is attributable to a 
     mental or physical impairment or combination of mental and 
     physical impairments;  (B) is manifested before the person 
     attains age twenty-two;  (C) is likely to continue 
     indefinitely;  (D) results in substantial functional 
     limitations in three or more of the following areas of major 
     life activity:  (i) self-care, (ii) receptive and expressive 
     language, (iii) learning, (iv) mobility, (v) self-direction, 
     (vi) capacity for independent living, and (vii) economic 
     self-sufficiency;  and (E) reflects the person's need for a 
     combination and sequence of special, interdisciplinary, or 
     generic care, treatment, or other services which are of 
     lifelong or extended duration and are individually planned 
     and coordinated.

Program expenditures (both federal and state) in FY 1990 were 
$7.6 billion, providing for approximately 143,000 residents in 
5,700 facilities.  States are required to review each ICF/MR 
resident's continuing eligibility and appropriateness for ICF/MR 
care at least twice a year.  In addition, states must assure and 
monitor each person's receipt of continuous active treatment, in 
line with an Individual Program Plan (IPP) that has been 
developed by each person's interdisciplinary team.

Active treatment is defined as "aggressive, consistent 
implementation of a program of generic training, treatment, 
health services, and related services."  Each resident within an 
ICF/MR facility must receive a continuous active treatment 
program consisting of needed interventions and services in 
sufficient number and frequency to support achievement of the 
objectives identified in the IPP. [42 CFR 283.440(d)(1)].

B.   Financing Assistive Technology

Assistive technology can and must be financed through the ICF/MR 
program when it is determined to be part of the individual's 
active treatment program.  The federal regulations and standards 
for ICF/MR certification include several requirements that 
support access to assistive technology.  IPP development must 
begin with individualized assessments, including sensorimotor 
development that
looks at the extent to which corrective, orthotic, prosthetic, or 
support devices are needed; and communication development that 
includes identification of augmentative or assistive devices that 
may be needed to improve communication and functional status.

The IPP must describe specific objectives based on the 
comprehensive assessment, with single "behavioral outcomes" that 
are measurable and that have defined dates for implementation.  
It must identify also mechanical supports as needed to achieve 
proper body position, balance or alignment and the availability 
of any needed mobility devices [42 CFR 483.440(c)].

ICF/MR facilities are further required to furnish, maintain in 
good repair, and teach residents to use and make informed choices 
about the use of the assistive devices identified as needed by 
the interdisciplinary team and provide sufficient space and 
equipment to enable staff to provide needed services [42 CFR 
483.470(g)].

ICF/MR surveyors are expected to check on the furnishing of 
assistive technology to residents and to ensure that items are in 
good repair, repaired on a timely basis, properly fitted to the 
individual, and that loaners are made available during repairs. 
C.   State Flexibility

States have great flexibility in the ways they use the ICF/MR 
program to finance facilities for the eligible population, with 
some states using the program primarily or exclusively for large 
state institutions, some using ICF/MR to finance many small 
private facilities in the community, and others with various 
mixes of facility size and public-private auspices.  States also 
may have sub-categories of ICF/MR facilities with varying 
eligibility and level of care criteria.  Because ICF/MR is an 
optional Medicaid service, states with medically needy programs 
can choose to limit the ICF/MR benefit to only the categorically 
needy Medicaid eligible.

D.   Current Policy Issues

Like EPSDT, there are no unique services that are listed under 
the ICF/MR services definitions;  rather, they are a vehicle for 
securing health, nursing, rehabilitative, social, physician and 
other services, as defined in the general Medicaid program, and 
as appropriate, assistive technology.
E.   Facilitators

The primary facilitator that promotes access to financing is the 
requirement for active treatment.  Standards and guidelines 
governing the monitoring of active treatment, including the 
related requirements on individual assessments, the IPP, and 
physical condition of the equipment, include several references 
to assistive technology.  These policies support full access to 
assistive technology when found appropriate to meet individual 
needs.

F.   Barriers

The two barriers associated with the ICF/MR program are lack of 
knowledge of assistive technology options and its significance 
among the professionals who determine the individual program 
plan.  Also retrospective determination of reimbursement levels 
leaves providers short of resources to meet current needs.  A 
related barrier is a lack of coordination in many states between 
the state survey-quality assurance program and the reimbursement 
system.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Require all Qualified Mental Retardation Professionals 
     (QMRPs) to receive training in assistive technology;
.    Continue/expand training to states on quality assurance, 
     including access to assistive technology;
.    Examine disparities between quality assurance and state 
     Medicaid plan requirements (e.g., assistive technology 
     services per individual program plan vs. state limits on 
     amount or duration).

LEGISLATIVE 
.    Include knowledge/competency in assistive technology in 
     professional qualifications;
.    Include definition of assistive technology in standards, 
     using definition  found in the Technology-Related Assistance 
     Act. 

STATE LEVEL:
.    Provide technical assistance/disseminate information on 
     assistive technology to ICF/MR directors and state directors 
     of Medicaid agencies;
.    Emphasize the full range of assistive technology in ICF/MR 
     monitoring;
.    Help providers negotiate state Medicaid limits.

4.   HOME AND COMMUNITY BASED SERVICES (HCBS OR SECTION 2176) 
     WAIVERS

A.   Background

HCBS waivers, including Model waivers, are Medicaid program 
options enacted in OBRA 1981 (P.L. 97-35) that can be used by 
states to provide a wide range of home and community-based 
services (other than room and board) for individuals who in the 
absence of such services would require Medicaid funded 
institutional services (e.g., in an ICF/MR, nursing home or 
hospital).  States may request waivers of statewideness and 
comparability of services under HCBS.  States also may also 
expand eligibility up to 300 percent of the SSI standard 
including supported employment for persons leaving institutions.

Services may include case management, habilitation, 
homemaker/home health care, personal care, adult day health 
services, medical supplies, physical, occupational and speech 
therapy, nursing care, respite, and other services requested by 
the state and approved by the Secretary of the Department of 
Health and Human Services.

For regular HCBS waivers (i.e., not including Model waivers), the 
number of HCBS participants approved for each state waiver is 
limited by the federal requirement that total Medicaid waiver 
costs cannot exceed the amount that would have been expended for 
the participants' institutional care.  Thus only those 
individuals may be served through the waiver who otherwise would 
have been served in a Medicaid funded institution; states have 
been required to document that sufficient beds exist (or would be 
certified or built) to serve all individuals who would be 
institutionalized in the absence of a waiver ("cold bed" 
provision).   HCBS waivers can be targeted to people with mental 
retardation and related conditions eligible for ICF/MR services, 
people with mental illness, those with physical disabilities who 
do not meet the definition for related conditions, individuals 
with AIDS/HIV infection, and the elderly.

Total federal expenditure for FY 1991 was $1,186,970,300 for 
55,626 participants with forty-one states participating for FY 
1990 or 1991. This is an average per capita expenditure of 
$21,338.

Model waivers are limited to a maximum of 200 individuals and 
there are currently 160 active waivers.  Although frequently 
considered to be a program for children with disabilities and 
associated with the Katie Beckett waiver, there is no federal 
restriction on age.  States also may target their model waiver to 
any subgroup of the population with disabilities who would 
otherwise be institutionalized.  

B.   Financing Assistive Technology

Federal financial participation is available for assistive 
technology covered in the state's approved waiver program.  
Waiver applications include specific references to environmental 
modifications, specialized medical equipment and supplies, and 
Personal Emergency Response Systems (PERS) as allowable services.  
Specialized medical equipment and supplies are limited to items 
not furnished under the state's Medicaid plan or are furnished in 
greater quantity or scope.  States also can define other types of 
assistive technology.

C.   State Flexibility 

States have great flexibility in determining which services they 
will provide through their waiver programs and the amounts of 
service to be covered, subject only to a cost-neutrality test.  
Although the maximum number of waiver participants is capped for 
the HCB waiver (total number of people who would otherwise be 
institutionalized and a maximum of 200 for the model waiver), 
states may use the waiver for fewer than the number that the 
Health Care Financing Administration would approve.

In addition, waiver participation is a state option, and states 
may choose not to request any waivers.  States also have the 
option of refusing waiver services to individuals whose waiver 
costs would exceed average institutional care costs.  As 
indicated above, states also have complete flexibility regarding 
the specific disability related eligibility criteria for waivers, 
and in addition may offer waiver services only to residents of 
certain geographic areas.

D.   Current Policy Issues

HCFA has developed a streamlined waiver application format, 
including pre- defined services that states can use to submit 
their waiver application just by checking them off; it is these 
definitions that include environmental
modifications, specialized medical equipment and supplies, and 
PERS.  States also are free to continue to develop their own 
definitions.

E.   Facilitators

The primary advantage of the waiver program is that access to 
Medicaid financing is not dependent on institutional placement, 
but is available in home and community settings to individuals 
who would require an institutional level of care.  In addition, 
states can provide waiver services that are not available as 
optional services in the states's Medicaid plan, or can authorize 
broader amount, scope and duration, all within a fiscally 
controlled environment.

F.   Barriers

The primary barrier for many HCBS waiver participants is that 
their state waiver does not necessarily include assistive 
technology.  Lack of knowledge among professionals is a related 
barrier.  Residents of some states who could benefit from 
assistive technology in home and community based settings are 
unable to use the waiver program because their state has chosen 
not to participate or to limit participation.  In addition the 
federal caps on HCBS waiver programs act as a barrier to 
financing for an unknown number of individuals.

States which choose not to provide waiver services to individuals 
whose care would be less costly if they were institutionalized 
may limit to access to financing by forcing them to choose 
between access to assistive technology and life in their home and 
community.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Continue/expand efforts to help states use these waivers 
     effectively;
.    Review cap provisions and "cold bed" provisions;
.    Conduct an evaluation of the program, including an 
     examination of assistive technology as a significant support 
     to home and community-based living;
.    Improve program monitoring to include outcomes for 
     individuals and consumer satisfaction.

LEGISLATIVE 
.    Expand/modify definition of assistive technology in waiver 
     application to conform to one used in the Technology-Related 
     Assistance Act.

STATE LEVEL:
.    Include assistive technology as a waiver service;
.    Conduct state-level evaluation that includes outcome 
     measures, consumer satisfaction.

5.   COMMUNITY SUPPORTED LIVING ARRANGEMENTS (CSLA) PROGRAM 

A.   Background

OBRA 1990 (P.L. 101-508) established the CSLA program as an 
optional Medicaid state plan service for recipients with 
developmental disabilities who would otherwise be eligible for 
Medicaid and are living in their own or in their family's home, 
apartment, or other rental unit with no more than three other 
service recipients.  Unlike the HCBS waiver program, eligibility 
does not require that people be at risk of institutionalization 
to be eligible for CSLA services.

A maximum of eight states were authorized to participate during 
the first five years of the program, with a total federal 
authorization of $100 million.  The Health Care Financing 
Administration selected eight states through a competitive review 
of twenty-seven state applications during September 1991.  These 
were awarded to California, Colorado, Florida, Illinois, 
Maryland, Michigan, Rhode Island and Wisconsin.

The CSLA program authorizes participating states to provide one 
or more services to assist in activities of daily living 
necessary to permit them to live in the community.  Services may 
include adaptive equipment, assistive technology, personal 
assistance, training, and "habilitation services necessary to 
assist the individual in achieving increased integration, 
independence, and productivity."  Services are to be defined in 
an individual support plan (ISP).  Room and board, 
pre-vocational, vocational and supported employment services may 
not be financed.

CSLA includes several requirements for checks and balances in 
program
planning and monitoring.  State CSLA plans must be reviewed by 
the state's Developmental Disabilities Planning Council and 
Protection and Advocacy System.  Public hearings must be held on 
the CSLA quality assurance plan prior to its adoption and 
implementation.  Additionally, monitoring boards must be 
established that include consumers and family members as well as 
providers and neighbors; and  information on monitoring findings 
must be available to the public.

B.   Financing Assistive Technology

Adaptive equipment and assistive technology are mentioned 
specifically as examples of services that states can provide in 
their CSLA program.  In addition, the law mandates supports such 
as personal assistance, and training and habilitation services, 
24-hour emergency assistance, services necessary to aid an 
individual to participate in community activities, among others, 
to permit such individuals to live in the individual's own home, 
family home or rental unit.

C.   State Flexibility

States are not required to submit applications for the CSLA 
program, however, twenty-seven states applied in competition for 
the eight available approvals.  States have considerable 
flexibility in the design of their individual CSLA programs, 
within federal guidelines and the checks and balances outlined 
above.

D.   Current Policy Issues

National disability organizations continue to press Congress to 
expand CSLA and to make it a regular Medicaid state plan option 
available to all fifty states as a state decision rather than as 
a competitive national contest.   Advocates feel also that there 
should be continued research and evaluation in the area of 
supported living.

E.   Facilitators

Assistive technology is specified as an eligible service, along 
with adaptive equipment.  In addition, the program's focus on 
individualized supports for community participation, 
independence, productivity and integrated living, are directly 
related to the rationale for optimal access to assistive 
technology.  

Financing also should be facilitated by the various opportunities 
for consumer input on CSLA program design and monitoring.

F.   Barriers

The primary barrier is the limited funding available for CSLA, 
and its availability in only eight states as presently 
authorized.  Additional barriers may be identified as the program 
is implemented in the states.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Conduct an evaluation of CSLA, including the use of 
     assistive technology, beginning as soon as possible to 
     permit accurate collection of baseline data;
.    Include at least minimum requirements for state level 
     evaluation and agreement to participate in a national 
     evaluation in future CSLA applications;
.    Support research and technical assistance on supported 
     living, including the use of assistive technology.

LEGISLATIVE 
.    Amend statute to make CSLA an optional Medicaid state plan 
     service for all states choosing to use it;
.    Use common definition of assistive technology, as described 
     in Appendix D.

STATE LEVEL:
.    Include assistive technology in supports being provided;
.    Include knowledge/competency in assistive technology in 
     training and qualifications for supported living providers;
.    Collect data/conduct an evaluation focused on the cost 
     effectiveness of supported living;
.    Include access and appropriate use of assistive technology 
     in monitoring supported living services.


III. TITLE V OF THE SOCIAL SECURITY ACT:  MATERNAL AND
     CHILD HEALTH SERVICES

ÀÀ The Maternal and Child Health Services Block Grant
ÀÀ Children with Special Health Care Needs
ÀÀ Special Projects of Regional and National Significance

[42 USC 701]

Background

Title V of the Social Security Act has authorized the Maternal 
and Child Health Services programs since 1935.  Significant 
amendments to the program were made in 1981 when seven 
categorical programs, including Maternal and Child Health 
Services and the Crippled Children's Services Program, were 
consolidated into a single Maternal and Child Health Services 
(MCH) Block Grant.  Title V also authorizes the smaller Special 
Projects of Regional and National Significance (SPRANS) program.

The block grant mechanism gives states considerable flexibility 
in using federal funds to achieve the purposes of the 
legislation, consistent with documented state needs.  At the same 
time, however, the consolidation reduced federal funding for the 
combined programs by 25 percent in the first year.  Program 
amendments in the Omnibus Budget Reconciliation Act of 1989 (OBRA 
1989 -  P.L. 101-239) linked the purpose of the Title V programs 
to national health goals.  The redefined purpose is "to improve 
the health of all mothers and children consistent with applicable 
health status goals and national health objectives established by 
the Secretary under the Public Health Services Act for the Year 
2000."

1.   THE MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT

OBRA 1989 made major changes to the MCH block grant.  These 
changes included refinement of the basic program purposes such as 
reduced state flexibility in expenditures of federal block grant 
funds and new reporting and application requirements.  A stronger 
focus on family-centered and community-based systems development 
and required coordination with the Medicaid program was mandated.

A.   Background
The purposes of the MCH block grant are to:  (1) enable each 
state to provide as well as to assure access to quality MCH 
services, especially to those with low income or limited access 
to health services;  (2) prevent and reduce death, disease, and 
disability/health promotion, in particular for low income women 
and children; (3) provide rehabilitation services not otherwise 
covered by Medicaid for low income children under the age of 16 
with blindness or other disability who are receiving SSI 
payments;  and (4) to promote family-centered, community-based, 
coordinated care for children with special health care needs.

The authorized federal funding level for the MCH block grant was 
increased by $125 million by OBRA 1989 to $686 million, including 
a 15 percent set-aside. This 15 percent set-aside, to be 
determined by the Secretary of HHS, was for demonstrations, 
research and training.  An additional 12.75 percent set-aside of 
any appropriations exceeding $600 million was also mandated for 
six specific types of projects.

Actual appropriations however were $587.3 million in FY 1991, 
with $499.2 million only going to the states.  The Maternal & 
Child Health Block Grant appropriation for FY 1992 is $000.00 
million.   State block grant amounts are determined by such 
factors as the state's population of low income children.  Grants 
ranged in FY 1991 from $990,000 to $37.6 million.  States are 
required to match every $4 in federal funds with $3 in state 
funds.

OBRA 1989 also added new requirements on state use of MCH funds, 
including maintenance of state effort at FY 1989 levels; a 10 
percent limit on expenditures for program administration; a 30 
percent earmark for preventive and primary care for children; and 
a 30 percent earmark on services for children with special health 
care needs (see below).  OBRA 1989 also added several 
requirements to the block grant application process.  Under the 
original block grant legislation (OBRA 1981 - P.L. 97-35), states 
submitted a "description of intended expenditures" to DHHS.  The 
new provisions require an application following a specific 
format, including the results of statewide needs assessments and 
plans consistent with national health objectives in three areas:  
(1) preventive and primary care for pregnant women, mothers and 
infants; (2) preventive and primary care for children; and (3) 
community-based services for children with special health care 
needs.  In addition the applications must be available for public 
comment prior to their submission to DHHS.  Extensive annual 
reporting requirements also were added.

A fourth emphasis of OBRA 1989 was on more effective coordination 
between services funded by the MCH block grant and by Medicaid.  
Provisions include linkages between MCH and Medicaid on the 
implementation of the Early Periodic Screening, Diagnosis and 
Treatment (EPSDT) program; requirements for each state to have a 
toll-free telephone service to provide information on Title V, 
Medicaid, and other relevant health and health-related providers 
and practitioners; outreach and assistance for pregnant women and 
infants in obtaining Medicaid coverage; and detailed reporting 
requirements on use of the Medicaid program for MCH services.

B.   Funding of Assistive Technology

The major MCH block grant funding mechanism for assistive 
technology is the Children with Special Health Care Needs 
program, described below.  The basic MCH program can be used to 
finance assistive technology, primarily in coordination with the 
Medicaid program, in particular the EPSDT component.

C.   State Flexibility

State flexibility was reduced to some extent by the OBRA 1989 
amendments, including the earmarking of funds for preventive and 
primary care, for children with special health care needs, and 
the 10 percent limit on administrative expenditures. These 
restrictions apply only to the federal funds, not to the state 
funds provided as match.  Beginning with their FY 1992 
applications and annual reports, states also are required to 
provide much more detailed information than previously regarding 
their needs assessments, plans for expenditures, and coordination 
activities, using a standardized format developed by DHHS that 
reflects the purposes contained in the legislation.  What effects 
this may have on state flexibility in program design are unclear.  
According to the Association of Maternal & Child Health Programs, 
states responded well to the new requirements in their FY 1991 
applications.

D.   Current Policy Issues

Implementation of the Title V amendments in OBRA 1989 is still in 
process, and federal guidance on state block grant applications 
and annual reports is being refined for the FY 1992 applications.  
Based on a review of the draft application guidelines, these will 
refine and expand guidance on needs assessment and coordination 
between the MCH and Medicaid programs,
especially the expansion of the EPSDT program.  The first 
applications to come in under OBRA 1989 based guidelines were 
those for the FY 1991 grants.

E.   Facilitators

The increased emphasis on coordination with the Medicaid program 
(EPSDT in particular), coupled with Medicaid outreach and 
application assistance, as well as the program's overall focus on 
the needs of low income mothers and children and on 
family-centered, community-based care, should be significant in 
promoting access to financing.  The toll-free telephone service 
is a potential facilitator in helping families identify assistive 
technology providers.

Another strength of the program is the requirement that MCH 
services be based on a statewide needs assessment, and that there 
be opportunities for public review and comment on the state MCH 
block grant application.

Other features of the Children with Special Health Care Needs and 
SPRANS programs are also relevant to access to assistive 
technology and are described below.

F.   Barriers

There are no inherent barriers.  Funding constraints and the 
federal appropriation levels well below authorized amounts may 
make it difficult for states to expand or to develop an assistive 
technology initiative.  Adjusted for inflation, current funding 
is approximately one-half of pre-1981 funding levels for the 
consolidated programs.

2.   CHILDREN WITH SPECIAL HEALTH CARE NEEDS

A.   Background

The Crippled Children's Services program was renamed the Children 
with Special Health Care Needs (CSHCN) program in 1986.  The 
purpose of the CSHCN program is "to provide and to promote 
family-centered, community-based, coordinated care (including 
care coordination services) ... for children with special health 
care needs and to facilitate the development of community-based 
systems of services for such children and their families" (OBRA 
1989 - P.L. 101-239).

Care coordination services are defined as "services to promote 
the effective and efficient organization and utilization of 
resources to assure access to necessary  comprehensive services 
for children with special health care needs and their families."   
OBRA 1989 deleted references to specific services that could be 
provided (e.g., medical, surgical and corrective services) to 
focus the CSHCN program on family, community, coordination, 
access to a comprehensive array of services, and the development 
of appropriate systems of care.

States must include a specific description of needs and plans for 
CSHCN expenditures in a separate section of their MCH block grant 
application.  For example, preliminary guidance from DHHS on the 
assessment requires documentation that the CSHCN agency conducted 
an inventory of the public programs which are actual or potential 
sources of services or funding for children with special health 
care needs and their families, as well as relevant collaborative 
mechanisms.

States must indicate how they will conduct needs assessments at 
the local level on the development of community-based systems of 
services.  The application also must provide information 
regarding the basic purposes of the CSHCN program, including a 
description of the activities that will be conducted to assure 
that services provided or funded by the state CSHCN agency are 
coordinated, family-centered, and culturally competent.

Information also must be provided on the ways services to 
children with special health care needs and their families are 
coordinated with basic MCH program services.

B.   Financing Assistive Technology

Although there is no mention of assistive technology in the 
legislation or policy guidance, it can be financed through the 
CSHCN program as a community based service.  State CSHCN agencies 
may provide assistive technology directly or through the 
provision of assistance.  Technology also may be financed through 
rehabilitation services provided to children and adolescents 
receiving SSI.  OBRA 1989 amendments added a requirement, 
however, that MCH funds only be used to the extent that 
assistance is not provided through the Medicaid program.

In addition, MCH/CSHCN programs in several states are responsible 
for
reviewing complex or expensive assistive technology Medicaid 
claims.  Traditionally, Crippled Children's Services programs in 
most states included various types of assistive technology, 
provided primarily to children with orthopedic disabilities.  
Title V funding restrictions prohibit the use of funds for 
inpatient services, other than inpatient services provided to 
children with special health care needs or to high-risk pregnant 
women and infants; cash payments to intended recipients of health 
services; facility construction or major improvement;  and the 
purchase of major medical equipment (e.g., hospital CAT scans).
C.   State Flexibility

States continue to have broad flexibility in the design of their 
CSHCN programs, including target populations, eligibility 
requirements, and services.  The extent of provisions of OBRA 
1989 that will be implemented to require certain kinds of service 
priorities or eligibility standards is not clear.  Based on the 
proposed application guidance for the FY 1992 block grant, it 
appears that states will continue to have great flexibility so 
long as they document that their approach is based on their own 
needs assessment.

OBRA 1989 also requires documentation of public participation in 
the applications process.  As noted above, states also are not 
required to use a minimum of 30 percent of state MCH funds on 
CSHCN, as they must with their federal MCH allocation.

D.   Current Policy Issues

As with the overall implementation of the OBRA 1989 amendments, 
it is too early to tell what the effects will be of new federal 
application and reporting guidance.  Observers are particularly 
interested in the extent to which state CSHCN programs shift 
emphasis from direct services to service development and 
coordination.  The federal MCH division is currently developing a 
technical assistance plan to help states meet the new 
requirements.

E.   Facilitators

The primary features of the CSHCN program that can facilitate 
access to the financing of assistive technology are the emphasis 
on family-centered and community-based services are the focus on 
the development of coordinated community- based systems of care 
and the overall emphasis on coordination.

Access also may be helped by the new requirements for the 
application process, including the opportunity for public review.

F.   Barriers

There are no inherent barriers in the CSHCN program.  It is 
unclear to what extent barriers exist in implementation at the 
state level.  Implementation of the application and reporting 
requirements of OBRA 1989 is just underway, and
there is therefore little information on the impact of these 
provisions.  However, there is no reference to assistive 
technology in the legislation or in the proposed application and 
reporting requirements and the program receives limited federal 
funding.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Add specific policy to clarify that promoting access to 
     assistive technology is an appropriate use of MCH funds, 
     including the definition of assistive technology and the 
     recognition of its significance in optimal development;
.    Designate assistive technology as a priority in research and 
     technical assistance activities;
.    Promote coordination with EPSDT, IDEA Parts B and H, Head 
     Start and Technology-Related Assistance grant programs on 
     assistive technology financing;
.    Collect/analyze information on access to assistive 
     technology.

LEGISLATIVE 
.    Include the need for assistive technology in the 
     guidelines/requirements on the needs assessment and state 
     plan for children with special health care needs.

STATE LEVEL:
.    Provide technical assistance on assistive technology at the 
     local level, including coordination on funding strategies 
     and reduction of duplication/gaps.

3.   SPECIAL PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE

A.   Background

The MCH Block Grant provides for a 15 percent set-aside used by 
the Department of Health and Human Services to carry out special 
projects of regional and national significance (SPRANS).  The 
federal set-aside funds grants for research, training, hemophilia 
diagnosis and treatment; genetic
diseases screening, counseling, and referral; MCH improvement 
projects to demonstrate and test a variety of approaches intended 
to improve the health of and services delivered to mothers, 
infants, children, adolescents, and children with special health 
care needs; pediatric AIDS health care demonstration projects; 
and projects to improve emergency medical services for children.

Approximately 500 grants receive funding during a fiscal year.  
Specific grant eligibility criteria vary depending on the focus 
of the grant (e.g., research, training, etc.)

B.   Financing Assistive Technology

Two types of SPRANS grants are especially relevant to the 
financing of assistive technology:  MCH improvement project 
grants focused on children with special health care needs, and 
training grants in relation to this population.  Some research 
grants also may involve the use of assistive technology.  Many 
training grants help support diagnostic and multi-disciplinary 
services at public clinics, such as those operated by the 
University Affiliated Programs (UAPs) co-funded by the 
Administration on Developmental Disabilities. 

C.   State Flexibility

Some SPRANS grants are directly targeted to state MCH programs, 
and others require their review and coordination.  States also 
frequently provide support to the individual grantees in their 
application and implementation of SPRANS resources.

D.   Current Policy Issues

Policymakers are awaiting reports on the implementation of the 
OBRA '89 requirements.

E.   Facilitators

SPRANS grants can support a wide range of training, research and 
demonstrations that include assistive technology.  The program is 
potentially significant through its direct support (e.g., through 
the UAPs' clinics) and indirectly through the training of 
personnel to become knowledgeable about assistive technology and 
the research on specific devices and interventions. 
Federal funding is consistent through the 15 percent set-aside 
mechanism. 

F.   Barriers

Assistive technology, other than ventilators and respirators, has 
very low visibility in the SPRANS program, and has not been 
listed as a priority in federal grant announcements.  Information 
on the use of funds for assistive technology is not available.  
Although the set-aside provision assures federal support for the 
grant program, the federal MCH block grant appropriation is 
consistently well below the authorization level, affecting 
resources available at the state level and the 15 percent SPRANS 
funding accordingly.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Designate assistive technology as a priority for research 
     and dissemination activities;
.    Synthesize/disseminate information on previously funded 
     projects that have included assistive technology.

STATE LEVEL:
.    Use the review and coordination process to ensure that 
     assistive technology is included in SPRANS activities.


IV.  INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA)

ÀÀ Part B:  State And Local Grant Program For Special Education
ÀÀ Part H:  State Grants For Infants And Toddlers

[20 USC Section 1400-1485]

ÀÀ Related programs:
     .    Special Education in State Operated Programs; and
     .    Vocational Education

Background

The Education of the Handicapped Act (EHA) in 1975 (P.L. 94-142) 
established as a federal mandate the right to education for 
children with disabilities. The law was expanded to include 
pre-school, infants and toddlers with disabilities (P.L. 99-457).  
The purpose of the Individuals with Disabilities Education Act is 
to

     "assure that all children with disabilities have available 
     to them ... a free appropriate public education which 
     emphasizes special education and related services designed 
     to meet their unique needs, to assure that the rights of 
     children with disabilities and their parents or guardians 
     are protected, to assist States and localities to provide 
     for the education of all children with disabilities, and to 
     assess the effectiveness of efforts to educate children with 
     disabilities." 

The amendments of 1990, the Individuals with Disabilities 
Education Act (IDEA - P.L. 101-476) included rewording of "the 
handicapped" and "handicapped children" to "individuals" and 
"children with disabilities."

Definitions of both assistive technology devices and assistive 
technology services were added to Part A of IDEA through P.L. 
102-119, The Individuals With Disabilities Education Amendments 
of 1991.  These definitions therefore apply to all programs 
authorized by IDEA.

1.   PART B:  STATE AND LOCAL GRANT PROGRAMS FOR SPECIAL 
     EDUCATION

A.   Background

Part B of IDEA provides two types of grants to state education 
agencies:  pre-school grants for children ages three to five and 
grants for children ages six to twenty-one, commonly known as 
Part B grants.  Federal funding to the states in FY 1990 was 
estimated at $1,524,610,000; the FY 1991 estimate is 
$1,615,125,000, of which approximately 13.6 percent is for 
pre-school programs.

Basic grants to the states are determined by a formula based on 
the total number of children with disabilities ages 3 - 21 
receiving special education in each state and the national 
average per pupil expenditure by state.  In FY 1990 federal Part 
B grants to states ranged from $644,295 to $152,398,865; the
national average was $26,596,724.  States are required to channel 
at least 75 percent of the federal Part B grant funds to local 
and intermediate educational agencies.  Over 4.5 million children 
with disabilities nationwide, ages 3 - 21, are receiving special 
education and related services under this program. 

In order to receive their Part B funds, each State Education 
Agency must submit a plan outlining how it will assure the 
implementation of federal requirements.  Children with 
disabilities include those who are "mentally retarded, hard of 
hearing, deaf, speech or language impaired, persons with visual 
impairments, seriously emotionally disturbed, orthopedically 
impaired, other health impaired, or children with specific 
learning disabilities who by reason thereof require special 
education and related services."  Federal regulations include two 
additional categories of disability:  deaf-blind and multiple 
disabilities.

An individualized educational program (IEP) must be developed for 
each eligible child.  Federal legislation and regulation include 
requirements for IEP development and review, as well as the 
composition of the interdisciplinary committee charged with IEP 
preparation.  The IEP must include a statement of the child's 
current educational performance; annual goals and short-term 
instructional objectives; a description of the services to be 
provided and the extent to which the child will be able to 
participate in regular educational programs; the projected 
initiation date and the anticipated duration of services; and the 
methods to be used in determining the accomplishment of the 
educational objectives.

States are required to provide a free appropriate public 
education (FAPE) to eligible children in accordance with each 
child's IEP, provide "full educational opportunity," and to use 
the "least restrictive environment" in providing these 
opportunities.  Federal regulations clarify that children with 
disabilities must be allowed to participate in and to benefit 
from all programs and services, including non-academic and 
extra-curricular activities, that are available to children 
without disabilities [34 CFR 300.304-307].

The IEP also must specify what related services, if any, are 
required to help the child benefit from special education.  
Although federal regulations provide a list of services that may 
be covered as related services. Related services are an essential 
part of a children's appropriate education.  As stated in IDEA, 
these include, but are not limited to the following:

     transportation, speech pathology, occupational therapy, 
     audiology, psychological services, physical therapy, early 
     identification and assessment of disabilities, medical 
     services for diagnostic and evaluation purposes, school 
     health services, social work services, parent counseling and 
     training, counseling services.
     [34 CFR 300.13].

B.   Financing Assistive Technology

On August 15, 1990, the federal Office of Special Education 
Programs (OSEP) of the U.S. Department of Education, issued a 
policy letter which clarifies that assistive technology must be 
considered in the process of developing a child's IEP.  The 
letter noted that

     "if the participants on the IEP team determine that a child 
     with handicaps requires assistive technology in order to 
     receive [a] FAPE, and designate such assistive technology as 
     either special education or a related service, the child's 
     IEP must include a specific statement of such services, 
     including the nature and amount of such services."

Further, OSEP clarified that the Part B provisions for education 
in the least restrictive environment are linked to the use of 
assistive technology as "a form of supplementary aid or service 
utilized to facilitate a child's education in a regular 
educational environment."  The policy statement was contained in 
a letter from Judy Schrag, Director of the Office of Special 
Education Programs, to Susan Goodman (August 10, 1990).  A full 
copy of the letter may be found in Appendix C. 

Access to assistive technology under Part B was significantly 
reinforced by new language in IDEA (1990) to define assistive 
technology devices and services and include references to them 
throughout the legislation.

Assistive technology device is defined as any item, piece of 
equipment, or product system, whether acquired commercially off 
the shelf, modified, or customized, that is used to increase, 
maintain, or improve functional capabilities of individuals with 
disabilities.

Assistive technology services is defined as any services that 
directly assists an individual with a disability in the 
selection, acquisition or use of an assistive
technology services.  Such term includes:
     
(a)  the evaluation of needs...including a functional evaluation 
     ... in the individual's customary environment;
(b)  purchasing, leasing or otherwise providing for the 
     acquisition of assistive technology devices ... ;
(c)  selecting, designing, fitting, customizing, adapting, 
     applying, maintaining, repairing, or replacing of assistive 
     technology devices;
(d)  coordinating with other therapies, interventions, or 
     services with assistive technology devices, such as those 
     associated with existing education and rehabilitation plans 
     and programs;
(e)  training or technical assistance for an individual with 
     disabilities, or, where, appropriate, [his/her] family ... ;
(f)  training or technical assistance for professionals 
     (including individuals providing education and 
     rehabilitation services), employers, or other(s) who provide 
     services to, employ, or are otherwise. substantially involve 
     in the major life functions of individuals with 
     disabilities.
     [(20 USC Sections 1401 (a) (25); and (a) (26)].

C.   State Flexibility 

Participation in Part B is at state option, however, all states 
participate.  IDEA does not state precisely what educational 
program must be provided to eligible children.  IDEA lists only 
general goals as to its expectations (i.e., FAPE and "least 
restrictive environment") and defines in statute and regulations 
terms that are key to the provision of special education and 
related services, including assistive technology.  States vary 
widely in their special education funding levels; there is no 
federal match requirement.  There is also considerable state 
flexibility in the organization of special education services, 
for example, the use of intermediate school districts.  States 
also have the option of extending the entitlement beyond age 21.

D.   Current Policy Issues

A 1989 federal court decision reaffirmed a basic principle of 
entitlement for children with severe disabilities, overturning a 
previous ruling that a local school district could exclude a 
child on the basis that he or she was "too severely handicapped 
to benefit from education."  The U.S. First District Circuit 
Court of Appeals in the "Timmy W" case ruled as follows:

     "The language of the Act makes it clear that a 'zero reject' 
     policy is at the core of [P.L. 94-142] and that no child ... 
     is to ever again be subjected to the deplorable state of 
     affairs which existed at the time of the Act's passage, in 
     which millions of handicapped children received inadequate 
     education or none at all."
     [875 F.2nd, 954, 1st Circuit, 1989]

This ruling may positively affect access to special education for 
many children with severe disabilities who may require assistive 
technology.

Individual planning requirements in the 1990 IDEA amendments for 
the transition from school to employment and other adult 
activities may enhance access to assistive technology financing 
for high school age students.  Provisions were added to require 
inclusion of a statement of needed transition services within the 
IEP beginning at age 16 and as early as age 14 when appropriate 
to the individual student. 

The federal Office of Special Education Programs (OSEP) is 
beginning funding of new discretionary grants focused on 
assistive technology, and has funded five year extensions of 
grants for two technology centers.  OSEP also encourages 
coordination between state special education programs and 
assistive technology grantees of the National Institute on 
Disability and Rehabilitation Research (NIDRR), some of which are 
state education agencies or have special components on assistive 
technology in education.

Recent changes in legislation governing the Medicaid program also 
affect access to the funding of special education related 
services, including assistive technology.  The Medicare 
Catastrophic Coverage Act of 1988 (P.L. 100-360) expressly made 
Medicaid responsible for financing all related services stated on 
a Medicaid eligible child's IEP which also are covered services 
under the state's Medicaid Plan.  Although Congress later 
repealed most of the Medicare provisions of this law, the 
Medicaid provision remained unchanged.  The Omnibus Budget 
Reconciliation Act (OBRA) of 1989 (P.L. 101-239) amended the 
terms of the mandatory Medicaid Early Periodic Screening, 
Diagnosis and Treatment (EPSDT) services, to entitle children 
under age 21 to Medicaid reimbursement for any needed services 
eligible for Medicaid coverage under federal regulation, 
regardless of inclusion in the state Medicaid plan.  Such 
services are, however, subject to state definitions of medically 
necessary.

Finally, it should be noted that despite increased authorization 
levels in the 1990 amendments to IDEA, the federal contribution 
toward special education consistently has been significantly less 
than the 40 percent level envisioned in P.L. 94-142.  In FY 1991 
the federal share for special education programs was 
approximately 7.5 percent of the excess cost of educating 
students with disabilities.  It is possible that this may rise to 
eight percent in FY 1992.

E.   Facilitators

IDEA has clear policy to support the financing of assistive 
technology, including (1) the definitions of assistive technology 
devices and services included in the legislation, and (2) the 
OSEP policy letter clarifying access to assistive technology as 
special education, related service, or supplementary aids and 
services for children in regular classrooms, and (3) proposed 
regulations to implement IDEA.

IDEA provides an entitlement to a free appropriate public 
education for children with disabilities, and therefore for 
assistive technology necessary for a student with a disability to 
benefit from education.  Families may not be required to share in 
the cost of this technology or to use their private insurance for 
assistive technology that is included on the child's IEP.  There 
are clearly defined rights of appeal regarding eligibility and 
IEP decisions, including inclusion of assistive technology 
services and/or devices as part of a student's IEP.

Finally, the law requires each States to have a comprehensive 
system of personnel development.  These requirements have the 
potential to include standards regarding expertise in assistive 
technology.  Some potential help in access to financing and 
related knowledge dissemination may come from the federally 
funded Parent Training Centers in each state, authorized under 
Part G of IDEA, and the six regional resource centers that 
provide technical assistance to State Education Agencies in their 
implementation of the requirements of Part B of IDEA.

F.   Barriers

Numerous barriers have been identified to the financing of 
assistive technology through the Individuals With Disabilities 
Act.  These include (1) lack of knowledge, (2) eligibility, (3) 
federal funding and (4) lack of implementation of
federal requirements.

Despite the requirements for personnel development, lack of 
knowledge of assistive technology among special and regular 
education professionals (including those providing related 
services) is reported as a barrier.  Many parents also lack 
information in this area, and are therefore less able to 
participate knowledgeably in IEP discussions regarding their 
child's need for assistive technology.

Some children with disabilities may not be eligible for Part B 
services because eligibility is limited to the diagnostic 
categories listed in the legislation and accompanying 
regulations.  In addition, despite the Timmy W.  (875 F.2nd, 954, 
1st Circuit, 1989) ruling, local school districts may still 
question the ability to "benefit" from education for some 
children with particularly severe or challenging disabilities.  
Children with disabilities in segregated settings can be helped 
by assistive technology to participate in integrated educational 
settings.  Historical patterns of special and segregated 
placement make it more difficult to consider how access to 
technology would facilitate movement of a child to a less 
restrictive setting.

The chronic federal underfunding of special education also serves 
as a barrier.  Assistive technology is widely perceived by the 
education system as expensive.  Resource concerns may also be a 
factor in the reluctance of school district's reluctance to 
purchase customized technology that will not be usable by other 
students.  In some districts the policy that technology must 
remain on school property may also result from resource concerns.  
All too often IEP decisions about inclusion of assistive 
technology devices and services are made based upon available 
resources rather than individual needs.  A lack of knowledge 
about assistive technology by parents and children with 
disabilities diminishes their ability to challenge these 
decisions.  

A further barrier is the problem of implementation of federal 
assistive technology policy throughout the state and local 
educational systems.  Federal enforcement and monitoring of 
policy implementation by State Education Agencies is 
insufficient.  Although there is a federal requirement that each 
state is intended to receive a comprehensive review every three 
years, there is currently a federal monitoring visit only every 
five to seven years.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Increase knowledge of assistive technology throughout the 
     education system, through training, technical assistance, 
     and encouragement to states to provide training/technical 
     assistance to local education agencies (LEA);
.    Focus personnel development priorities on assistive 
     technology for regular and special educators and related 
     services personnel;
.    Strengthen federal monitoring to include an emphasis on 
     assistive technology inclusion in the Individualized 
     Education Plan (IEP) and state agency leadership on 
     assistive technology personnel development, adhering to the 
     minimum every three year schedule, and on-site monitoring at 
     the LEA level;
.    Expand/improve inter-agency collaboration at the federal 
     level, including possible pooling of resources with the 
     Maternal and Child Health Division (U.S. Public Health 
     Service) and the Administration on Developmental 
     Disabilities (Administration on Children and Families) to 
     finance research and technical assistance activities.
.    Expand data collection requirements at state and local 
     level.

LEGISLATIVE 
.    Increase federal funding to meet the statutory promise of 40 
     percent of excess cost of educating children with 
     disabilities.

STATE LEVEL:
.    Provide training/technical assistance on assistive 
     technology;
.    Require knowledge/competency in assistive technology in 
     personnel standards;
.    Promote coordination/knowledge dissemination with NIDRR 
     grantees and other assistive technology resources;
.    Monitor access to assistive technology at the 
     LEA/intermediate school district level.

2.   PART H:  STATE GRANTS FOR INFANTS AND TODDLERS

[USC Sections 1471-1485]

A.   Background

In 1986, Congress amended the law to add Part H, the Handicapped 
Infants and Toddlers Program (P.L. 99-457).  The program provides 
financial assistance to states "(1) to develop and implement a 
statewide, comprehensive coordinated, multidisciplinary, 
interagency program of early intervention services to infants and 
toddlers with disabilities and their families, (2) to facilitate 
the coordination of payment for early intervention services from 
Federal, State, Local, and private sources (including public and 
private insurance coverage), and (3) to enhance its capacity to 
provide quality early intervention services and expand and 
improve existing early intervention services being provided to 
infants and toddlers with disabilities, and their families" (P.L. 
99-457).  Infants and toddlers with disabilities are defined to 
include individuals from birth through age two who need early 
intervention services because they are experiencing delays in one 
or more specific developmental areas (e.g., physical development) 
or have a diagnosed condition which has a high probability of 
resulting in developmental delay.

P.L. 99-457 established a five year grant program to fund state 
early intervention systems planning and development.  As 
originally conceived, states would have their systems in place by 
the time of their acceptance of fifth year (FY 1991) funding; 
acceptance of the year five grant triggers entitlement to early 
intervention services for eligible children.  Amendments that add 
up to two one-year waivers for states having difficulty meeting 
the Part H requirements were included in P.L. 102-52 (June 1991), 
the one year extension of the Rehabilitation Act.  The waiver was 
coupled with a differential funding provision that will provide 
additional funds for implementation to states that are "on 
schedule."  Total federal funding authorized in FY 1991 is $189 
million; individual state grants are expected to range from 
$31,010 to $10,061,348, with an average state grant of 
$1,395,088.  An estimated 250,000 infants and toddlers with 
disabilities are projected to receive early intervention services 
in some way associated with Part H, however, the primary focus of 
federal funding is to help states in systems development and 
coordination, rather than to help finance the services 
themselves.  Part H funds can only be used as a last resort.

The legislation includes a definition of early intervention 
services that must be part of participating states' early 
intervention systems.  P.L. 102-119 added assistive technology 
services and devices to this list of required early intervention 
services.  Each eligible child is to receive services that are 
provided in conformity with an individualized family services 
plan (IFSP). 
Each state must have an Interagency Coordinating Council to 
advise the designated lead agency; applications for federal funds 
must be made available for public comment prior to submission.

B.   Financing Assistive Technology 

P.L. 99-457 lists the services that are likely to comprise a 
state's early intervention system. Many of these are assistive 
technology funding resources.

(1)  Case Management Services:  Case management services means 
     assistance and services provided by a case manager to a 
     child eligible under this part and the child's family.
(2)  Nursing Services:  Nursing services includes --
     (i)  The assessment of health status for the purpose of 
          providing nursing care, including the identification of 
          patterns of human response to actual or potential 
          health problems;  (ii) Provision of nursing care to 
          prevent health problems, restore or improve 
          functioning, and promote optimal health and 
          development; and (iii) Administration of medications, 
          treatment, and regimens prescribed by a licensed 
          physician.

(3)  Nutritional Services includes --
     (i) conducting individual assessments, (ii) developing and 
     monitoring appropriate plans to address the nutritional 
     needs of children eligible;  (iii) making referrals to 
     appropriate community resources to carry out nutritional 
     goals.

(4)  Occupational Therapy:  The Part H regulations for 
     occupational therapy expressly state that assistive 
     technology is included within its scope.  The regulations 
     define this services as follows:
     
     (S)ervices to address the functional needs of a child 
     related to the performance of self help skills, adaptive 
     behavior and play, and sensory, motor and postoral 
     development.  These services are designed to improve the 
     child's functional ability to perform tasks in home, school, 
     and community settings, and include:  (i) identification, 
     assessment and intervention; (ii) adaptation of the 
     environment, and selection, design and fabrication of 
     assistive and orthotic devices to facilitation development 
     and promote the acquisition of functional skills; and (iii)  
     prevention or minimization of the impact of initial or 
     future impairment, delay in development, or loss of 
     functional ability.

(5)  Physical Therapy:  The Part H regulations define physical 
     therapy to include:
     (i)  screening of infants and toddlers to identify movement 
     dysfunction;  (ii)  obtaining, interpreting, and integrating 
     information appropriate to program planning, to prevent or 
     alleviate movement dysfunction and related functional 
     problems, and  (iii) providing services to prevent or 
     alleviate movement dysfunction and related functional 
     problems.
     [34 CFR Section 303.12(d)(9)].

(6)  Special Instruction:  The Part H regulations define special 
     instructions as (i)  the design of learning environments and 
     activities that promote the child's acquisition of skills in 
     a variety of developmental areas, including cognitive 
     processes and social interaction;  (ii)  curriculum 
     planning, including the planned interaction of personnel, 
     materials, and time and space, that lead to achieving the 
     outcomes in the child's IFSP;  (iii)  providing families 
     with the information, skills, and support related to 
     enhancing the skill development of the child, and (iv) 
     working with the child to enhance the child's development.
     [34 CFR Section 303.12(d)(12)].

(7)  Speech Pathology and Audiology:  The Part H regulations 
     define audiology and include a reference to assistive 
     technology:
     ... (iii) referral for medical and other services necessary 
     for the habilitation or rehabilitation of children with 
     auditory impairment; (iv) provision of auditory training, 
     aural rehabilitation, speech reading and listening device 
     orientation and training, and other services; (v) provision 
     of services for prevention of hearing loss; (vi) 
     determination of the child's need for individual 
     amplification, including selecting, fitting, and dispensing 
     appropriate listening and vibrotectile devices, and 
     evaluating the effectiveness of those devices.
 
(8)  Speech-language pathology:  Speech pathology is defined by 
     Part H regulations to include:
     (i) identification of children with communicative or oral 
     pharyngeal disorders and delays in development of 
     communication skills, including the diagnosis and appraisal 
     of specific disorders and delays in those skills;  (ii) 
     referral for medical or other professional services 
     necessary for the habilitation or rehabilitation of children 
     with communicative or oral pharyngeal disorders, and delays 
     in development of communication skills, including the 
     diagnosis and appraisal of specific disorders and delays in 
     those skills; (iii) provision of services for the 
     habilitation, rehabilitation, or prevention of communicative 
     or oral pharyngeal disorders and delays in development of 
     communication skills.
     [34 CFR Section 303.12(d)(1)].

C.   Current Policy Issues

On October 7th, President George Bush signed the reauthorization 
legislation
for Part H of the Individuals with Disabilities Education Act, 
the program for Infants and Toddlers with Disabilities and their 
Families, originally enacted in 1986 as P.L. 99-457.  These 
amendments now become P.L. 102-119, the Individuals with 
Disabilities Education Amendments of 1991.

P.L. 102-119 makes no changes to the eligible population, 
remaining quiet in the Part H program on the issue of infants and 
toddlers who are "at-risk".

Additional amendments are included to streamline the transition 
process between the Part H program and the preschool program, and 
to ensure inclusion of infants and toddlers with disabilities in 
natural environments.   Of great interest to families of children 
with cerebral palsy and other severe and multiple disabilities is 
report language elaborating on the inclusion of assistive 
technology services and devices as a specifically authorized 
early intervention service.  This report language states:

     "The Committee recognizes the critical importance of 
     assistive technology in liberating many infants and toddlers 
     with disabilities and their families from barriers 
     encountered in all aspects of daily living, and in 
     significantly enhancing learning and development.  The 
     Committee has been made aware of many instances in which the 
     provision of assistive technology has dramatically altered 
     prospects for a child's future -- where access to technology 
     has resulted in labels being dropped, in the provision of 
     opportunities in integrated environments, in increased 
     confidence and ability of the child, and in changed 
     perceptions of the child by the family and others.  ...  The 
     Committee has added assistive technology services and 
     devices to the definition of early intervention services 
     under Section 672(2) in order to clarify that these 
     important supports are included as part of early 
     intervention services for those infants and toddlers and 
     their families who can benefit, and thus ensure their 
     provision when appropriate."

Although the final legislation is quiet on the issue of sliding 
fee scales, report language urges states to "undertake an 
in-depth analysis, including studying the experiences of other 
states, before adopting policies regarding sliding fees."  The 
final legislation also requires a study of the funding formula to 
determine policy implications of various potential changes.
D.   State Flexibility

The legislation established strict timelines over the five years 
for states to develop and implement comprehensive coordinated 
interagency programs statewide.  The essential state flexibility 
is in the option of participation in the Part H program.  At the 
present time all states continue to participate.  States have the 
option of covering children "at risk of developmental delay;" if 
covered, these children are also entitled to the full array of 
early intervention services.  However, at this time, only a few 
states have chosen this option.  There is no federal definition 
of "developmental delay" and "at risk;" states are required to 
develop their own definitions and eligibility criteria.

Similarly, states have flexibility in the designation of the lead 
early intervention agency and their coordination mechanisms.  The 
tremendous variety in state early intervention systems is 
mirrored in the great variety in Part H implementation, including 
the services being made available to children and their families.  
States also have the option to charge fees on a sliding scale for 
most early intervention services, however, very few states have 
done so to date.

E.   Facilitators

The primary facilitators in Part H are coordination and case 
management. Part H is premised on the assumption that there are 
some services currently in existence to aid infants, toddlers and 
their families.  Part H assumes that the greatest need is the 
coordination of all the existing programs that provide services 
to infants and toddlers with disabilities and their families, and 
to fill the gaps with new, Part H funds.  Congress intended that 
the state early intervention system would be comprised of a 
interlocked network of Federal, state, local and private service 
providers. Formal interagency agreements would create the 
network. 

Case management is an integral part within the early intervention 
services system.  The case manager has much potential to aid 
children and families in the design of a comprehensive and 
effective program of services including the provision of 
assistive technology and related services.

Also important to financing is the provision is the provision of 
Special Instruction in Part H.  Special Instruction can offer the 
same assistive technology opportunities as special education in 
the IDEA program for children
age 3-21.  Computers and other learning aids are appropriate 
means of providing instruction to children with disabilities, and 
both the hardware and programs can be provided as part of the 
child's special education.  Part H regulations defines special 
instruction as
     
     (i) the design of learning environments and activities that 
     promote the child's acquisition of skills in a variety of 
     developmental areas, including cognitive processes and 
     social interaction; (ii) curriculum planning, including the 
     planned interaction of personnel, materials, and time and 
     space, that lead to achieving the outcomes in the child's 
     (IFSP);  (iii) providing families with the information, 
     skills, and support related to enhancing the skill 
     development of the child, and (iv)  working with the child 
     to enhance the child's development.
     [34 CFR Section 303.12(d)(12)].

Finally, Part H requires the states to undertake a comprehensive 
system of staff development with the purpose of ensuring that 
infants and toddlers with disabilities, and their families, have 
access to skilled personnel who can provide the necessary early 
intervention services.

The Part H regulations permit states to incorporate staff 
development procedures used in other IDEA programs, or to devise 
a separate program for early intervention.  Pre-service and 
in-service training on assistive technology can be an important 
staff development effort. 
 
F.   Barriers

The primary barrier is lack of resources for services.  Although 
some early intervention resources are available from other 
sources, there are many gaps in most state systems that are well 
beyond Part H funding levels.  There is concern that the current 
entitlement for year five states may be to a waiting list rather 
than to assistive technology and other needed services.

Lack of knowledge of assistive technology, in particular its 
significance for children in the 0 - 2 age range, has been widely 
reported to be a barrier.  Cumbersome application and 
reimbursement systems have also been noted in some states. 

Part H funds are available only to supplement existing resources, 
not supplant
them.  In addition, Part H mandates that in relation to the funds 
available from every other program, its funds are to be used only 
as a last resort.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE
.    Promote knowledge development/dissemination on assistive 
     technology;
.    Support implementation and oversight in Medicaid legislation 
     to clarify and ensure that Medicaid is responsible for 
     appropriate Individualized Family Support Plan (IFSP) 
     services.
.    Expand data collection requirements at state and local 
     level.

LEGISLATIVE
.    Increase federal funding levels;
.    Change the funding formula to one based on numbers served.

STATE LEVEL:
.    Emphasize focus on assistive technology in IFSP development;
.    Provide training/technical assistance on assistive 
     technology, including      information/training to parents;
.    Include access to assistive technology as priority in 
     coordination initiatives.


V.   RELATED PROGRAMS

1.   EDUCATION OF HANDICAPPED CHILDREN IN STATE OPERATED OR 
     SUPPORTED SCHOOLS

[20 USC Section 2791]

A.   Background
In 1965 P.L. 89-313 established a program to help states finance 
the education of children with disabilities in state operated 
programs, primarily residential schools for children with 
specific disabilities (e.g., schools for the deaf).  Provisions 
in the Hawkins-Stafford Elementary and Secondary School 
Improvements Amendments of 1988 (P.L. 100-297) added "training in 
the use and provision of assistive devices and other specialized 
equipment" to the list of
authorized services.

Commonly referred to as 89-313 funds, these federal state 
operated programs were appropriated $148.8 million in FY 1991.  
States receive varying amounts of 89-313 funding based on their 
enrollment of children with disabilities (including infants and 
toddlers) in programs or schools operated or supported by a state 
agency which is directly responsible for the education or early 
intervention of such children.  In FY 1991 89-313 grants ranged 
from $22,967 to $24,727,529.  The total number of 89-313 children 
in FY 1991 is estimated to be 268,000.

The definition of eligible children under P.L. 89-313 is the same 
as that for IDEA Parts B and H in relation to their disability.  
In addition, 89-313 children must be those for whom the state is 
directly responsible for providing special education or early 
intervention services and either participating in state-operated 
or state-supported schools or programs for children with 
disabilities, or have previously participated in such a program 
and are now receiving special education or early intervention 
services from local education agencies. 

B.   Financing Assistive Technology

89-313 can be used to finance assistive technology for children 
with disabilities, including infants, toddlers and pre-schoolers, 
who meet the 89- 313 criteria.  Programs and projects may 
include, but are not limited  --

     1)   services provided in early intervention, preschool, 
          elementary, secondary, and transition programs;
     2)   acquisition of equipment and instructional materials;
     3)   employment of special personal;
     4)   training and employment of education aids;
     5)   training in the use and provision of assistive devices 
          and other specialized equipment;
     6)   training of teachers and other personnel;
     7)   training for parents of children with disabilities;
     8)   training of nondisabled children to facilitate 
          participation with children with disabilities in joint 
          activities;
     9)   training of employers and independent living persons 
          involved in the transition of children with 
          disabilities from school to the world of work and 
          independent living;
     10)  outreach activities to identify and involve children 
          with disabilities and their families more fully in a 
          wide range of educational and recreational activities 
          in their communities; and 
     11)  planning for, evaluation of, and dissemination 
          information regarding such programs and projects 
          funded.

C.   State Flexibility

States have great flexibility in their use of program funds.  In 
particular, they have latitude in their definition of what 
constitutes a state operated program.  Some states identify 
proportionately large numbers of 89-313 students; four states 
receive nearly half of all federal 89-313 funds. 

D.   Current Policy Issues 

Congress has raised several questions regarding the continuing 
viability of the 89-313 program in light of the implementation of 
IDEA Parts B and H.  The conference report on the FY 1991 
appropriations legislation included a statement in support of the 
future transfer of 89-313 to IDEA.  One issue related to this 
debate is the incentive states have had to classify children as 
89-313 rather than IDEA, due to the higher federal funding per 
child.  Although the gap between 89-313 and IDEA funding was 
narrowed by the IDEA amendments of 1990, some effects of the 
incentive remain.  The question of merging or transferring 89-313 
to IDEA also was raised by the General Accounting Office (GAO) in 
a report requested by the Congress as part of P.L. 100-297.

The GAO reported that although the program was generally 
considered to be targeted to children with more severe 
disabilities, some states were using the program for children 
with milder disabilities - presumably in order to collect the 
higher federal rate.  The Department of Education is generally 
supportive of such a merger, providing that it is phased in and 
that states are "held harmless" in the amount of funding 
received.

There is considerable variation among states regarding the use of 
89-313 grants to finance assistive technology.  A recent 
questionnaire found that 17 percent of the states responding 
indicated that they never use 89-313 funding for assistive 
devices and equipment.  Advocates for integrated early 
intervention and education have not been successful in efforts to 
require states to use a
designated portion of their 89-313 funds for students 
transferring to local schools, and there is continuing support 
among other advocates for 89-313 funding of the traditional state 
schools.

E.   Facilitators

89-313 funds can be used for assistive technology, which is 
specifically included in the list of services that can be 
provided.  In addition to providing more federal funding per 
pupil than IDEA, 89-313 funding is considered to be more 
flexible.  For example, assistive technology equipment purchased 
with 89-313 funds can be used to benefit other children in the 
same school or classroom.  Advocates for integrated education 
also applaud the transfer provision, which can improve access to 
assistive technology for students moving from a state operated to 
local school or early intervention program.  89-313 funds for 
training and personnel are important to the promotion and access 
to appropriate assistive technology and related services.

F.   Barriers

There is a lack of knowledge of assistive technology among 89-313 
program personnel paralleling the lack of knowledge throughout 
the education system.  Resources are generally seen as 
inadequate, despite the fact that federal funding rates have been 
higher than those for special education students.  Advocates for 
the use of 89-313 to finance assistive technology and other 
supports to students transferring to their local education/early 
intervention programs have been frustrated by the reluctance of 
state 89-313 administrators in several states to use the transfer 
provision.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Promote assistive technology knowledge 
     development/dissemination in coordination with IDEA;
.    Do more to encourage use of the transfer provision, with 
     enhanced use of assistive technology as a component.

LEGISLATIVE 
.    If folded into IDEA, ensure that current 89-313 funding 
     levels per student
     are maintained.

STATE LEVEL:
.    Emphasize use of assistive technology; include in standards 
     for 89-313 programs;
.    Explore ways assistive technology can expand use of the 
     transfer provision.
2.   VOCATIONAL EDUCATION (CARL D. PERKINS VOCATIONAL AND APPLIED 
     TECHNOLOGY EDUCATION ACT)

[20 USC 2331-2342]

A.   Background 

The Vocational Education Act of 1963 (P.L. 88-210) as amended by 
the Carl D. Perkins Vocational and Applied Technology Act of 1990 
(P.L. 101-392), authorizes a program of federal grants to the 
states to assist them in developing vocational education programs 
through the public school system.

The purpose of the Act is to make the U.S. more competitive in 
the world economy by developing more fully the academic and 
occupational skills of all segments of the population, 
principally through concentrating resources on improving 
educational programs leading to academic and occupational skill 
competencies needed to work in a technologically advanced society 
(the Carl D. Perkins Vocational and Applied Technology Act 
Amendments of 1990 - P.L. 101-392).

State boards of vocational education receive federal grants 
according to a formula that is based on state population in 
various age groups and per capita income.  The formula is 
weighted to state populations of youth age 15 - 19 and to states 
with lower per capita incomes.  The range of state grants in FY 
1991 was from $190,000 to $76,918,280, with an average of 
$14,794,000; total federal appropriations for FY 1991 were $957.9 
million, including $849,4 mullion for the state grants, an 
additional funds for technology p[reparation, state councils, and 
other purposes.

The amendments of 1968 (P.L. 90-576) added a requirement that 10 
percent of the state vocational education grant be set aside for 
vocational education of students with disabilities.  This 
provision was deleted in the amendments of 1990.  Instead, 
students with disabilities are one of several categories of 
"special populations."   The amendments stipulate that 
individuals who are members of special populations must be 
provided with equal access to recruitment, enrollment, and 
placement activities, as well as equal access to the full range 
of vocational education programs available to individuals who are 
not members of special populations.

In addition to the general assurances for special populations, 
the law requires that individuals with disabilities be served in 
conformity with IDEA and Section 504 of the Rehabilitation Act 
and in the least restrictive environment. If the student has an 
IEP, service must be provided in accordance with it. If the 
student does not have an IEP, services must be provided under 
Section 504 guarantees.  Such rights and protections are to 
include making vocational education programs readily accessible 
to eligible individuals with disabilities through the timely 
provision of information and coordination.  P.L. 101-392 also 
added requirements for public participation in the state 
vocational education planning process, including representatives 
of people with disabilities and other special populations.  

States also must conduct assessments of their current vocational 
education systems, and use 75 percent of the grant for program 
improvement/grants to LEAs, with funding priority to sites or 
programs that serve the highest concentrations of special 
populations.  Allocations to LEAs are restricted to those 
receiving Chapter I Education funds; eligible LEAs also must 
receive vocational education funding in proportion to their 
percentage of students with IEPs under IDEA.  The law further 
requires that local applications contain a report on the number 
of special population individuals being served, an assessment of 
the needs of special populations, and the planned use of funds to 
meet those needs.  This application must also show that parents 
and special population students have been involved in developing 
programs and that there has been coordination with 
community-based organizations.

B.   Financing Assistive Technology

Each state must provide assurances that it will:  (1) assist 
students who are members of special populations to enter 
vocational education programs and, with respect to students with 
disabilities, assist in fulfilling the transitional service 
requirements of Section 626 of IDEA; (2) assess the special needs 
of students participating in programs receiving assistance with 
respect to their successful completion of the vocational 
education program in the most integrated setting possible; and 
(3) provide supplementary services to students who are members of 
special populations. The state must also assure modifications of 
curriculum, equipment, and classrooms, supportive personnel, and 
instructional aids and devices.  Counseling and career guidance 
is required also for people with disabilities.

In addition, students with disabilities are covered by IDEA and 
Section 504 requirements regarding education and related 
services, access to services, and rights of appeal.

C.   State Flexibility

There is considerable state flexibility in the design of 
vocational education programs, priorities based on identified 
needs, supplementary state funding levels, and oversight of 
implementation at the local level. States have limited 
flexibility in the allocation of funds to LEAs, and must follow 
funding allocation formulas specified in the legislation.  There 
is more flexibility at the local level, including decisions at 
individual schools regarding which programs to fund.

D.   Current Policy Issues

Proposed regulations to implement the new provisions of P.L. 
101-392 were published on October 11, 1991.  Concerns have been 
raised by several advocates for students with disabilities and 
other special populations on the initial implementation of P.L. 
101-392, including weaknesses in the new public hearing process 
and reports in some states that the dropping of the 10 percent 
requirement for students with disabilities is being interpreted 
as no longer having to provide vocational education to these 
students.

Questions also have been raised about the quality of needs 
assessments being conducted.  Discretionary funding for research 
and technical assistance also is authorized under the Act, 
including $5 million per year to the National Center for Research 
on Vocational Education, currently at the University of 
California at Berkeley.  These activities can include assistive 
technology, although a focus on assistive technology is not 
mandated.

E.   Facilitators

Assistive technology is specifically identified as a 
supplementary service to be provided to students with 
disabilities.  The link to IDEA and Section 504 provides 
additional policy in support of access.  The inclusion of 
students with disabilities as one of the special populations 
further supports full access to vocational education programs.  
Participation and, potentially, increased access to assistive 
technology, can be enhanced through knowledgeable public
participation in the development and review of state vocational 
education plans.
F.   Barriers

The primary barrier being reported at this time is on the 
implementation of the new provisions of P.L. 101-392, in 
particular the misunderstanding in several states that 
elimination of the set-aside for students with disabilities 
relieves them from responsibility for services to this 
population.  However, implementation is still just getting 
started.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Clarify and enforce full access to federally funded 
     vocational education programs for students with 
     disabilities;
.    Clarify that a full range of assistive technology can be 
     provided through the vocational education program, based on 
     the definitions found in IDEA and the Technology-Related 
     Assistance Act;
.    Develop/disseminate policy clarifying that assistive 
     technology is to be considered in the vocational education 
     process, similar to that previously issued by the Office of 
     Special Education Programs;
.    Promote assistive technology knowledge 
     development/dissemination;
.    Reinforce/monitor full access, public participation, and 
     effective needs assessment, including assistive technology.


VI.  THE REHABILITATION ACT OF 1973, AS AMENDED

ÀÀ Title I, Basic State Grants
ÀÀ Title VI-C, Supported Employment
ÀÀ Title VII, Independent Living

[29 USC 720 et seq.]

Background

As described in the 1986 amendments to the Rehabilitation Act 
(P.L. 99-506), the purpose of this Act is

     "to develop and implement through research, training, 
     services,
     and the guarantee of equal opportunity, comprehensive and 
     coordinated programs of vocational rehabilitation and 
     independent living, for individuals with handicaps in order 
     to maximize their employability, independence, and 
     integration into the workplace and the community." [P.L. 
     99-506]

Individuals with handicaps are defined in law and regulation as

     "any individual who (i) has a physical or mental disability 
     which for such individual constitutes or results in a 
     substantial handicap to employment and (ii) can reasonably 
     be expected to benefit in terms of employability from 
     vocational rehabilitation services."
     [34 CFR Section 361.1]

Three titles are significant in terms of their impact on 
financing of assistive technology.  These include Title I (the 
Basic State Grant Program), Title VI-C (State Supported 
Employment Services Program), and Title VII (Independent Living 
Services). Prior to 1986, there was little statutory emphasis in 
these Titles on assistive technology.  However, the 1986 
amendments placed a new emphasis on access to assistive 
technology and by adding requirements for an assessment of the 
need for rehabilitation engineering (i.e., assistive technology) 
for people applying for federally funded rehabilitation services, 
by exempting rehabilitation engineering from the requirement for 
consideration of similar benefits (see below).  The amendments 
also required states to indicate in their state vocational 
rehabilitation plan how rehabilitation engineering will be 
provided to assist an increasing number of individuals with 
disabilities.

The law defines rehabilitation engineering as follows:

     The systematic application of technologies, engineering 
     methodologies, or scientific principles to meet the needs of 
     and address the barriers confronted by individuals with 
     handicaps in areas which include education, rehabilitation, 
     employment, transportation, independent living, and 
     recreation.
     (P.L. 99-506)

The requirement to provide assistive technology was reinforced by 
a policy directive issued by the Commissioner of the federal 
Rehabilitation Services Administration to state vocational 
rehabilitation agencies on November 16,
1990.  The directive noted that

     "It is the policy of the Rehabilitation Services 
     Administration (RSA) to promote, encourage and support the 
     application of rehabilitation engineering technology in the 
     provision of services to people with disabilities ... ."

A copy of this directive is included in Appendix C.

The amendments on rehabilitation engineering primarily affect the 
Title I Basic State Grant program; however, these provisions also 
can influence activities provided under other sections of the 
Act.

1.   Title I:  Basic State Grants

A.   Background

Title I of the Rehabilitation Act authorizes formula grants to 
designated state vocational rehabilitation agencies; the 
estimated total federal funding in FY 1991 is $1,593,287,000.  
Federal funds are distributed to the states based on population 
weighted by per capita income.  States are required to match 
their federal funds they receive; the 1986 amendments raised the 
requirement for state matching funds one percent per year 
beginning in FY 1988, from 20 percent to 25 percent by FY 1993.  
A total of 216,109 persons received services from state 
vocational rehabilitation agencies in FY 1990, which represents 
two percent less than the number of individuals served in FY 1989 
(220,408).

The purpose of the VR Basic State Grant program is "to assist 
states to meet the current and future needs of handicapped 
individuals so they may prepare for and engage in gainful 
employment to the extent of their capabilities" (P.L. 93- 112).  
The scope of authorized activities include assessment, 
counseling, training, and rehabilitation engineering/assistive 
technology.  States have wide latitude and significant discretion 
in providing a wide array of additional services.  As noted 
above, state vocational rehabilitation agencies are required to 
assess each applicant's need for rehabilitation engineering.

The 1973 amendments to the Rehabilitation Act (P.L. 93-112) 
required that priority for service be given to individuals with 
severe handicaps.  The law and
regulation define such individuals as a person:

     "(i) who has a severe physical or mental disability which 
     seriously limits one or more functional capacities (such as 
     mobility, communication, self-care, self direction, 
     interpersonal skills, work tolerance, or work skills) in 
     terms of employability; (ii) whose vocational rehabilitation 
     can be expected to require multiple vocational 
     rehabilitation services over an extended period of time; 
     (iii) whose has one or more physical or mental disabilities 
     resulting from amputation, arthritis, autism, blindness, 
     burn injury, cancer, cerebral palsy, cystic fibrosis, 
     deafness, head injury, heart disease, hemiplegia, 
     hemophilia, respiratory or pulmonary dysfunction, mental 
     retardation, ental illness, multiple sclerosis, muscular 
     dystrophy, musculoskeletal disorders, neurological disorders 
     (including stroke and epilepsy), paraplegia, quadriplegia 
     and other spinal cord conditions, sickle cell anemia, 
     specific learning disability, end-state renal disease, or 
     another disability or combination of disabilities determined 
     on the basis of an evaluation of rehabilitation potential or 
     cause comparable substantial functional limitation."
     [34 CFR Section 361.1]

State eligibility for the Title I Basic State Grant requires 
submission of a comprehensive rehabilitation services plan every 
three years.  The plan must include a description of and 
justification of the state's order of selection, the policies and 
procedures to be employed if vocational rehabilitation services 
must be rationed because of insufficient funds.  As noted above, 
states also must include information on how they plan to increase 
the number of individuals with disabilities who will be assisted 
by rehabilitation engineering.

Other key state plan requirements include an assurance that each 
person will receive rehabilitation services consistent with an 
individualized written rehabilitation plan (IWRP), a description 
of methods to be used in expanding services to individuals with 
the most severe disabilities, and assurances that the state has 
an acceptable plan for providing supported employment services 
through Title VI- C of the Act (see below).

Individual eligibility for vocational rehabilitation (VR) 
services funded through Title I is determined by state VR 
agencies within federal guidelines.  Eligible individuals are 
those with a physical and/or mental disability which "constitutes 
or results in a substantial disability to employment" and for 
whom vocational
rehabilitation service may "reasonably be expected to be 
beneficial in terms of employability" (34 CFR 361.1).  As 
previously described, priority for services must first be given 
to individuals with severe handicaps.

The eligibility determination process must include consideration 
of the person's need for assistive technology (i.e., 
rehabilitation engineering.)  An extended evaluation (up to 18 
months) may be used to determine rehabilitation potential.  
Individuals not accepted as Title I VR services clients may 
appeal their rejection through the VR Client Assistance Program.  
In addition, the regulations state that before a person can be 
declared ineligible for Title I VR services, there must be clear 
evidence that the person is ineligible for services (34 CFR 
361.35).

Although there is no federal requirement to limit access based on 
financial need, the Act permits states to impose such criteria if 
they are in writing, included in the state plan, and specify 
which services will be exempt from financial need consideration.  
No financial needs tests are permitted, however, for the 
evaluation of rehabilitation potential, counseling or placement 
services; for all other VR services the state VR agency may 
examine whether the person has the resources to pay for some or 
all of the cost of the services being covered.

B.   Financing Assistive Technology

The Individualized Written Rehabilitation Program (IWRP) is the 
basic document outlining the vocational objectives toward which 
the individuals will work.  The IWRP must list all services to be 
provided under the plan, and specify the expected date when each 
service will commence.  If rehabilitation engineering services 
are to be provided, they too must be stated on the IWRP.

Rehabilitation engineering services provides opportunity for 
assistive technology devices to be provided to persons with 
disabilities through the Title I VR program.  The key is to tie 
the rehabilitation engineering services to the person's 
vocational objective, i.e., one of the activities that comprise 
the definition of employability. 

Regulations implementing the Act define employability as a 
determination that "with the provision of vocational 
rehabilitation services, the individual is likely to enter or 
retain, as a primary objective ... employment".  The definition
provides that employment can be any of the following:
     full time or part time competitive work
     the practice of a profession
     self employment
     homemaking
     farm or family work
     sheltered employment
     home based employment
     supported employment
     other gainful work
     [34 CFR Section 361.1.]

Title I VR program is considered the payer of last resort and 
thus requires consideration of similar benefits, i.e., whether 
the person is eligible for any other federal or state program 
that may fund some of the necessary services.  The statute 
requires consideration of similar benefits for most VR services.  
Regulations specify that the following services are exempt from 
this requirement:

     (i)  evaluation of rehabilitation potential;
     (ii) counseling and guidance;
     (iii)vocational training;
     (iv) placement;
     (v)  rehabilitation engineering;
     (vi) post-employment services.

     [29 U.S.C Section 721(a)(8); 34 CFR Section 361.47(b)]

The November 1990 RSA policy directive informs states that this 
does not mean that "if such services are readily available to the 
individual from other sources they should not be utilized by VR 
agencies." (see Appendix C)

C.   State Flexibility

There are four areas of state discretion which may affect access 
to the financing of assistive technology:  (1) flexibility in the 
way basic and priority (i.e., individuals with severe handicaps) 
eligibility is determined; (2) state definition of order of 
selection; (3) state options in the use of financial need 
determination; and (4) the amount of state funds appropriated, 
with some states
providing considerable funds above the required state match.  
States also may choose not to provide the full state match, and 
therefore may lose a portion of their federal Title I grant 
amount.
D.   Current Policy Issues

Those with severe multiple or very challenging disabilities are 
still denied entry into vocational rehabilitation under the 
assumption that the severity of their disability would prevent 
their ability to enter and maintain employment.  Of critical 
importance in such denials are the concepts of feasibility for 
employment/ employability, which are embedded in the eligibility 
process for the current system.

Individuals who have been determined eligible for other federal 
or state disability-related programs and services should be 
presumed eligible for rehabilitation services.  Under such a 
system, the rehabilitation agency would be required to reach out 
to agencies which conduct disability-related programs, and should 
include education agencies. For many individuals, this process 
would shorten substantially the time between application and 
initiation of services, streamlining entry and eliminating costly 
and time-consuming duplicative evaluations.

In addition, provisions could be added to the Rehabilitation Act, 
probably in a new section of Title 1, to deal specifically with 
transition from school to work.  The provisions would build on 
the new transition provisions added to the Individuals With 
Disabilities Education Act (IDEA) last year, and are based on 
data showing that fewer than half of youth with disabilities find 
competitive, paid employment.

Furthermore, the current definition of severe disability needs to 
be maintained and strengthened to tie it to functional 
limitations.  The current requirement that state agencies specify 
an Order of Selection when they anticipate that they will be 
unable to serve every individual with disabilities who meets 
eligibility requirements is also a necessary safeguard to focus 
on the needs of individuals with the most severe disabilities. 

Last but not least, assistive technology has unlocked access to 
and ability to control environments for individuals with 
disabilities enabling improved independence and productivity in 
the home and workplace.  Without a doubt, the explosion of 
technology will ultimately remove most of the biggest barriers to 
integrated, competitive employment for people with the most 
severe disabilities.  The focus of rehabilitation must shift from 
counseling to enabling access.   Assistive technology is a means 
to unlock ability and provide
workplace skills. 
E.   Facilitators

The Title I program has several features that facilitate -- or 
have the potential to facilitate -- access to the financing of 
assistive technology.  These include clear policy statements in 
support of access, broad eligibility, an appeals process, 
requirements for outreach, broad coverage of assistive 
technology, promotion of funding coordination, and mechanisms to 
enhance staff qualifications.  Opinion is divided regarding the 
adequacy of federal Title I funding levels and the 
appropriateness of the level of state flexibility.

The specific references to rehabilitation engineering (i.e., 
assistive technology) in the legislation, coupled with RSA policy 
statements on implementation, are considered particularly 
significant.  As described above, these include the requirement 
that rehabilitation engineering be considered in the individual's 
initial assessment and in development of the person's IWRP and 
the state plan requirements that the state spell out how it will 
increase people's access to rehabilitation engineering and 
funding on a case by case basis of appropriate technology devices 
and services.

The exemption of rehabilitation engineering from the similar 
benefits provision is generally seen as a facilitator, as access 
to financing is not delayed for long periods during back and 
forth negotiations with other potential payment sources.  
(Related therapies, however, are subject to the similar benefits 
requirement.)  The legislation contains a state plan requirement 
for assurances of staff development programs.  Resources to 
enhance personnel quality (e.g., counselors and therapists) are 
authorized in other parts of the Rehabilitation Act.

Access to financing also is enhanced by the priority given to 
people with severe disabilities through a mandated Order of 
Selection process that goes into effect whenever the state feels 
it is incapable of meeting all the needs of its applicants for 
services.  The Order of Selection is required to ensure that 
persons with the most severe disabilities are served first.

Finally, access to financing is also facilitated by a prohibition 
on discrimination on the basis of age or type of disability.  The 
expectation of outreach in the state plan requires strategies to 
increase the use of rehabilitation engineering and facilitates 
access. 
F.   Barriers

The primary barrier identified is variable and weak state 
implementation of the federal policies and requirements that 
promote access to assistive technology, in particular the 
rehabilitation engineering amendments of 1986.  This has been 
recognized by RSA in its policy directives of fall 1990 and in 
its provision of additional resources for monitoring and 
technical assistance.

Other barriers include concerns about the basic eligibility 
concepts, gaps in coverage because of limits imposed by 
individual states, incentives for the lowest cost assistive 
technology, and cumbersome funding approval procedures.  Many 
advocates view the Title I eligibility criteria as a barrier, in 
particular the way concepts of feasibility for rehabilitation and 
employability are applied to exclude many people with severe 
disabilities.

There is also a concern that the broadness of the Act's 
definition of severe handicap makes it possible for state 
agencies to meet their priority requirement without necessarily 
serving significant numbers of people with the level of 
functional disability defined in such legislation as the 
Developmental Disabilities Assistance and Bill of Rights Act.  
This concern is magnified when assistive technology is not 
adequately considered during the evaluation (individual 
assessment) process.

Two barriers widely associated with this issue are a lack of 
knowledge among rehabilitation personnel and the slow pace of 
implementation of the 1986 amendments.  Resources also may be a 
factor in limiting access to financing.  States frequently place 
limits on the scope of assistive technology that can be covered 
or caps on the amount that can be expended.  Some states also 
require that assistive technology be purchased through the 
state's procurement program, which may limit access to specially 
designed items as well as being a generally cumbersome process.  
Opinion is divided regarding the adequacy of federal Title I 
funding levels for purchase of assistive technology devices and 
services to respond to individuals needs.  Although funding has 
not kept up with inflation, some advocates feel that the issue is 
more one of how funds have been used (e.g., for state program 
administration and eligibility determination) rather than 
inadequate levels.

Additional barriers identified include a lack of attention by RSA 
to monitoring state implementation of the 1986 assistive 
technology amendments and no
funding of national or regional technical assistance efforts  to 
identify and replicate  effective approaches to eligibility 
determinations utilizing rehabilitation technologies.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Enforce policies on the use of assistive technology in the 
     assessment/evaluation process and inclusion in 
     Individualized Written Rehabilitation Plans (IWRP);
.    Conduct a major training and technical assistance initiative 
     on assistive technology service delivery, including 
     information/technical assistance for individuals with 
     disabilities and employers;
.    Continue/enhance the promotion of effective transition from 
     school to work, including the importance of continuity in 
     access to assistive technology.

LEGISLATIVE 
.    Redefine the goal of the statute as provision of support to 
     all people with disabilities who want to work;
.    Eliminate outmoded concepts of employability and feasibility 
     as a basis for eligibility to the program which continues to 
     be used to discriminate against people with severe and 
     multiple disabilities;
.    Change the focus/program incentives from closure to 
     employment outcomes, i.e., jobs, and place more emphasis on 
     the individual's preferences in employment, career goals, 
     and supports;
.    Modify definition of rehabilitation engineering to assistive 
     technology and use the same definitions as in IDEA and the 
     Technology-Related Assistance Act;
.    Encourage or mandate states to require knowledge/training in 
     assistive technology for VR counselors and IWRP reviewers;
.    Put more resources into training/technical assistance.

STATE LEVEL:
.    Develop/expand assistive technology knowledge and competency 
     among counselors and those who review evaluations and IWRPs;
.    Provide technical assistance as needed;
.    Assure that assistive technology is considered in the 
     evaluation and IWRP
     process, especially for those with severe and multiple 
     disabilities, and including those with severe disabilities 
     other than spinal cord injury.

2.   Title VI-C:  Supported Employment Services For Individuals 
     With Severe Disabilities 

A.   Background

Title VI, Part C of the Rehabilitation Act authorizes 
supplementary federal grants to assist states in developing 
collaborative programs with appropriate public agencies and 
private nonprofit organizations for training and traditionally 
time-limited post-employment services leading to supported 
employment for individuals with severe handicaps (P.L. 99-506).

Supported employment is defined as "competitive work in 
integrated settings - (1) for individuals with severe handicaps 
for whom competitive employment has not traditionally occurred; 
or (2) for individuals for whom competitive employment has been 
interrupted or intermittent as a result of a severe disability, 
and who because of their handicap, need ongoing support services 
to perform such work" (P.L. 99-506).

Regulations implementing the supported employment program define 
competitive work as "work that is performed on a full-time basis 
or on a part-time basis, averaging at least 20 hours per week for 
each pay period, and for which an individual is compensated in 
accordance with the Fair Labor Standards Act" [34 CFR 363.7].

The FY 1991 federal appropriation for the Supported Employment 
program was $29.15 million.  Grants to states ranged from 
approximately $250,000 to $3,048,825, averaging a little over 
$500,000 per state.  Unlike the Title I State Grant Program, 
there is no state match requirement for Title VI-C Supported 
Employment funds.  Since this program is intended to assist 
people with the most severe disabilities become employed, 
assistive technology plays an important role in its 
implementation.  Additional funding for supported employment 
services is provided in virtually all states through the Title I 
program.  Other resources for supported employment have been 
available in the twenty-seven states which have received federal 
supported employment Systems Change grants; an additional 
seventeen began October 1, 1991.

In total, approximately 73,000 individuals were estimated to have 
participated in supported employment programs during FY 1990.  A 
little over 52,000 individuals with severe disabilities 
participated in supported employment during FY 1989, the last 
year for which this information is available.

To be eligible for Title VI-C supported employment grant funds a 
state must submit a supplement to its basic state rehabilitation 
plan, showing how the state will provide services leading to 
supported employment for persons with severe handicaps.  A key 
requirement is that the state indicate the resources for extended 
supported employment services; these must be provided by sources 
other than the state VR agency (i.e., other public agencies and 
private organizations.)

B.   Financing Assistive Technology

Because supported employment is required to be a collaborative 
effort among many agencies and programs, it should be viewed as 
offering the most complete array of funding possibilities for 
assistive technology.  Individuals become eligible for supported 
employment under Title VI-C by going through the eligibility 
determination and assessment process for Title I services; they 
are referred to supported employment based on the assessment that 
supported employment is their appropriate employment goal.  
Services to be provided are specified in their IWRP.  A 
non-exclusive list of allowable Title VI-C services includes such 
items as an evaluation of rehabilitation potential which is 
provided supplementary to the evaluation provided under Title I.  
Evaluation of rehabilitation potential includes:  
     the provision of rehabilitation engineering services to any 
     individual with a handicap (disability) to assess and 
     develop the individual's capacities to perform adequately in 
     a work environment.
     [P.L. 99-506]                          
 
Assistive technology could be considered for financing as other 
services needed to support employment; anything that can be 
funded under Title VI-C can be funded under Title I.  VR funding 
for supported employment, however, under either Title I or Title 
VI-C, is limited to a maximum of 18 months duration.  If 
assistive technology is needed beyond that period, funding has to 
come from other (non- VR) sources.

C.   State Flexibility

This is a formula grant program available to all states meeting 
application requirements.  While all states participate, 
variation in priority/target populations may occur from state to 
state.

D.   Current Policy Issues

RSA hopes to increase participation in supported employment by 
people with severe disabilities over the next few years through a 
discretionary grant program.  One aspect would be to promote the 
use of assistive technology for this population.

E.   Facilitators

As described above in relation to Title I, the Basic State Grant 
program, generally apply to the Title VI-C program.  Thus, while 
there is no clear policy statement in Title VI-C regarding access 
to assistive technology (rehabilitation engineering), the 
requirement that assistive technology be addressed in the IWRP if 
found appropriate would extend to the supported employment 
program.  In addition, the Title VI-C program defines people with 
severe disabilities (handicaps) as the target population, 
although this is still evolving in its implementation.

Before individuals are rejected for Title I services, they are to 
be assessed for supported employment as well.  Agencies to be 
involved in both short term and long term (extended services, 
i.e., beyond the eighteen months of VR support) are required to 
be identified in the supported employment IWRP, and state plans 
are to indicate the non-VR resources to be used.

Indirectly, the requirements that long term funding sources be 
identified for extended services can promote coordination among 
funding sources; as described below, however, these requirements 
also act as a major barrier.

F.   Barriers

The ban on VR funding of supported employment beyond 18 months 
and the requirement that funding for supported employment after 
the 18 months be identified as a condition of eligibility acts as 
a major barrier to the financing of assistive technology through 
this program.  Those particularly affected are individuals for 
whom there is no designated state agency of responsibility, e.g.,
people with physical disabilities who do not come under the 
responsibility of their respective state mental 
retardation/developmental disability or mental health agency.

The second major barrier is the overall slow pace of change in 
serving those with the more severe disabilities, and the outdated 
concepts in the system regarding feasibility and employability, 
affecting many who could benefit from access to assistive 
technology.  In addition the requirement that people must average 
20 hours per week per pay period also functions as a barrier for 
some individuals.  
Lack of knowledge of assistive technology among supported 
employment professionals contributes to these barriers. 
Individuals may find dollar caps on the assistive technology that 
can be financed through the program in some states.

Another barrier is the requirement for multiple evaluations 
(i.e., for Title I eligibility, for the initial IWRP, and for 
supported employment), which can be a cumbersome process for the 
individual.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE & LEGISLATIVE 
.    Consider elimination of the 20 hour per week requirement;
.    Eliminate the requirement for identification of the 
     long-term funding before providing services;
.    Eliminate the requirement for mandatory job skills training 
     twice a week on-site;  use only as appropriate on an 
     individual basis.

STATE LEVEL:
.    Eliminate redundant assessments by including identification 
     for assistive technology and other supports in the initial 
     evaluation/IWRP;
.    Promote the use of assistive technology as needed on an 
     individual basis;
.    Integrate Title I/Title VI-C and other supported employment 
     program procedures;
.    Provide training/technical assistance on assistive 
     technology in coordination with the Title I program.
.    Examine options in long-term funding in collaboration with 
     other federal  agencies, state officials (both disability 
     services and vocational
     rehabilitation agencies), consumers and advocates.
3.   Title VII:  Comprehensive Services For Independent Living

A.   Background

The 1978 amendments to the Rehabilitation Act (P.L. 95-602) added 
Title VII, including Part A, authorizing formula grants to the 
states for comprehensive services; Part B for discretionary 
federal grants to support centers for independent living.  Part C 
is to assist states in providing services to older individuals 
with blindness.

The target population of these programs is people for whom other 
VR services have not been considered appropriate because of the 
severity of their disabilities.

The FY 1991 appropriations for these programs are --

                        Part A: $13,619,000
                        Part B: $27,579,000
                        Part C: $5,900,000.

Grants to states range from $16,173 to $948,651 in Part A, 
$175,000 to $225,000 in Part B, and $193,000 to $250,000 in Part 
C.  The state match requirement is 10 percent.

The estimated number served in FY 1991 was 18,500 in Part A, 
76,500 in Part B, and 8,000 in Part C.

Services funded under Title VII must be designed "to meet the 
current and future needs of individuals whose disabilities are so 
severe that they do not presently have the potential for 
employment but may benefit from vocational rehabilitation 
services which will enable them to live and function 
independently" (P.L. 95- 602).

Priority is to be given to people with disabilities who are not 
already served by other programs under the Rehabilitation Act.  
All states with federally approved independent living state plans 
are eligible to receive Part A grants, and all states 
participate.  Grants are made to state VR agencies, with a 
minimum of 20 percent required to be passed through to non-state 
providers of independent living services unless waived by the RSA 
commissioner.

In order to be eligible to participate in programs under Title 
VII, states must submit a three year state plan based on a needs 
assessment conducted by the state that identifies the types of 
services that are needed as part of the independent living 
program.  The state plan must demonstrate that the state has 
studied and considered methods for providing services that will 
to the maximum extent feasible provide meaningful alternatives to 
institutionalization.  [29 USC 796d(a)(3)(A)].

In addition the state plan must describe its inter-agency 
coordination of independent living services, its order of 
selection in prioritizing services when funds are not sufficient, 
the ways in which it assures that independent living services 
will be provided to those with the most severe disabilities, and 
ways it is providing technical assistance to poverty areas.  
States also must have an Independent Living Council which is 
responsible for development of the five year state plan.

Grants under Part B are awarded on a competitive basis to 
establish and operate centers for independent living.  Each 
center must have a governing board comprised of a majority of 
individuals with disabilities who are substantially involved in 
the policy development and management of the centers.

Grants under Part C also are awarded on a competitive basis, to 
provide independent living services for people over age 55 whose 
visual impairment is severe enough to make gainful employment 
very difficult (older blind individuals).

Persons eligible for services under Title VII are defined as "any 
individual whose ability to engage in or continue in employment, 
or whose ability to function independently in the family or 
community, is so limited by the severity of the disability that 
vocational or comprehensive rehabilitation services are 
appreciably more costly and are of appreciably greater duration 
than those vocational and comprehensive rehabilitation services 
for the rehabilitation of an individual with handicaps are 
required to improve significantly either the ability to engage in 
employment or the ability to function independently in the family 
or community" (P.L. 95-602).

Federal regulations further specify that there must be

     "a reasonable expectation that [independent living] services 
     will
     significantly assist the individual to improve his ability 
     to function independently in a family or a community or to 
     engage in or continue in employment," and that such improved 
     ability should be measurable in areas such as self care, 
     communication, driving, and activities of daily living."
     [34 CFR 365.31].

B.   Financing Assistive Technology

All three components of the Independent Living program may be 
used to finance assistive technology.  Under Part A, services are 
to be provided to eligible persons based on an individual plan 
for independent living, including assistive technology, which is 
referenced in examples of an allowable service (e.g., needed 
prostheses and other appliances and devices).  Federal 
regulations also added telecommunications, sensory and other 
technological aids and devices to the list.

Unlike Titles I and VI-C, Title VII also can include assistive 
technology and related services to young children.  Provisions in 
Part A specifically note that funds can be used to provide 
services to children of pre-school age, including physical 
therapy, development of language and communication skills, and 
child development services.  Part B applications must provide 
assurances that the independent living center will offer 
individuals with disabilities an array of services as 
appropriate, including evaluation of client needs, advocacy, 
information and referral, and skills training.  There are no 
references to assistive technology in the descriptions of these 
services other than "independent living skills, counseling, and 
training, including such programs as training in the maintenance 
of necessary equipment" (P.L. 95-602).  Part C services also can 
include assistive technology for older individuals with severe 
visual impairment.

C.   State Flexibility

The Rehabilitation Act and regulations for the Part A program do 
not set forth a list of services that are mandatory components of 
the independent living program, and therefore states have wide 
discretion in the services that are funded.  Each state is to 
have conducted its own independent living needs assessment as the 
basis for the design of its independent living program.  
Regulations do require, however, that the state plan assure that 
no group of
individuals is excluded from services solely on the basis of the 
type of disability or on the basis of age [34 CFR 365.31]. 
D.   Current Policy Issues

Each round of competition for Part B grants to centers for 
independent living can include specific federal priorities in its 
requirements.  No new competition for Part B grants was held 
during FY1991, and it now appears likely that there will be no 
competition for new Part B grants in FY 1992; all existing 
centers, however, are to receive continuation funding.  Had a new 
competition been scheduled, RSA might have included provisions to 
address access to assistive technology (e.g., priority for 
inclusion of a staff person with expertise in this area).

RSA also hopes to encourage promotion of assistive technology in 
the Part A program.  Amendments to Title VII in 1992 may include 
further references to assistive technology in the independent 
living assessment process and in resources for staff training.

E.   Facilitators

The various components of the Title VII program potentially 
improve access to assistive technology through their focus on 
individuals with very severe disabilities and their broad purpose 
- i.e., services are not tied to a short term goal of 
employability.  Although references to assistive technology are 
limited, there are no prohibitions against financing, and 
technology is specifically referenced as an allowable service in 
Parts A and C.  Specific service coverage, however, is decided by 
the individual states, and there are no mandatory services.

Individual choice is especially supported through Parts B and C, 
which emphasize individual empowerment and maximum independence; 
centers for independent living financed through Part B are 
required to have majority consumer involvement in their 
administration.  Although limited data are available, it is 
likely that most independent living centers help people access 
assistive technology through their information, referral, 
coordination, and advocacy services.

RSA hopes to encourage more emphasis on assistive technology 
through program policy guidance.

F.   Barriers

The primary barrier to financing in the Title VII programs is the 
limited funding, especially for state-of-the-art technology.  For 
example, the FY 1991 Part B federal funding of $27 million is 
spread across 144 grantees and 202 centers for independent 
living, providing an average of only around $200,000 per center.  
There is also a lack of emphasis on assistive technology despite 
expressions of interest at many individual centers.  Some 
observers also feel that the eligibility concept for Title VII 
programs (i.e., that it is only for people who are not eligible 
for other VR programs) is outmoded.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Promote knowledge/technical assistance on assistive 
     technology as part of  independent living center services 
     with targeted special project and demonstration grants;

LEGISLATIVE 
.    Expand funding and availability of Independent Living 
     Centers;
.    Include policy language on assistive technology in the 
     legislation, including the definition of assistive 
     technology in IDEA and the Technology-Related Assistance 
     Act, and clarification of promoting access to assistive 
     technology as one of the goals of Title VII independent 
     living programs.
.    Require as a mandated service in Parts A, B and C the 
     provision of technology-related assistance including 
     awareness and education, training in the use of devices, 
     financing and advocacy.
.    Require under Part B that each center employ an individual 
     with appropriate competencies to direct their mandated 
     assistive technology service and advocacy program.

Suggestions For All Rehabilitation Act Programs

.    Collect/analyze data on the use of assistive technology in 
     promoting employment, independence and productivity;
.    Expand training and technical assistance on assistive 
     technology assessment, service delivery options and 
     financing alternatives to states, centers on independent 
     living and nonprofit providers.
VII. DISABILITY PROGRAMS OF THE SOCIAL SECURITY ACT

ÀÀ Title II:  Social Security Disability Insurance (SSDI)
ÀÀ Title XVI:  Supplemental Security Income (SSI)
ÀÀ Impairment Related Work Expenses (IRWE)

1.   TITLE II: THE SOCIAL SECURITY DISABILITY INSURANCE PROGRAM 
     (SSDI)

[42 USC 420-425]

A.   Background

Title II of the Social Security Act of 1935 (P.L. 84-880, as 
amended) authorizes a program of federal disability insurance 
benefits for workers who have contributed to the Social Security 
Trust Funds and become disabled or blind before retirement age.  
Spouses and dependent children of fully insured workers, 
including adult children with disabilities whose disability began 
prior to age 22, also are eligible for benefits upon the 
retirement, disability or death of a primary beneficiary.

The purpose of the SSDI program is to replace part of the 
earnings lost when a physical or mental disability is severe 
enough to prevent a person from working.  SSDI is financed 
primarily by a portion of the Federal Insurance Contribution Act 
(FICA) payroll tax on wages which is allocated to the Disability 
Insurance (DI) Trust Fund; the DI Trust Fund is the source of 
payment for monthly DI benefits and for administrative expenses.

Total outlays from the DI trust fund are projected to increase at 
an annual compounded rate of 6.6 percent between 1988 and 1994, 
rising to $32.8 billion.  FY 1991 expenditures are projected to 
be $26.7 billion.  Cash benefits for a worker disabled in 1991 
range up to a maximum of $1,218 per month, based on the level of 
the worker's prior earnings and the age at which the worker 
became disabled.  The corresponding maximum for each worker with 
a family is $1,828.30.  As of December 31, 1990, the average 
monthly benefit paid to a disabled worker alone was $571 and the 
average amount payable to a disabled worker with dependents was 
$1,026.

An average of 4,166,000 workers with disabilities and their 
dependents received
monthly cash benefits during FY 1990.  Disability benefits are 
provided to a person who is unable to engage in any substantial 
gainful activity (or SGA, which is defined as earnings of $500 or 
more per month from employment) by reason of medically 
determinable physical or mental impairment that has lasted or is 
expected to last at least 12 months, or to result in death.  
Applicants must furnish medical and other evidence as specified 
by the Social Security Administration (SSA) to prove the 
existence of a disability.

A worker also must have achieved insured status through work in 
employment covered under Social Security.  There is a five month 
waiting period between the time the claimant is determined 
entitled to SSDI benefits and the time in which the payments 
begin.  People with disabilities on the basis of visual 
impairment or blindness are eligible for SSDI under less 
stringent criteria, including higher levels of SGA ($810 in 1991, 
compared to $500 for people with other disabilities).

Workers with disabilities receiving SSDI benefits are eligible 
for coverage under the Hospital Insurance (HI) component of 
Medicare, also referred to as Medicare Part A. However, there is 
a 24-month waiting period between the month in which the worker 
becomes entitled to SSDI benefits and the month in which the 
worker becomes eligible for Medicare.  Since there is a 5-month 
waiting period for SSDI benefits, an individual may have to wait 
29 months from the determination of disability until Medicare 
coverage begins.

Once disabled beneficiaries become eligible for Medicare Part A, 
they are also eligible for the Supplementary Medical Insurance 
(SMI) program (Medicare Part B), which covers physician and 
ancillary services.  As for other Medicare beneficiaries, 
participation in Part B is voluntary, and requires the payment of 
a Part B premium.  If a worker with disabilities loses 
entitlement to SSDI benefits because his or her impairment 
ceases, Medicare eligibility is generally terminated at the end 
of the month following the month in which SSDI benefits are 
terminated.

Work Incentives:  One work incentive provision for SSDI 
recipients is the trial work period.  Under a provision enacted 
in December 1987, a 45-month period of extended eligibility for 
Social Security benefits is provided to beneficiaries with 
disabilities who attempt to work.  This period includes a nine 
month trial work period during which benefits are not suspended 
because of work and a 36-month extended period of eligibility, 
during the last 33 months of which
SSDI benefits are suspended for any month in which the individual 
is engaged in SGA.

However, during the extended period of eligibility, entitlement 
to benefits is not terminated.  If an individual medically 
recovers to the extent that s/he no longer meets the definition 
of disability, benefits are terminated regardless of the trial 
work provision.  Only one trial work period is permitted in any 
five year period.  A trial work month is defined as any month in 
which earnings exceed $200.  
Provisions in the law extend Medicare benefits to workers with 
disabilities who attempt to return to work under a trial work 
program or whose SSDI benefits cease due to earnings which exceed 
the SGA level.  For these beneficiaries, Medicare coverage is 
extended for not less than 39 months after the end of the trial 
work period, and possibly longer.  Additional Medicare retention 
privileges were included in OBRA 1989 (P.L. 101-239), allowing 
SSDI recipients with disabilities who return to work to purchase 
Medicare insurance coverage after they have exhausted their trial 
work period and extended regular Medicare coverage.

The law also requires the states to pay all or part of the 
premium for Medicaid for SSDI recipients earning less than 200 
percent of the federal poverty level.  For beneficiaries who have 
completed the two-year waiting period and who come back onto the 
SSDI rolls after a period of work, there is no additional two- 
year waiting period for Medicare coverage.

Another work incentive provision is the waiving of the five month 
waiting period for former SSDI beneficiaries who become 
re-entitled within five years of a prior period of disability.  
Deductions for impairment related work expenses (IRWE), applying 
to both the SSDI and SSI programs, are discussed below.  

Another trust fund program reimburses states for vocational 
rehabilitation (VR) services to SSDI beneficiaries if the 
rehabilitation services result in federal savings and are 
successful, defined by law as the completion of a continuous 
9-month period of employment at the SGA level.  State disability 
determination staff refer persons awarded disability benefits to 
state vocational rehabilitation agencies.  Under federal 
guidelines, only those beneficiaries who are considered good 
candidates for rehabilitation and could potentially benefit from 
state VR services are referred.  If referred, a DI beneficiary 
may lose his or her benefits
for refusing rehabilitation services without good cause.

OBRA 1990 (P.L. 101-508) extended the same benefit continuation 
rights as those for individuals who medically recover while 
participating in a state VR program (Section 301) to SSDI and SSI 
beneficiaries who medically recover while participating in an 
approved non-state VR program.

B.   Financing Assistive Technology 

Some assistive technology is financed through the IRWE program, 
as discussed below.  Indirectly, the SSDI program's link to 
Medicare eligibility can be a source of financing.

C.   State Flexibility

There is no state flexibility per se.

Disability determination units operated by the states are 
governed by federal laws, regulations and procedures.  States do 
vary significantly in the use of referrals to the state 
vocational rehabilitation program.

D.   Current Policy Issues

The Social Security Administration is conducting an initiative to 
expand the use of work incentives for both SSDI and SSI 
recipients.  Called Project NetWork, the initiative centers on 
the use of case managers who are well versed in all relevant work 
incentives, including the financing of assistive technology.  
Four case management models will be tested, including two using 
SSA employees, one with case management provided by state VR 
agency staff, and one using private sector case managers.

The first model, using specially trained SSA personnel as case 
managers, is being implemented in selected locations during the 
fall of 1991.  The training includes some information on the 
financing of assistive technology.

E.   Facilitators

The primary feature that facilitates access is the link to 
Medicare eligibility and the related work incentive provisions 
that protect access to the Medicare
program.  Some features of the IRWE program also are relevant, as 
discussed below.  SSDI monthly benefit amounts are greater than 
those in the SSI program or an average of $571 vs. $260 for an 
individual with disabilities as of December 31, 1990.  SSDI is 
also a family benefit, i.e., payment amounts increase if there 
are dependents.

SSA is optimistic that the new case management initiative will 
increase the use of work incentives, including access to 
assistive technology, among SSDI beneficiaries. 

F.   Barriers

There are no inherent barriers to the financing of assistive 
technology in the SSDI program, other than the 24 month waiting 
period for Medicare coverage following the five month initial 
waiting period.  Provisions under COBRA (the Consolidated Omnibus 
Budget and Reconciliation Act of 1985 - P.L. 99-272, as amended) 
offer access to continued employment-based health insurance 
coverage for the 29 months, but only at the expense of the 
individual.  However, the Medicare program contains many barriers 
to the financing of assistive technology (see Part II of this 
Section IV on Page XX).

Fear of loss of Medicare coverage has been associated with some 
individuals' reluctance to use SSDI work incentives.  It is not 
clear to what extent the provisions of OBRA 1989 on retention of 
Medicare eligibility help people who fear loss of coverage of 
assistive technology and other medical care financed through the 
Medicare program; these provisions went into effect in April 
1990.  It should be noted, however, that the cost to individuals 
for the Medicare buy-in is $203 per month during 1991, and will 
increase in 1992; buy-in costs for those who are below 200 
percent of the federal poverty level, however, will be made by 
state Medicaid programs.

Many advocates for people with disabilities have indicated that 
the lack of SSDI work incentive provisions similar to the 1619 
program that protects Medicaid eligibility for SSI recipients 
(see below) can be a barrier to employment.  In addition, there 
is no gradual phase-out of benefits similar to the 1619 program's 
gradually declining SSI payment amounts.

G.   Suggestions for Reform 

FEDERAL LEVEL:
EXECUTIVE 
.    Establish the SGA level for all persons with disabilities 
     and blindness at $810 per month with annual Cost of Living 
     Adjustments.

LEGISLATIVE 
.    Establish a work incentive program more like the 1619 
     program that is available to SSI recipients;
.    Explore the impact of the Medicare two year waiting period 
     on those unable to take advantage of COBRA continuation of 
     private insurance coverage, including access to needed 
     assistive technology;
.    Examine the affordability of new Medicare buy-in provisions 
     for people returning to work, including access to assistive 
     technology;
.    Allow an SSDI recipient to borrow from the Trust Fund to 
     purchase needed assistive technology.

2.   TITLE XVI SUPPLEMENTAL SECURITY INCOME (SSI)

[42 USC 1382]

A.   Background

Title XVI of the Social Security Act was added in the Social 
Security Amendments of 1972 (P.L. 92-603).  The purpose of the 
Supplemental Security Income (SSI) program is to assure a minimum 
level of income to persons who have attained age 65 or are blind 
or disabled whose income and resources are below certain levels.

To qualify for SSI payments, persons must satisfy both the 
program criteria for age, blindness or disability and income and 
resources limitations.  The aged are people who are age 65 years 
or older.  Individuals who are blind are individuals with 20/200 
vision or less with the use of a correcting lens in the person's 
better eye, or those who have tunnel vision of 20 degrees or 
less.  Individuals with disabilities are those who are unable to 
engage in any substantial gainful activity by reason of a 
medically determined physical or mental impairment expected to 
result in death or that has lasted or can be expected to last, 
for a continuous period of at least 12 months.

The criteria and determination process for individuals with 
disabilities or with
blindness/visual impairment are the same in the SSI and SSDI 
programs.  In addition, SSI eligibility is based on a review of 
income and resources (e.g., a bank account or life insurance 
policy).  Although some income and resources are not fully 
counted in determining eligibility, the basic limit is less than 
$386 per month in income and $2,000 in assets for an individual 
and $579 and $3,000, respectively, for a couple.  Within federal 
limits and guidelines, values of household goods, personal 
effects, an automobile, and property needed for self support are 
excluded in determining the value of resources; the cost of 
disability related expenses needed for work also can be deducted 
in meeting income criteria (see below).

Children's eligibility for SSI is defined as disability of the 
basis of any medically determinable physical or mental impairment 
of comparable severity to that which would define disability in 
an adult.  As defined in SSA's interim final regulations, in 
response to the Zebley v. Sullivan Supreme Court decision, 
comparable severity is linked to limitations in the child's 
ability to function independently, appropriately, and effectively 
in an age-appropriate manner.  The income of the parents of an 
eligible child under the age of 18 is considered in determining 
the eligibility and payment for the child.  In determining the 
amount of the income of the ineligible parent to be deemed to the 
SSI applicant or recipient, the needs of the parent and other 
children in the household are taken into account.  Similar 
provisions apply to ineligible spouses in the same household.

As of March 1991 a total of 3,385,307 individuals with 
disabilities were participating in the SSI program, including 
220,302 (6.5 percent) who were working.  The estimated average 
federal payment during FY 1991 is $260 per month, ranging from $1 
to $407 for individuals without an eligible spouse.  Total 
federal SSI payment costs, including administration, are 
estimated at $16.881 billion in FY 1991.

B.   Financing Assistive Technology

The primary access to the financing of assistive technology is 
through the SSI program's link to the Medicaid program.  States 
have three options as to how they treat SSI recipients in 
relation to Medicaid eligibility: (1) they can enter into an 
agreement with SSA to automatically cover all SSI recipients with 
Medicaid eligibility, eliminating separate applications for 
Medicaid (31 states and the District of Columbia); (2) states 
provide Medicaid eligibility for all SSI
recipients only if the recipient completes a separate application 
with the state Medicaid agency (six states); and (3) the 
so-called 209(b) option, under which states may impose Medicaid 
criteria which are more restrictive than SSI criteria (either on 
disability or income and resources), so long as the criteria 
chosen were part of the state's approved state Medicaid plan in 
January 1972 (thirteen states).

Work Incentives:  The major work incentive program for SSI 
recipients with disabilities is the 1619 program, initiated as a 
pilot program in the Social Security Amendments of 1980 (P.L. 96- 
265) and made permanent by the Employment Opportunities for 
Disabled Americans Act of 1986 (P.L. 99-643).

Section 1619(a) of the Social Security Act provides for 
continuation of cash benefits for those SSI recipients who are 
receiving benefits on the basis of disability even if they are 
working at the SGA level and as long as there is not a medical 
improvement.  The amount of their cash benefits is gradually 
reduced as their earnings increase until their countable earnings 
reach the SSI benefit standard or breakeven point.  After an 
individual is no longer eligible for Section 1619(a) benefits due 
to excess earning, s/he may qualify for Section 1619(b) retention 
of Medicaid coverage.  This special eligibility status applies as 
long as the individual: (1) continues to have a disabling 
impairment; (2) except for earnings, continues to meet all the 
other requirements for SSI eligibility; (3) would be seriously 
inhibited in continuing to work by the termination of eligibility 
for Medicaid services; and (4) has earnings that are not 
sufficient to provide a reasonable equivalent of the Medicaid 
benefits that would have been available if s/he did not have 
those earnings.

Individuals with disabilities in the 1619 program have the 
ongoing protection of being able to reinstate their eligibility 
to cash assistance benefits under regular SSI or 1619 (a), or 
Medicaid only eligibility under 1619(b) if their work attempt 
fails or their physical or mental disability makes their ability 
to work erratic.  However, if the individual recovers medically, 
a new application and new disability determination is required.

As of March 1991, there were 13,330 participants nationwide in 
the 1619(a) program, and 22,221 in the 1619(b) program.  This 
reflected a decrease of 4.7 and 5.5 percent respectively from 
December 1990 due to the rise in the SGA level to $500, which 
gave some people renewed eligibility for the regular SSI program.  
The average monthly earnings of 1619(a) recipients is $711,
however, over half of the participants earn less than $200 per 
month.

Another work incentive is the Plan for Achieving Self-Support 
(PASS) program, added in the Social Security amendments of P.L. 
92-603.  This program permits individuals to set aside income 
from sources other than SSI (e.g., SSDI benefits or earnings from 
employment) and resources (e.g., a bank account) to purchase 
assistive technology and other items that are needed to pursue 
their vocational goals.  Income/resources set aside in a PASS are 
not counted in determining SSI eligibility or in calculating the 
amount of the SSI benefit.

A PASS is flexible in what it can finance, so long as it approved 
by the SSA under minimal federal guidelines (e.g., that it relate 
to vocational goals that are obtainable).  The first PASS is 
written for an 18 month period; extensions are available up to a 
maximum of 48 months.  The PASS program is available to people 
who are already receiving SSI and to people whose income and 
resources are too high to qualify for SSI without taking the PASS 
into account.

In addition to helping finance assistive technology directly, the 
PASS program also supports access to financing through increased 
SSI payments for those who are already receiving benefits, and 
through both payments and access to Medicaid for those who would 
otherwise not be eligible for SSI.  As of March 1991, 
approximately 2,500 individuals were participating in the PASS 
program.

A third work incentive that can be used in financing assistive 
technology is the Property Essential to Self Support (PESS) 
program, which permits individuals to exclude the value of 
property used in a trade or business or for work as an employee, 
such as specially adapted tools or equipment, in the 
determination of SSI benefits.  Eligibility is available to both 
current and potential SSI beneficiaries, as with the PASS 
program.  For SSI recipients on the basis of blindness, the Blind 
Work Expenses program permits deduction of all work expenses from 
earned income in determining SSI eligibility and payment amounts.  
Although the program helps finance assistive technology and other 
expenses related to a visual disability, it is not limited to 
work expenses that are related; for example, it can be used to 
cover income tax payments.

In contrast, the Impairment Related Work Expenses (IRWE) program, 
a work incentive available to both SSDI and SSI recipients (see 
below), can be used only for work expenses that are directly 
related to the person's disability. 
Approximately 4,000 individuals were participating as of March 
1991.

C.   State Flexibility

States may elect to supplement the basic federal SSI payment.  
Approximately 42 percent of the SSI recipients receive a State 
Supplementary Payment (SSP); SSP amounts range from $2 to $366 a 
month for individuals.  Although nearly all states provide SSP, 
they have considerable flexibility in the SSP amount and the 
eligibility criteria.  States also have flexibility in the way 
they link SSI and Medicaid eligibility, as described above.

Approximately 75 percent of SSI recipients are in states that 
have chosen the automatic eligibility option;  22 percent are in 
209(b) states; and the rest are in the six states that require 
separate Medicaid applications.  Under the 1619 program, each 
state determines a threshold level which is the point at which it 
is assumed that individuals have sufficient income to be 
responsible for the purchase of their own health insurance rather 
than continue on Medicaid.

States also vary in their support to promotion of the 1619 
program, and participation rates vary considerably among the 
states.

D.   Current Policy Issues 

The criteria and procedures for determining SSI eligibility for 
children with disabilities have recently been changed, following 
litigation that challenged SSA's use of eligibility determination 
methods that were not comparable to those used with adults 
(Sullivan v. Zebley, U.S. No. 88-1377).  As part of the Court 
Order implementing the Zebley decision, SSA is undertaking a 
major public information and outreach initiative to contact the 
approximately 425,000 children whose SSI eligibility was either 
denied or terminated from January 1, 1980 and February 11, 1991.  
Public comments on new childhood disability standards are under 
review currently by SSA.

In a separate action, SSA has revised standards for determining 
mental disability in children under age 18.  Going forward, the 
full implementation of the Zebley decision is expected to 
increase the number of SSI children with disabilities 
significantly, and consequently will increase the number of 
children eligible for Medicaid on the basis of their SSI status.

SSA has undertaken the Supplemental Security Income Modernization 
Project, beginning with an examination of SSI program 
effectiveness in meeting the needs of the target population, 
including people with disabilities.  Recommendations will be made 
to the Commissioner of SSA in January 1992, in such areas as 
benefit amounts, income and resource limits, definition of SGA, 
appeals procedures, work incentives, and linkage between the SSI 
and Medicaid programs.

E.   Facilitators

The primary feature is the link to the Medicaid program, 
including the work incentive provisions of the 1619(b) program 
which allow individuals to retain their Medicaid eligibility.

F.   Barriers

There are no inherent barriers in the SSI program with the 
possible exception of the 209(b) provisions allowing some states 
to restrict access to the Medicaid program for some SSI 
recipients.

G.   Suggestions for Reform

FEDERAL LEVEL:
LEGISLATIVE 

.    Raise the Substantial Gainful Activity (SGA) limits further 
     and provide for automatic annual changes in relation to the 
     cost of living index;
.    Raise monthly payment levels at least to federal poverty 
     levels;
.    Clarify that assistive technology is an appropriate use of 
     funds in the PASS and PESS programs, using the definitions 
     found in the Technology-Related Assistance Act.

EXECUTIVE 
.    Phase out eligibility and payment differences between people 
     with blindness and those with other disabilities;
.    Continue/expand the 1619 program;
.    Conduct an evaluation of the implementation of the Zebley 
     decision and the new criteria for children's mental 
     disabilities.

3.   IMPAIRMENT RELATED WORK EXPENSES (IRWE)

A.   Background

The IRWE program applies to both SSDI and SSI recipients.  It was 
authorized in the Social Security Act amendments of 1980 (P.L. 
96-265), which also authorized the 1619 work incentive program.  
With IRWE, costs of allowable disability related items and 
services can be deducted from earnings and income from other 
sources, even if these items and services are also needed for 
non-work activities, so long as the cost is borne by the 
individual with the disability.  IRWE deductions can be used to 
reduce the amount of earnings from employment used to calculate 
substantial gainful activity (SGA) in determining SSI and SSDI 
eligibility (currently $500 per month for people with 
disabilities other than blindness) and in determining the amount 
of an SSI beneficiary's monthly payment.

IRWE is available for individuals who are self-employed as well 
as those who are employed by others.  Unlike the PASS program, 
there is no time limit to IRWE deductions and they can be used 
for ongoing expenses.

B.   Financing Assistive Technology

IRWE expenses are approved at the SSA field office level, based 
on such criteria as the necessity of the item or service to job 
performance, the need in relation to the person's disability, and 
the reasonableness of the expense.  Many examples of assistive 
technology that would be considered for IRWE deductions are 
included in materials published by SSA on work incentives, such 
as vehicle modifications, wheelchairs, prosthetics, adaptive 
equipment used in the workplace, and communications systems used 
in employment.

C.   State Flexibility

State flexibility is not relevant to the IRWE program.

D.   Current Policy Issues

Work incentives are believed to be helpful in increasing the 
proportion of individuals working.  For example, the percentage 
of working SSI eligible recipients has increased from 3.4 percent 
in December 1976 to 6.5 percent
from June 1990 through the present.  SSA has been trying to 
promote increased use of IRWE and other work incentives by 
designating a work incentive specialist at each SSA field office.

In addition, SSA hopes to increase the use of work incentives 
through the Project NetWork case management initiative described 
above.  It should be noted that the percentage of SSI program 
participants who are working varies greatly among the states, 
ranging from 2.3 to 20.3 percent.  Another work incentive that 
applies to both SSI and SSDI beneficiaries is the Section 301 
program, which protects access to work incentives for people who 
are found to be medically improved (i.e., no longer disabled) and 
are participating in a vocational rehabilitation program.
E.   Facilitators

Although assistive technology is not mentioned in the 
legislation, it is clearly covered under guidance and public 
information published by SSA.  IRWE deductions can cover a broad 
range of assistive technology, so long as it is work related; 
items can be included even if they are used to some extent for 
non-work activities, if the primary purpose is for employment.  
IRWE is relatively easy to apply for and to use, and can be used 
indefinitely while people are employed and eligible for either 
SSI or SSDI.

F.   Barriers

The only significant barrier is that only half of the amount 
expended under IRWE is actually available as a deduction of 
earnings, because of the way deductions and SGA, income, and 
payment amounts are calculated.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Continue Project NetWork and other work incentive 
     initiatives;
.    Clarify that assistive technology is a significant part of 
     all work incentives, including use of the same definition as 
     found in the Technology-Related Assistance Act;
.    Ensure that assistive technology is included in the training 
     of work incentive specialists in each district and of the 
     case managers in Project NetWork;
.    Expand training of Social Security Administration workers on 
     all work incentive programs and expand outreach to people 
     with disabilities and local service providers;
.    Conduct research on alternative decisionmaking models that 
     minimize time delays and which responds to consumer needs to 
     access appropriate technology solutions;
.    Conduct research on the significance of assistive technology 
     in obtaining and maintaining employment for SSI and SSDI 
     beneficiaries.
VIII VETERANS' BENEFIT PROGRAMS

ÀÀ Prosthetics and Sensory Aids
     [38 USC 1162, 1701, 1710, 1717, 1719, 1723-1724, 3104, 8123]

ÀÀ Related Programs
     .    Automobiles And Adaptive Equipment For Certain Disabled 
          Veterans And Members Of The Armed Forces [38 USC 
          3901-3903]
     .    Specially Adapted Housing [38 USC 2101-2106]
     .    Compensation [38 USC 1101 et seq.]
     .    Veterans' Outpatient Care [38 USC 1712]
     .    Vocational Rehabilitation [38 USC 1524, 3102]

A.   Background

Federal legislation authorizes a wide range of benefits to 
veterans of the U.S. armed services, including disability 
compensation, life insurance, education, vocational training for 
veterans with disabilities, and medical care, including assistive 
technology.  Some benefits are available to dependents and 
survivors.  These programs are authorized as a form of additional 
compensation to individuals who served their country, especially 
those who did so during periods of armed conflict.  Several 
programs are targeted to those with disabilities.

Regional offices of the Department of Veterans Affairs (VA) 
administer most benefits other than medical care.  Medical care 
is generally administered through the network of VA medical 
centers and includes inpatient and outpatient health care, 
prosthetics appliances/adaptive devices, nursing home services, 
domiciliary care, adult day health care, home care, hospice 
services, respite, mental health and substance abuse treatment, 
and special programs for veterans who are homeless.

Eligibility for most VA benefits is based on an "other than 
dishonorable" discharge from active military status following 
minimum periods of service as specified by law.  Eligibility 
requirements vary for individual benefits; programs directed to 
veterans with disabilities frequently refer to a service 
connected disability or condition as an eligibility criterion.  A 
service connected disability is one caused by an incident or 
illness that occurred while the veteran
was a member of the armed services and not necessarily as a 
result of combat activity, e.g., a spinal cord injury from an 
automobile accident that occurs while an individual is home on 
leave is considered a service-connected disability.

In FY 1990 the VA handled 1,388,217 benefit cases.  Medical care 
was provided to 1,653,798 veterans during FY 1990, at a cost of 
$12.7 billion.

There are several avenues of access for the funding of assistive 
technology for veterans with disabilities.  The most significant 
is the Prosthetic and Sensory Aids program but five other related 
programs are also limited sources of assistive technology and 
devices for veterans with disabilities.  These programs are 
summarized below.

PROSTHETICS AND SENSORY AIDS:  This program provides prostheses 
and related appliances, equipment and services to veterans with 
disabilities through purchase and/or fabrication, so that they 
may live and work as productive citizens.  Veterans may be 
provided prosthetic appliances necessary for treatment of any 
condition when receiving hospital, domiciliary, or nursing home 
care in a facility under the direct jurisdiction of VA.

Veterans who meet the basic requirements for outpatient medical 
treatment may be provided needed prosthetic services if the 
appliance is required for a service-connected disability or 
adjunct condition;  for a disability for which a veteran was 
discharged or released from active service;  for a veteran 
participating in a VA rehabilitation program;  as part of 
outpatient care to complete treatment of a disability for which 
hospital, nursing home, or domiciliary care was provided; for any 
medical condition for a veteran with a service-connected 
disability rated at 50 percent or more;  for a veteran receiving 
increased pension or allowance based on needing aid and 
attendance or being permanently housebound;  or specific 
conditions of service (e.g., having been a prisoner of war).  
Veterans whose disability is not service-connected may be 
eligible for services in some cases, e.g., to prevent or reduce 
the need for hospitalization.

During FY 1990, the Prosthetic Appliances program provided 
approximately 1,300,000 prosthetic items/services to nearly one 
million veterans.  These included  prostheses, sensory aids, 
medical equipment, medical supplies, therapeutic devices and 
repair services.  Expenditures were $111 million for
devices and repairs ($152 million if surgical implants are 
included), expected to rise to $121 million in FY 1991.

The range for individual devices is approximately $10 to $25,000, 
with an average expenditure of $68.00.

RELATED PROGRAMS:
Automobiles And Adaptive Equipment For Certain Disabled Veterans 
And Members Of The Armed Forces:  This program provides financial 
assistance to active duty service persons and veterans with 
disabilities, based on their level of disability, toward the 
purchase price of an automobile or similar vehicle (e.g., a van) 
and an additional amount for adaptive equipment considered 
necessary to insure that eligible persons will be able to operate 
or make use of the vehicle.  Another component pays for adaptive 
equipment, including its repair, replacement, or re-installation 
required because of disability for the safe operation of a 
vehicle purchased with VA assistance or for a previously or 
subsequently acquired vehicle.

Eligibility for the adaptive equipment only program requires a 
less severe level of disability.  Estimated federal funding in FY 
1991 is $18.8 million, including purchase of 830 vehicles.  There 
is no statutory maximum for adaptive equipment; the maximum for a 
vehicle is $5,500.  Assistance toward purchase of a vehicle is a 
one-time payment only.  Adaptive equipment is provided for no 
more than two conveyances during any four-year period unless one 
of those two vehicles becomes unavailable to the veteran.

Specially Adapted Housing:  This program assists veterans with 
severe disabilities (based on definitions of specific types of 
disabilities) to acquire suitable housing that is equipped with 
special fixtures and facilities necessitated by the disability.  
VA may approve a grant of not more than 50 percent of the cost of 
building, buying or remodeling adapted homes or paying 
indebtedness on those homes already acquired, up to a maximum of 
$38,000.  Grants also may be approved for the actual cost, up to 
a maximum of $6,500, for adaptations to a veteran's residence 
determined to be reasonably necessary.  Alternatively, the grant 
may be used to assist eligible veterans in acquiring a residence 
which has already been adapted with special features.

Eligible veterans must be entitled to compensation for permanent 
and total service-connected disability.  Eligibility for the 
larger grant amount is based on
greater severity of the disability, such as "the loss or loss of 
use of both lower extremities, such as to preclude locomotion 
without the aid of braces, crutches, canes, or a wheelchair."   
The estimated federal cost of veterans' Specially Adapted Housing 
is $14.4 million, for a total of 422 grants in FY 1991.

Compensation:  The compensation program pays monetary benefits to 
veterans with disabilities from injury or disease incurred or 
aggravated during active military service in the line of duty and 
which is not a secondary effect of willful misconduct or 
substance abuse.

The amount of the monthly payment increases by the percentage 
level of disability.  The current range is from $80 for a 
service-connected disability at 10 percent to $1,620 for 100 
percent disability.  The entitlement for a few severe 
disabilities at special benefit rates, can be up to $4,628 per 
month.

Veterans whose service-connected disabilities are rated at 30 
percent or more are entitled to additional allowances for 
dependents, ranging from $28 to $563 per month, depending on the 
number of dependents and the degree of disability of the veteran; 
spouses of these veterans are entitled to receive a special 
allowance for a spouse who is in need of the aid and attendance 
of another person.

Federal expenditures for the veterans' disability compensation 
program are projected at $11.5 million in FY 1991, representing 
payments to 2,493 veterans and their dependents.

Veterans' Outpatient Care:  The outpatient care program provides 
medical and dental services to eligible veterans on an outpatient 
basis, including medical examinations and related services such 
as drugs and medicines, rehabilitation, consultation, 
professional counseling, training, and mental health services in 
conjunction with treatment of physical and mental disabilities.

As part of outpatient medical treatment, some veterans may be 
eligible for home health services necessary or appropriate for 
the effective and economical treatment of their disabilities, 
including home improvements and structural alterations that are 
determined necessary to assure the continuation of treatment or 
to provide access to the home or to essential lavatory and 
sanitary facilities, within certain cost limitations.

In general, the VA must furnish outpatient care without 
limitation for service-connected disabilities, with eligibility 
criteria partly tied to the level of the disability (e.g., 50 
percent vs. 30-40 percent service-connected disability).  The VA 
also must provide outpatient care for veterans in VA-approved 
vocational rehabilitation programs and may be furnished on an 
optional basis to other veterans, including some who may be 
required to make copayments of $26 per visit.

Federal funding in FY 1991 is estimated at $3.2 billion.  Costs 
in FY 1990 were approximately $2.9 billion, covering nearly 23.4 
million outpatient visits.

Vocational Rehabilitation:  The VA vocational rehabilitation 
programs provides services and assistance necessary to promote 
maximum independence in daily living and employability, to the 
maximum extent feasible.  Eligibility is for veterans of World 
War II and later who have a compensable service-connected 
disability as well as certain hospitalized service persons 
pending discharge or release from service whom VA determines need 
vocational rehabilitation.

The Veterans' Benefits Improvement Act of 1988 (P.L. 100-687) 
added provisions for vocational rehabilitation for 
service-disabled veterans receiving VA unemployment compensation 
and for vocational training for veterans who are awarded a VA 
pension February 1, 1985 - January 31 1992, for whom the 
achievement of a vocational goal is determined to be reasonably 
feasible.

This rehabilitation program finances vocational training 
expenses, and may pay for special supportive services, including 
prosthetic devices, lipreading training and signing for 
individuals with deafness.  It may pay for counseling and 
transportation expenses related to the veteran's disabilities.  
Veterans receive a monthly subsistence allowance in addition to 
their disability pension benefit, and are eligible for advances 
of up to $666 to meet unexpected financial difficulties.

Total federal funding is estimated at $162.6 million in FY 1991, 
plus an additional $1.5 million in no-interest loans.  37,300 
veterans are expected to participate.  Training provided through 
P.L. 100-687 usually may not exceed 24 months, and may not be 
started after August 1, 1992.

B.   Financing Assistive Technology

Each VA program provides different medically necessary 
prosthetics and other assistive devices to eligible veterans.  
Applicants may request services by reporting in person at any VA 
Medical Center as well as by correspondence, telephone, or 
community physician prescription.  Medical necessity for 
assistive technology is interpreted to include technology that 
will help the veteran to be more independent and to meet basic 
needs.

The Prosthetic Appliances program, for instance, covers a wide 
scope of technology, including training, maintenance, repair and 
replacement; and technology/assistive devices from hearing aids 
and wheelchairs to highly sophisticated augmentative 
communication devices.  Most technology is provided without 
special approval processes but more expensive items are reviewed 
by the local VA medical center's major medical equipment 
committee.

C.   State Flexibility 

There is no state flexibility.  However some states contribute 
support to local veteran outreach centers and veteran information 
and referral services.  Local VA medical center prosthetics 
programs may vary in some ways, e.g., on the interpretation of 
federal guidelines on the reviews of some items by the major 
medical equipment committee.

D.   Current Policy Issues

The VA has its own standards and specifications for wheelchairs.  
For other assistive technology, the VA relies on the approval 
process of the Food and Drug Administration (FDA).  VA also has a 
research and development center which has been involved 
previously in the testing and design of some assistive devices.  
The center's mission and activities are currently under review. 

E.   Facilitators

As most of these programs are entitlements, access to financing 
of assistive technology is facilitated for eligible veterans.  
The technology devices and services are provided at no cost to 
the individual.

Another significant facilitator is the VA's broad coverage of 
assistive technology, including use of a liberal definition of 
medical necessity.  For example, veterans may have sports 
wheelchairs prescribed.

The position of the Department of Veterans Affairs also is that 
anything on the market for civilians should be available to 
veterans.  A new centralized financing system has improved the 
ability of the regional VA center prosthetic programs to respond 
to the need for assistive technology throughout the fiscal year; 
phase two will include a central computer system which is 
expected to improve program efficiency further.

The program currently uses on-line computer communication to 
inform VA personnel of available technology, supplemented by 
in-service training programs.  
F.   Barriers

Lack of knowledge of assistive technology remains a barrier 
despite the efforts to improve communication and in-service 
training among VA personnel.  Another barrier is lengthy delays 
on some items and services financed by the prosthetics program or 
related to obtaining devices, such as the typical 120 day wait 
for a hearing test.  Some items also are still being supplied 
through national contracts, contributing to delays and other 
problems of distribution.

G.   Suggestions for Reform 

FEDERAL LEVEL:
EXECUTIVE 
.    Continue personnel training initiatives to improve the 
     efficiency of the system;
.    Collaborate with the broader assistive technology field in 
     the review of efforts to develop national standards and to 
     encourage the development/distribution of assistive 
     technology needed by veterans and others with disabilities;
.    Extend coverage of assistive technology devices and services 
     to children with disabilities who have a parent who is a 
     veteran;
.    Promote research on assistive technology as a priority at 
     the research and development center;
.    Decentralize purchasing to regional offices or medical 
     centers where national contracts contribute to delays and 
     distribution problems;
.    Initiate review of decisions by local Veterans' 
     Administration (VA) medical centers major medical equipment 
     review boards where purchases of more expensive assistive 
     technology items are decided;  implement changes in policy 
     and practice to more accurately reflect the choices of
     veterans' with disabilities and their families;
.    Establish new priorities to reflect the goals of integrating 
     veterans with disabilities more fully into the community;
.    Review the Food & Drug Administration approval process and 
     make changes appropriately to reflect state-of-the-art 
     knowledge about assistive technology and establish and 
     implement policies that are consumer-driven;
.    Develop further the VA's national database on assistive 
     technology.

STATE LEVEL:
.    Encourage state support and interagency collaboration at VA 
     centers at regional, state and local levels;
.    Disseminate information about assistive technology devices 
     and services via the veterans' outreach centers.


IX.  OLDER AMERICANS ACT OF 1965, AS AMENDED

[42 USC 3022-3030]
 
A.   Background

The Older Americans Act of 1965 (P.L. 89-73) created a federal 
grant program to state agencies on aging for social service 
programs serving the elderly.  As amended, the Act's definitions 
of national objectives include the best possible physical and 
mental health, suitable housing designed and located to meet 
special needs, full restorative services for those who require 
institutional care including a comprehensive array of 
community-based long term care services, and efficient community 
services with emphasis on maintaining a continuum of care for the 
vulnerable elderly.

Although the Act prohibits means tests that would limit 
participation only to older people with low incomes, amendments 
have emphasized that nutrition and supportive services should be 
targeted to low income individuals, those whose racial or ethnic 
status may heighten the need for services, and those with social 
need for services who are not economically deprived.

The primary mechanism is the Title III grants to the states, 
which in turn provide funding to local area agencies on aging 
(AAAs).  Grants to state
agencies on aging totaled $750 million in FY 1991, ranging from 
$3.7 million to $69.7 million; the grant amount is based on each 
state's percentage of the national population of individuals aged 
60 or over.  Approximately seven million older individuals 
received Title III supportive services in FY 1991; about 2.7 
million received congregate meals and an additional 800,000 
received home-delivered meals.

Requirements for AAAs were added by the 1973 amendments P.L. 
93-29.  P.L. 92-258 in 1972 had added the national nutrition 
program for the elderly.  Subsequent amendments consolidated 
social services, nutrition services, and multi-purpose senior 
center programs under Title III of the Older Americans Act; 
authorized in-home services for frail older individuals and 
assistance to older persons with special needs; and designated 
information and referral, in-home services, transportation, 
outreach, and legal services as priority supportive services.

The Act requires that AAAs designate a community focal point for 
the delivery of services to promote coordination, assure that 
preference will be given to providing services to older persons 
with the greatest economic and social needs, and establish and 
maintain information and referral services, with special emphasis 
on people with severe disabilities and other special populations.

State units on aging and AAAs also are required to consider the 
needs of older persons with disabilities in developing their 
service plans and to develop collaborative programs as 
appropriate to meet their needs, giving particular attention to 
individuals with severe disabilities.

Disability is defined as substantial functional limitation in one 
or more life activity (e.g., mobility).  Severe disability is 
defined as "a severe, chronic disability attributable to mental 
or physical impairment, or a combination of mental and physical 
impairments, that (A) is likely to continue indefinitely; and  
(B) results in substantial functional limitation in 3 or more ... 
major life activities... ."
[42 USC 3002]. 
 
B.   Financing Assistive Technology
 
Through Title III grants to the states, local agencies on aging 
provide support
services to assist older individuals in avoiding 
institutionalization and assist individuals in long-term care 
institutions who are able to return to their communities, 
including client assessment through case management and 
integration and coordination of community services.  The term 
client assessment through case management includes providing 
assistive technology.  In addition, home modifications, which are 
subject to a cap of $150 are provided as part of Title III 
services.  

The term assistive technology is defined as engineering 
methodologies, or scientific principles appropriate to meet the 
needs of, and address the barriers confronted by, older 
individuals with functional limitations.

Formula grants are awarded to states to develop and strengthen 
service systems on aging.  A state plan covering two, three or 
four years, with annual revision as necessary must be submitted 
for approval to the Commissioner on Aging.  

State plans must have several assurances including access to 
information on assistive technology:

.    Assurances associated with access to community-based 
     services (i.e., transportation, outreach, and information 
     and referral);
.    Provide for the establishment and maintenance of information 
     and referral services in sufficient numbers to assure that 
     all older individuals within the planning and services area 
     covered by the plan will have reasonably convenient access 
     to such services;
.    Assure the use of outreach efforts that will identify 
     individuals eligible for assistance under the Act; with 
     special emphasis on ... older individuals with severe 
     disabilities.
     
The phrase information and referral includes information relating 
to assistive technology.

C.   State Flexibility

Although the priorities and requirements defined in the Older 
Americans Act provide numerous guidelines, states and communities 
have considerable flexibility in the design of their aging 
service systems.  Each state defines its application of the 
definition of greatest economic or social need and its system of 
allocating funds to the AAAs.  Supplementary funding levels from 
state and
local government sources also vary widely.   
 
D.   Current Policy Issues
 
Amendments of 1987 (P.L. 100-175) stimulated several initiatives 
to improve services to older persons with developmental 
disabilities and/or mental health needs, including planning 
linkages between the Administration on Aging, Administration on 
Developmental Disabilities, and the Alcohol, Drug Abuse and 
Mental Health Administration; consultation between the 
Commissioner of Aging and the Commissioner of the Rehabilitation 
Services Administration in planning Older Americans Act programs; 
and consultation with developmental disabilities organizations in 
evaluating Older Americans Act programs whenever possible. 
 
Authorization for additional programs and services in the 1987 
amendments, including assistance to older persons with special 
needs, was linked to a provision prohibiting funding for the new 
programs unless total appropriations for programs increased by at 
least 5 percent over the previous year.  As a result, funding for 
some of the authorized services (e.g., outreach to people who may 
be eligible for benefits under the SSI, Medicaid and food stamp 
programs) has not been available.  
Amendments to the Older Americans Act for 1992 are currently 
being considered by Congress. 

E.   Facilitators
 
The primary feature supporting access to the financing of 
assistive technology is the requirement that AAAs provide 
information and referral services which includes information 
relating to assistive technology.  In addition, the Act requires 
that states and AAAs consider the need for people with 
disabilities in planning services, with priority to those with 
severe disabilities.  Local and state service plans must be made 
available for public comment.

The home modifications program can be used to finance assistive 
technology directly, however, no more than $150 can be expended 
per individual.  The Title III program does include a priority to 
people with low incomes and to members of racial and ethnic 
minority groups when there is increased need for services.

F.   Barriers
 
The primary barrier is the overall demand on resources, in 
particular at the AAA level.  Most of the AAA funding is used for 
the personnel who provide chore services, meals, and related 
supportive services.  Overall, it is not clear to what extent 
states and AAAs are focusing on people with disabilities; there 
is limited information other than aggregate data on services to 
frail older individuals. In addition, many of the services 
targeted to the frail elderly population are focused on people 
with Alzheimer's and related disorders and their families.  There 
is a strong perception that more could be done, e.g., through 
training and technical assistance, to increase AAA capabilities 
in serving people with disabilities, including help with access 
to assistive technology.
G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE 
.    Collect and analyze information on assistive technology, 
     including unmet needs as well as current expenditures;
.    Collaborate with other federal agencies, including HCFA, the 
     Office of the Assistant Secretary for Planning and 
     Evaluation, the National Council on Disability, and NIDRR 
     (Department of Education), and the aging network in research 
     on assistive technology - its significance in older people's 
     lives, the cost effectiveness of assistive technology in 
     relation to other services, and current access to assistive 
     technology;
.    Develop research/technical assistance capabilities on 
     assistive technology;
.    Designate assistive technology as a priority in 
     discretionary grant programs.

LEGISLATIVE 
.    Add clear policy goal of expanding access to assistive 
     technology that recognizes its importance in the lives of 
     older individuals;
.    Add the definition of assistive technology devices and 
     services as stated in the Technology-Related Assistance Act;
.    Mandate the provision of assistive technology services as an 
     activity under the Title III program;
.    Require as a state plan and area agency planning requirement 
     assessment of need for assistive technology services;
.    Expand federal funding to levels required for implementation 
     of the outreach initiatives.

STATE LEVEL:
.    Include assistive technology in state and area needs 
     assessments and service plans;
.    Develop training/technical assistance in assistive 
     technology;
.    Collaborate with Technology-Related Assistance grant 
     programs;
.    Collect/analyze data on local programs that have been 
     successful in promoting access to assistive technology. 
XI   THE UNITED STATES TAX CODE 

A.   Background 

The U.S. Tax Code contains thousands of provisions that affect 
the rate of taxation paid by individuals, businesses, and other 
organizations.  In addition, the tax code provides for a myriad 
of deductions, adjustments to income and tax credits that can 
reduce the amount of tax owed to the federal government.  The 
establishment of these provisions in tax legislation reflects 
federal policy goals, such as the promotion of home ownership, by 
allowing the deduction of real estate interest paid on a primary 
residence.  One important tax credit is the Targeted Jobs Tax 
Credit that promotes employment of people with disabilities and 
others facing employment barriers.

B.   Financing Assistive Technology

There are three ways in which the tax code addresses the cost of 
technology as a tax deduction for individuals with disabilities.  
First and most common is the deduction of technology purchases as 
a health care expense either for the individual with the 
disability or as a dependent of a taxpayer.  Second, a deduction 
can be claimed when the technology expense is incurred in the 
production of income whether through the conduct of business or 
as an employee business expense.  Third, a deduction can be 
claimed when there is a gift of technology devices to a nonprofit 
entity as a charitable contribution.  The applicability of one or 
more deductions depends upon the circumstances, purpose, and 
documentation for the purchase.  When more than one category is 
applicable, the desirability of which provision to use will vary 
because of differences in the length of time over which the 
deduction can be claimed or the proportion of total cost that can 
be deducted. 

The following summarizes six different tax code related methods 
of paying for assistive technology that can be used by 
individuals with disabilities.

Medical Expenses:
[IRS Sec. 213 as amended by the Tax Reform Act Sec. 133]
 
Assistive technology can be financed through tax deductions for 
medical care expenses, on the basis of their role in overcoming 
or mitigating the effects of disabilities or "defects" (26 CFR 
1.213).  For example, expenditures for text
telephones (TTs) (previously known as telecommunication devices 
for the deaf or TDDs), equipment to make driving feasible for 
persons with physical disabilities, and powerful lamps and print 
enlargement equipment purchased by a taxpayer for use in school 
by a visually impaired dependent child have been held tax 
deductible as health care costs.

Individuals who itemize deductions may deduct amounts paid during 
the taxable year, if not reimbursed by insurance or otherwise, 
for medical care of the taxpayer and of the taxpayer's spouse and 
dependents, to the extent that the total of such expenses exceeds 
7.5 percent of adjusted gross income (AGI). 
 
Medical care expenses eligible for the deduction include amounts 
paid by the taxpayer for health insurance (including after-tax 
employee contributions to employer health plans);  diagnosis, 
treatment, or prevention of disease or malfunction of the body;  
and essential health care related transportation and lodging.  
The cost of prescription drugs and insulin are eligible also for 
the medical care expense deduction.  All medical expenses insured 
within a given year are deductible in that year. 

Business Deductions:
[IRS Secs. 67 and 162, Tax Reform Act of 1986 Sec. 132]

Deducting the cost of assistive technology as a business expense 
depends on its usage in the production of income.  Except in 
those cases where the item is inherently personal in nature, the 
use of adaptive technology for business purposes qualifies it for 
tax deductibility as an ordinary and necessary business expense. 
Unlike medical care, there is no threshold of AGI;  the entire 
cost is deductible.  Costs may, however, have to be depreciated, 
i.e., spread over several years.  Assistive technology costs for 
individuals who are self-employed also
fall under this provision.     

Employee Business Expenses:
[IRS Sec. 67(b) Tax Reform Act of 1986 Sec. 132]

Employee business expenses are a subcategory of business 
deductions.  Assistive technology is deductible as an employee 
business expense when it is used in, and is necessary for, 
employment by an individual with a disability, and is not 
reimbursable.

Other miscellaneous business expenses include non-reimbursed 
business travel expense and dues paid to a union or professional 
trade association by the employee with a disability.  Employee 
business expenses are deductible under the miscellaneous 
deductions category, but only to the extent that total 
miscellaneous deductions exceed 2 percent of Adjusted Gross 
Income (AGI).  This deduction is not available to taxpayers who 
do not itemize deductions. 

Targeted Jobs Tax Credit (TJTC):
[IRS Sec. 51 as amended by Tax Reform Act of 1986 Sec. 1701] 

The Targeted Jobs Tax Credit program was established in 1977 
under P.L. 97-300 to provide an incentive to employers to hire 
people with disabilities.  These individuals are referred by 
state and Veterans' Administration vocational rehabilitation 
programs and include eight other categories of disadvantaged 
individuals facing barriers to employment, such as youths and 
young adults from economically disadvantaged families.

The program provides a tax credit for one year for employment of 
individuals certified by the state Employment Service for a 
minimum of ninety days or 120 work hours.  The maximum tax credit 
is 40 percent of the first year's wage up to $6,000 per employee, 
or a maximum credit of $2,400 per employee.  A maximum credit of 
$1,200 per employee is available for summer youth employment for 
a minimum of fourteen days or twenty hours.

Approximately $4.5 billion in tax credits was claimed during the 
first ten years of the program.  In FY 1988 a total of 497,312 
TJTC employees were claimed; about seven percent (36,619 
individuals) were vocational rehabilitation referrals.  Although 
there is no specific reference to assistive technology in the 
legislation, the tax credit can be used by the employer to 
finance job adaptations.  The TJTC is provided in recognition of 
the potential for additional expense to the employer in the 
recruitment, hiring, and training of people in the target groups. 

Tax Credit For Architectural And Transportation
Barrier Removal Expenses:
[IRS Sec. 190]

Section 190 of the Internal Revenue Code provides up to a $15,000 
tax incentive to businesses to make their facilities and vehicles 
accessible to people
with disabilities (handicapped) and elderly persons.   
Handicapped is defined as a physical or mental disability 
including blindness and deafness, which constitutes or results in 
a functional limitation to employment; or which substantially 
limits one or more of such individual's major life activities 
such as walking, speaking, learning or working.

Taxpayers (individual proprietorships, partnerships, and 
affiliated corporations filing a consolidated return) can take a 
credit of up to $15,000 for qualified expenses for architectural 
and transportation barrier removal per year.  Qualified expenses 
must meet specific Section 190 standards, such as the slope, 
handrail height, and section lengths for ramps; public telephones 
if they are equipped for persons with a hearing impairment; and 
the installation of warning signals that include both audible and 
visual signals.

Prior to enactment of OBRA 1990, the maximum Section 190 
deduction was $35,000;  this was reduced to $15,000 in 
coordination with the enactment of the ADA Tax Credit for Small 
Business described in the following section. 

ADA Tax Credit For Small Business In OBRA 1990:
(OBRA 1990, P.L. 101-508)

The Omnibus Budget Reconciliation Act of 1990 includes a tax 
credit for small business for expenses associated with the costs 
of providing reasonable accommodation for individuals with 
disabilities while complying with Title I, Employment, and Title 
III, Public Accommodations of the Americans with Disabilities Act 
(see next section, Section XI, Civil Rights, below).

The credit is available for taxable years beginning after the 
date of enactment of OBRA 1990 to small businesses, defined as 
having gross receipts of $1,000,000 or less or employing thirty 
or fewer full-time individuals the previous tax year.

The available ADA tax credit is fifty percent of eligible access 
expenditures in excess of $250, to a maximum of $10,250.

The purpose of the eligible access expenditures must be to comply 
with the ADA.  Allowable expenditures include the acquisition or 
modification of equipment or devices for individuals with 
disabilities;  removing architectural, communication, physical, 
or transportation barriers which prevent a business from being 
accessible to, or usable by, individuals with disabilities;  
providing
qualified interpreters or other effective methods of making 
aurally delivered materials available to individuals with hearing 
impairments;  providing qualified readers, taped texts, and other 
effective methods of making visually delivered materials 
available to individuals with visual impairments; or providing 
other similar services, modifications, materials or equipment.

The eligible access expenditures must concur with the standards 
of the Architectural and Transportation Barriers Compliance Board 
and regulations set forth by the Attorney General.  At the same 
time, OBRA 1990 reduced the current tax credit for the removal of 
architectural and transportation barriers to individuals with 
disabilities and elderly individuals from $35,000 to $15,000. 
 
Charitable Contributions Deduction:
[IRS Secs. 170 and 501]

The deduction available to individual taxpayers and businesses 
for charitable contributions, i.e., those made to tax exempt 
nonprofit organizations with applicable charitable, educational 
or other public purposes, can be used to finance assistive 
technology.

For example, donations of cash or equipment can be made to 
assistive technology users who are not their dependents, with tax 
advantages for the donor through the charitable contributions 
deduction, if the donation is made to a tax-exempt organization 
willing to serve as conduit and if there is what is called an 
arms-length transaction.  Tax exempt agencies with programs for 
accepting equipment and for recycling it to clients can help 
donors gain tax advantages greater than they would by donating 
cash. 

C.   State Flexibility

There is no state flexibility as taxation is federal.  It remains 
to be seen whether states or cities that collect income tax also 
will create new incentives.

D.   Current Policy Issues

To the degree that an individual's own resources remain a major 
source for the financing of assistive technology purchases then 
tax deductions and credits are a major benefit.  To the degree 
that tax policy is utilized to capture resources of business and 
industry and direct or encourage expenditures on assistive
technology for employees or others, alternative funding options 
of significant magnitude emerge.

Increased understanding and knowledge by the business community 
of the role assistive technology plays in meeting the legal 
standard of reasonable accommodation or readily achievable 
accommodation can result in increased expenditures.

E.   Facilitators

The passage of ADA may increase the interest of business and 
industry in utilizing the targeted jobs tax credit, the barrier 
removal deduction, and the tax credit for small business.  New 
responsibilities under ADA have focused the attention of the 
private sector on the cost of reasonable accommodation.  
Assistive technology provides a means to reduce barriers to 
employment and access to transportation, communication, and 
public accommodations and tax policy has provided a means of 
reducing the costs of the private sector and benefitting 
individuals with disabilities at the same time.

F.   Barriers

The current use of the medical expense deduction and business 
deductions and credits remains underutilized.  The medical 
expense deduction is not widely understood by persons with 
disabilities and their families as a tax benefit that will cover 
a wide array of assistive technology devices and services.

This deduction is limited also to only those individuals who 
itemize deductions on their tax return and ignores the extra 
costs associated with disabilities for millions of Americans who 
file simplified returns.

G.   Suggestions for Reform 

FEDERAL LEVEL:
LEGISLATIVE 
.    Clarify the extent of coverage of assistive technology 
     purchases under the current medical expenses deduction;
.    Establish a tax deduction for non-itemizers that covers 
     assistive technology purchases for individuals with 
     disabilities and their families;
.    Establish an individual assistive technology account that is 
     deductible
     (similar to the existing individual retirement account) to 
     allow for the sheltering and saving of income for future 
     purchase of assistive technology devices.

 
XI.  CIVIL RIGHTS LEGISLATION 
 
ÀÀ The Americans With Disabilities Act 
ÀÀ Section 504 Of The Rehabilitation Act 
ÀÀ Section 508 Of The Rehabilitation Act 

1.   THE AMERICANS WITH DISABILITIES ACT

A.   Background
 
The Americans With Disabilities Act (ADA) was enacted in 1990 
(P.L. 101-336).  This historic legislation forbids discrimination 
against individualize with disabilities and extends, for the 
first time, federal civil rights protection to people with 
disabilities in the areas of employment, transportation, public 
accommodations, state and local government services, and 
telecommunications.  The law broadens civil rights protections 
for more than 43 million Americans by requiring all affected 
entities to provide reasonable accommodation to persons with 
disabilities.  Religious organizations and private clubs are 
exempt from the ADA provisions.

Private individuals, the Equal Employment Opportunity Commission 
(EEOC), and the Department of Justice (DOJ) have authority to 
bring actions in court to enforce compliance with the mandates of 
ADA.  The following summarizes ADA's Titles:

Title I, Employment:  Employers, employment agencies, labor 
organizations and joint labor management committees with 15 or 
more employees will be prohibited from discrimination against any 
qualified individual with a disability with regard to job 
application and interview procedures:  hiring, advancement or 
discharge; employee compensation; job training; and other terms, 
conditions or privileges of employment.  Effective date is July 
26, 1991, for employers with 25 or more employees; July 26, 1994 
by employers with 15 or more employees.

Title II, Public Service:  Discrimination on the basis of 
disabilities is prohibited in all programs, activities and 
services provided or made available by state and local 
governments and any instrumentalities thereof regardless of 
whether those entities receive federal financial assistance.  
This title includes buses, light and rapid rail, including fixed 
route systems, paratransit, demand response systems and 
transportation facilities) and public transportation by intercity 
Amtrak and commuter rail.  Effective date is January 26, 1992.

Title III, Public Accommodations Operated by Private Entities:  
Businesses that provide services to the general public, as well 
as public and private entities that provide public transportation 
services, are prohibited from discriminating on the basis of 
disability and must provide full and equal enjoyment of goods, 
services, facilities, privileges, advantages and accommodations 
to individuals with disabilities.  Commercial facilities and 
places of public accommodations, included are places of lodging, 
restaurants, theaters and concert halls, banks, barber shops, 
museums and libraries, day care centers, nursery schools and 
offices of accountants, lawyers, and health care providers, are 
required to be made accessible for people with disabilities.  
Effective date is January 26, 1992.

Title IV, Telecommunications:  Telephone services offered to the 
general public must include 24 hour daily interstate and 
intrastate telecommunications relay services for Text Telephone 
(TT) users so that individuals with disabilities have equal 
access to communications equivalent to those provided to 
individuals able to use voice telephone systems.  Effective date 
is July 26, 1993.

Disability is broadly defined in the Act.  Across the Titles, it 
is "an individual who has a physical or mental impairment that 
substantially limits one or more major life activities, or has a 
record of such an impairment, or who is regarded as having such 
an impairment."  

Examples of physical or mental impairments include contagious and 
noncontagious diseases and conditions as orthopedic, visual, 
speech and hearing impairments; cerebral palsy, epilepsy, 
muscular dystrophy, emotional illness, specific learning 
disabilities, HIV disease (whether symptomatic or asymptomatic), 
tuberculosis, drug addition and alcoholism.   Major life 
activities includes functions such as caring for oneself, 
performing manual tasks, walking, seeing, hearing, speaking, 
breathing, learning, and working. 

Auxiliary Aids & Services:  The statutory definition for such 
items, i.e., certain assistive technology, is as follows:  "the 
term "auxiliary aids and services includes (A) qualified 
interpreters or other effective methods of making aurally 
delivered materials available to individuals with hearing 
impairments;  (B) qualified readers, taped texts or other 
effective methods of making visually delivered materials 
available to individuals with visual impairments;  (C) 
acquisition or modification of equipment or devices; and (D) 
other similar services and actions."

However, in the final regulations for Titles II and III, as 
promulgated by the Department of Justice, such assistive 
technology is more broadly defined and described: "Auxiliary aids 
and services include a wide range of services and devices for 
ensuring equally effective communication" (and includes) (1) 
Qualified interpreters, notetakers, transcription services, 
written materials, telephone handset amplifiers, assistive 
listening devices, assistive listening systems, telephones 
compatible with hearing aids, closed caption decoders, open and 
closed captioning, telecommunications devices for deaf persons 
(TTDs), videotext displays, or other effective methods of making 
aurally delivered materials available to individuals with hearing  
impairments;  (2) Qualified readers, taped texts, audio 
recordings, Brailled materials, large print materials, or other 
effective methods of making visually delivered materials 
available to individuals with visual impairments;  (3) 
Acquisition or modification of equipment or devices; and  (4) 
Other similar services and actions."

This list is meant to be illustrative rather than all inclusive 
of what is possible.  While the definition is meant to include 
state-of-the-art devices and emerging technology, State and local 
public services are not required to use the newest or most 
advanced technologies as long as the auxiliary aid or service 
that is selected affords effective communication. 

The definition also indicates that auxiliary aids and services 
can include the acquisition or modification of equipment or 
devices or other similar services and actions which might be 
required in order to afford someone with a hearing, speech or 
vision disability with an equally effective opportunity to 
communicate with others.  In determining what kind of auxiliary 
aid and service is needed, the entity must "give primary 
consideration to the requests of the individual with 
disabilities."

Therefore, the provisions of ADA create a wide range of 
opportunities for the
expansion of access to assistive technology by persons with 
disabilities in the workplace and the marketplace.

B.   Financing Assistive Technology

The ADA does set parameters on the costs employers, government 
and business must allow for reasonable accommodation including 
assistive technology, on a case-by-case basis.

Title III, Public Accommodations:  ADA says that extra charges 
may not be imposed on individuals with disabilities to cover the 
costs of public accommodation.  For example, a restaurant may not 
charge a wheelchair user extra for home delivery when it is 
provided as the alternative to barrier removal.

The entity making accommodation and providing services is 
expected to pay for  accommodation for persons with disabilities 
as they now accommodate to persons without disabilities.  The 
threshold for costs by an entity is the level of "undue burden" 
it is required to reach to make accommodation.  Undue burden is 
defined as a significant difficulty or expense and serves as a 
limitation on the obligation to provide auxiliary aids and 
services and will be defined on a case-by-case basis.

Title I, Employment:  Factors to be considered in determining if 
an accommodation would pose an undue hardship include:

l.   the nature and net cost of the needed accommodation, minus 
     any available tax credits, deductions and outside funding;
2.   the overall size and financial resources of the employer's 
     entire business;
3.   the overall size and financial resources of the actual work 
     facility that the person with a disability would be working; 
     and,
4.   the impact that the accommodation would have on the 
     operations of the business and its other employees.

However, if a business can show that providing an accommodation 
would pose an undue hardship for it to do in its entirety, the 
business must be open to sharing the costs of doing so with the 
person with a disability and/or an outside funding agency.  Thus, 
if a person needs a series of job accommodations costing $5,000 
and a firm could only afford to pay $2,500
without incurring an undue burden, it has to pay at least this 
much of the costs if the individual or others can cover the 
remaining expenses.  Cost-sharing strategies can prove immensely 
important in opening up new job opportunities for individuals 
with significant disabilities who have extensive job 
accommodation needs.

While a business, as a public accommodation, is not required to 
provide personal devices such as wheelchairs, individually 
prescribed devices such as prescription eyeglasses or hearing 
aids or services, or services of a personal nature including 
assistance in eating, toileting, or dressing, there is nothing in 
the rule to say that a business cannot provide these if they wish 
to do so.  
 
Title IV of ADA is specific to telecommunications, providing that 
telephone service offered to the general public must include 
interstate and intrastate telecommunications relay service (TRS) 
for TT (text telephone) users.  Under ADA the terms TDD or 
Telephone Device for the Deaf has been replaced with the more 
generic term, Text Telephone or TT device.  Services must provide 
access to TT users equivalent to that provided for individuals 
able to use voice telephone systems.

ADA specifically states the cost parameters for the telephone 
relay system:  it states that TRS users shall pay rates no 
greater than the rates paid for functionally equivalent services 
with respect to such factors as the duration of the call, time of 
day and geographic distance of the call.

C.   State Flexibility

States have no role in the implementation of Titles I, III and 
IV.  However, state governments are responsible for 
implementation of the ADA in relation to Title II, the section on 
public services.  The ADA requires that all state and local 
government services be accessible to people with disabilities as 
defined in Section 504 (of the Rehabilitation Act), regardless of 
the funding source and including those provided by private 
entities with state or local government funds.

Although all public services will have to comply with federal law 
and regulations, states are expected to vary considerably in the 
speed and comprehensiveness of their ADA implementation.  State 
governments also may vary in the speed and comprehensiveness of 
their compliance as employers. 
Moreover, since much of the implementation of ADA is on a 
case-by-case basis, states will have considerable flexibility in 
creating means of reasonable accommodation.

States vary widely in their use of state anti-discrimination 
statutes on the basis of disability, as well as in the 
enforcement of such laws where they exist. 

D.   Current Policy Issues
 
Insurance:  Within Title 1, Employment, ADA's Final Rule stated 
that an employer's health insurance plan must be open to people 
with disabilities of all ages, i.e., for employees and their 
dependents, on a nondiscriminatory basis.  However, the ADA and 
these rules do permit insurance companies and others to set up 
and administer "the terms of a bona fide plans that are based on 
underwriting risks, classifying risks, or administering such 
risks that are based on or not inconsistent with State law, 
including pre-existing condition requirements." The disability 
community is concerned about this issue as many States' health 
insurance laws discriminate against those with disabilities and 
their families.

Language in the House and Senate committee reports indicates that 
Congress intended to reach insurance practices by prohibiting 
differential treatment of individuals with disabilities in 
insurance offered by public accommodations unless the differences 
are justified:

     "Under the ADA, a person with a disability cannot be denied 
     insurance or be subject to different terms or conditions of 
     insurance based on disability alone, if the disability does 
     not pose increased risks"

and
     "insurers may continue to sell to and underwrite individuals 
     applying for life, health or other insurance on an 
     individually underwritten basis, or to service such 
     insurance products, so long as the standards used are based 
     on sound actuarial data and not on speculation ... "

Since private health insurance can be a major source of financing 
of assistive technology, implementation of these provisions will 
be essential to thousands of
persons with disabilities.

Compliance/Enforcement:  It is too early to determine what role 
the EEOC and DOJ will take in responding to complaints, 
monitoring for compliance and assuring full enforcement of the 
law.  Until such data become available the ADA can only be 
described as a potential major financing stimulus for assistive 
technology for individuals with disabilities in the workplace and 
to a lesser extent in public accommodation.

E.   Facilitators

The Department of Justice and the Equal Employment Opportunity 
Commission are the lead federal agencies with enforcement 
responsibility. The DOJ is funding several technical assistance 
projects on cost effective implementation of the ADA.  Many of 
these projects are expected to include consultation to entities 
affected by the ADA on how they can and must use assistive 
technology in complying with the ADA. 

EEOC's definition of Reasonable Accommodation states that it can 
include but is not limited to: "Making existing facilities 
readily accessible to and usable by employees with disabilities; 
job restructuring, part-time or modified work schedules; 
reassignment to a vacant position; the  acquisition or 
modification of equipment or devices; appropriate adjustment or 
modifications of examinations, training materials or policies; 
the provision of qualified readers or interpreters; and other 
reasonable accommodations for individuals with disabilities."  
EEOC's section on supported employment indicates that this may be 
seen as a legitimate means of affording a reasonable 
accommodation to someone with a disability in a limited number of 
instances.

Also " ... an employer, under certain circumstances, may be 
required to provide modified training materials or a temporary 
'job coach' to assist in the training of a qualified individual 
with a disability as a reasonable accommodation." 

F.   Barriers

In the interpretive guidance to ADA by the EEOC there are no 
examples or illustrations of how different types of assistive 
technology can be used to provide reasonable accommodation to a 
job applicant or an employee with a
disability in a wide variety of cost-effective ways. 

Also, ownership and possession of assistive technology devices in 
the workplace and in places of public accommodation will be 
worked out on a case-by-case basis.  ADA does not require the 
employer to allow the assistive technology devices and/or 
services to be taken off-site.

G.   Suggestions for Reform

FEDERAL LEVEL:
EXECUTIVE
.    Ensure that assistive technology is a major focus of 
     technical assistance on implementation of the ADA;
.    Fund comprehensive monitoring and data collection on 
     implementation, including access through assistive 
     technology and access to assistive technology;
.    Examine the effects of the ADA on people's lives, as well as 
     more traditional analyses of complaints filed and responses 
     made.

LEGISLATIVE
.    Amend ADA to include a right to and definition of 
     communications accessibility to read as follows:  

     (A)  COMMUNICATIONS ACCESSIBILITY - means making all 
          expressive and receptive communications accessible to 
          persons with disabilities, and recognizes that every 
          individual is (1) capable of communicating, and (2) 
          knows best how to convey his or her thoughts to others;  
          and (3) extends the same basic common courtesies of 
          interacting with people with disabilities that are 
          extended to others in receiving the goods, services, 
          facilities, privileges, advantages, or accommodations 
          offered by an entity providing such services by;

     --   Affording such individuals with the necessary 
          opportunity, auxiliary aids and supports to effectively 
          communicate with others.  In determining what type of 
          auxiliary aid is necessary, an entity shall give 
          primary consideration to the requests of the individual 
          with
          disabilities.[*]

     --   Providing a communications environment which allows and 
          encourages persons  with motor, cognitive, hearing, 
          speech or vision disabilities to effectively express 
          themselves, understand others, and/or receive or send 
          information and signals over public alert, public 
          address and telecommunications systems and networks;

     --   Providing individuals with disabilities the assistive 
          technology, interpretive services and personal 
          assistance each needs to communicate effectively with 
          others.

.    Amend ADA to recognize communications access as an issue 
     that impacts individuals with a variety of disabilities 
     other than hearing impairment and therefore to expand any 
     definition of access with an added reference to 
     "augmentative communication devices, computer modem access 
     via the telephone lines, or other effective methods of 
     making communication available to individuals with hearing 
     or speech impairments" whenever TTDs/TTs are listed as a 
     device.

.    Amend ADA to include an explanation of communications 
     accommodation as follows:

     (B)  Accommodation by an entity means taking the time to 
          communicate to a person with limited speech or who is 
          using a manual communication board or assistive device;  
          speaking and responding directly to such an individual 
          rather than any third party unless directed otherwise 
          (to the extent practical, this should apply to children 
          and adults);  not hanging up on or refusing telephone 
          inquiries from such individuals or not forcing someone 
          to write
          everything out on a note pad if he or she does not want 
          to communicate in this fashion;  or not inferring or 
          implying that just because an individual has limited 
          natural speech that he or she also has limited or 
          impaired intelligence, hearing or judgment.

.    Amend ADA to include examples of assistive devices that 
     could be a reasonable accommodation to someone with cerebral 
     palsy or other severe physical disabilities as follows;

     (C)  The following lists examples of assistive technology 
          devices that could be a reasonable accommodation to 
          someone with cerebral palsy or other severe physical 
          disability and includes but is not limited to:

          Remote control switches for use of computers and other 
          office equipment;  adaptive switches to turn on/off 
          lights;  telephone adaptations such as speaker phones, 
          headsets, modems, TDDs or TTs;  reachers; simple 
          adaptions/fixtures for using office machines;  
          magnifiers;  adjustable furniture;  adaptive computer 
          software;  page turners;  lever door handles;  access 
          to a regular computer or typewriter to fill out forms;  
          communication boards;  telephones with audio and data 
          transmission capability;  telephones with wireless 
          audio and data communication capabilities;  
          augmentative communication devices;  automated 
          interpreters;  computer and computer modem access in 
          commonly used access forms such as ASCII; voice 
          recognition systems;  voice activated telephones;  
          pointing and typing aids such as headpointers and 
          mouthsticks;  alternative switches to control lights 
          and elevator doors and other access devices;  
          electronic equipment which can be activated by sipping, 
          puffing,  movement of the eye, head, wrist, finger, or 
          by remote or wireless means;  alternative keyboards;  
          keyguards;  large button telephones;  automatic 
          dialing, and other effective and efficient methods of 
          assuring reasonable accommodation and access to 
          telecommunication networks, switching services and 
          similar services that allow an individual with a 
          disability to enjoy the same benefits and privileges of 
          services that are made available to individuals without 
          speech, mobility or manual dexterity impairments.

.    Amend ADA to incorporate the same definition of assistive 
     technology as found in the Technology-Related Assistance 
     Act. 

STATE LEVEL:
.    Move quickly toward full compliance, including expanded 
     training/technical assistance on assistive technology and 
     its significance in promoting access and compliance;
.    Monitor compliance at the local level;
.    Examine and publicize ways assistive technology can be used 
     in cost effective compliance;
.    Emphasize consumer choice as much as possible in all 
     assistive technology used in compliance activities.

2.   SECTION 504 OF THE REHABILITATION ACT OF 1973 [29 USC 794] 

A.   Background 

Section 504 of the Rehabilitation Act of 1973 was enacted to 
extend to disability the prohibition against discrimination that 
previously had been stated for gender, national origin, race and 
religion.  Section 504 states that "No otherwise qualified 
handicapped individual...shall, solely by reason of his handicap, 
be excluded from the participation in, be denied the benefits of, 
or be subject to discrimination under any program or activity 
receiving federal assistance."

The definition of a handicapped individual is a person who has a 
physical or mental impairment which substantially limits one or 
more of such person's major life activities, a record of such 
impairment, or is regarded as having such an impairment. 
 
Each federal agency has established regulations to govern Section 
504 implementation in its respective programs.  For example, 
regulations at 34 CFR 104 apply to IDEA and other programs 
administered by the U.S. Department of Education.  Agencies have 
developed different definitions of qualified handicapped 
individual and of reasonable accommodation, a key provision of 
Section 504 in regards to compliance activities by entities 
receiving federal funds. 

B.   Financing Assistive Technology
 
Section 504 is a civil rights statute that requires equal access 
and equal opportunity to persons with disabilities, and therefore 
does not provide any direct funding.  The reasonable 
accommodation and access provisions have been interpreted to 
include a wide range of technology, including low technology 
adaptations to the environment and TDD lines for people with 
hearing impairments.

Section 504 can be significant in promoting access to assistive 
technology in individual programs.  For example, under Section 
504 children can receive assistive technology regardless of 
whether it is needed to allow the child to benefit from special 
education, potentially expanding the scope of possible assistive 
technology integration in the schools.  Section 504 prohibits 
schools from denying children the opportunity to take home 
assistive devices if those devices are needed to enable those 
children to have an equal opportunity to participate in school.

Section 504 regulations for education also broaden the 
eligibility of children with disabilities to include those with 
conditions other than the eleven listed in the IDEA regulations, 
children whose disability affects a major life activity, and 
children whose disability is temporary.   
 
C.   State Flexibility 
 
There is essentially no flexibility in Section 504, as this is a 
federal civil rights statute.  There have been wide differences, 
however, in the consistency of state monitoring of compliance 
activities, assistance to entities in timely compliance, and 
compliance in federally funded state government activities. 
 
D.   Current Policy Issues 
 
The Americans with Disabilities Act (ADA), P.L. 101-336, 
strengthened the anti-discrimination provisions of Section 504 by 
extending its coverage to all services provided by state and 
local governments and their agents, regardless of whether or not 
the programs receive any federal funds.

Over the past few years legislation also has been enacted that 
clarifies the right of individuals with disabilities to be 
covered simultaneously by both IDEA and
Section 504, the coverage of Section 504 to the entire entity 
receiving federal funds rather than just the program component, 
and the right to sue state governments that are not complying 
with Section 504.  For example, the IDEA amendments of 1990 (P.L. 
101-476) included a provision clarifying that states waive their 
11th Amendment immunity against suits filed by individuals by 
receiving federal IDEA funding. 

E.   Facilitators
 
Although not specific to assistive technology, Section 504 has 
clear policy on non- discrimination, access, and reasonable 
accommodation that provides support for access to assistive 
technology.  Section 504 also provides a broad definition of 
people with disability who are covered by its provisions, and a 
potentially broad scope of covered technology in publicly funded 
programs.  Section 504 regulations issued by individual federal 
agencies frequently provide additional support to access, as 
illustrated by the 504 regulations governing education under 
IDEA.  Section 504 also provides for the involvement of people 
with disabilities in service programs' assessment of their need 
for compliance. 
 
F.   Barriers
 
The most frequently heard concern is the lack of enforcement of 
Section 504, compounded by lack of information and 
misunderstanding of the requirements among individuals  with 
disabilities and family members as well as those providing 
services.  Implementation of the extended coverage of Section 504 
under ADA is just beginning. 
 
G.   Suggestions for Reform 

FEDERAL LEVEL:
EXECUTIVE    
.    Expand monitoring/enforcement of Section 504 across all 
     federal programs;
.    Clarify the significance of assistive technology in 504 
     compliance, using the definition of assistive technology 
     found in the Technology-Related Assistance Act;
.    Provide technical assistance on assistive technology and 
     other 504 compliance strategies in coordination with ADA 
     compliance technical
     assistance.

3.   SECTION 508 OF THE REHABILITATION ACT 
 
[29 U.S.C. 794d]
 
A.   Background 

Section 508 is an amendment to the Rehabilitation Act of 1973 
adopted by Congress in 1986 (P.L. 99-506) to promote equal access 
for people with disabilities to federal jobs, including public 
information services and electronic tools.  Section 508 
establishes federal-wide procurement policy for computer 
accommodation to ensure that individuals with disabilities may 
use electronic office equipment with or without special 
peripherals.  The guidelines apply to federal agencies as they 
acquire information technology and services.  The needs of 
persons with disabilities for access to work-related and public 
information resources must be met in agency procurement. 

B.   Financing Assistive Technology 

Workstations for Federal employees with disabilities which are 
sensory, cognitive or mobility related should be equipped with 
the necessary assistive technology.  All Federal agencies that 
are regulated by the Federal Information Resources Management 
Regulations (FIRMR) must ensure information accessibility through 
electronic office equipment for individuals with disabilities.  
The financing of assistive technology is by the acquisition or 
modification of Federal Information Program (FIP) resources in a 
manner that accommodates the functional limitations of 
individuals with disabilities.  
 
Federal agencies that acquire information technology and services 
must comply with the guidelines of Section 508.  Additionally, 
states funded under Title I of P.L. 100-407, The Technology 
Related Assistance for Individuals with Disabilities Act of 1988, 
are required to demonstrate that they are in compliance with 
Section 508 in the third year of their projects in order to be 
eligible to apply for an extension grant.   

C.   State Flexibility

There is no state flexibility, per se.

D.   Current Policy Issues

The pending reauthorization of Rehabilitation Act and any 
significant policy changes that occur at that time may positively 
affect access to funding of assistive technology.  (See Section 
VI, Rehabilitation Act.)

E.   Facilitators 
 
To facilitate the implementation of 508, in 1985, General 
Services Administration Information Resources Management Service 
(IRMS) established an information resource center called the 
Clearinghouse on Computer Accommodation (COCA), to assist federal 
agencies in providing information accessibility to individuals 
with disabilities.  COCA provides regular training programs for 
governmental officers and provides technical assistance upon 
request to employees who seek information on accessibility for 
computers, telecommunication systems, and other electronic office 
equipment. 

States funded under the Technology Related Assistance for 
Individuals with Disabilities Act of 1988, P.L. 100-407, must 
comply with Section 508.  This mandate covers all agencies, 
entities, and commissions, of the State and their employees.  
This requirement comes as a result of a recent request to clarify 
and interpret Section 34 CFR Section 345.21(g) of the regulation 
from the National Institute on Disability and Rehabilitation 
Research.  According to counsel, States receiving a development 
grant and applying for an extension grant under Title I of the 
P.L. 100-407, must comply with Section 508 of the Rehabilitation 
Act of 1973.   
 
Finally, Section 508 requires that each agency designate a senior 
official (DSO) for federal information processing who is 
primarily responsible for ensuring electronic office equipment 
accessibility for current or prospective employees with 
disabilities.  This responsibility also includes providing access 
to Federal public information resources for individuals with 
disabilities.  The authorized representative monitors progress 
toward achieving electronic equipment accessibility goals. 

F.   Barriers
 
Several points in the government's procurement procedures account 
for the delays in full implementation of, or compliance of, 
Section 508:  
.    There is a lack of awareness by federal agencies of the 
     requirements of the law compounded by a lack of awareness by 
     agencies about where to go for solutions to accessibility 
     requirements. 

.    The vast majority of governmental purchases of electronic 
     office equipment made in the last three years were not made 
     through large GSA monitored procurements. Although GSA has 
     responsibility for overseeing governmental procurement of 
     office equipment, only a relatively small portion of these 
     portion of these purchases are made through large purchases 
     that require preapproval by GSA.  Smaller 
     procurements--generally under $2,500,000--can be made under 
     "delegated authority" granted agencies by GSA.

.    Even when large procurements of accessible electronic office 
     equipment are made by federal agencies, employees with 
     disabilities are not assured of obtaining needed access 
     technology.  Often, program managers in the branches where 
     the employee works must make an official purchase request 
     for the needed equipment.  Many program officers do not know 
     the regulating accessibility and accommodations for persons 
     with disabilities.  They may also have equipment budgets 
     that seriously limit their equipment acquisitions, and 
     personal or branch priorities may not place access 
     technology high  on the list of equipment to be secured.

.    There is a general lack of enforcement of Section 508 by the 
     General Services Administration which is charged with the 
     oversight of large procurements by any Federal agency.

.    Section 508 includes electronic office equipment.  Only PCs 
     and microcomputers have been addressed by GSA.  There are 
     many other types of electronic office equipment, 
     photocopiers, facsimile machines and especially telephone 
     equipment which is integrated into the total office 
     environment. Telephone equipment, in particular with data 
     handling capacity, must be accessible to individuals with 
     disabilities. Federal Acquisition Regulations have not been 
     updated to include all electronic office equipment available 
     on the market.
  
G.   Suggestions for Reform 

FEDERAL LEVEL:
EXECUTIVE    
.    Speed up implementation of Section 508.
.    Conduct evaluation of Section 508 implementation.
.    Increase technical assistance to states on compliance with 
     Section 508.
.    Update the Federal Acquisition Regulations to include all 
     electronic office equipment available on the market. 
.    Exercise caution when considering the purchase of new 
     computer hardware and software and the effect on the 
     productivity of employees who are blind and visually 
     impaired.  For example, computer displays that are based on 
     a video image, rather than on the display of individual 
     letters, is becoming commonplace.  This technique, often 
     called a graphical use interface, remains inaccessible to 
     individuals who are blind although progress has been made by 
     some manufacturers. Another example is the CD-ROM which is 
     growing in popularity as a medium for storing large 
     quantities of information and raw data.  The format in which 
     this information is stored on the CD-ROM again may limit 
     access to users who are blind.
.    GSA implementation and enforcement activities should provide 
     more education and services for program as well as 
     procurement managers.  Education and training on 
     accessibility must be infused into all GSA training 
     programs.  Information on guidance on product accessibility 
     should be incorporated into all other GSA management 
     training courses and in all information resources management 
     (IRM) materials.
.    GSA should provide all Federal program and procurement 
     managers increased education, training materials, and 
     technical services.  GSA should diligently enforce the 
     accessibility regulations, both in large procurements and in 
     small ones.         

Suggestions For All Civil Rights Initiatives

FEDERAL LEVEL:
EXECUTIVE  
.    Collect/analyze data on implementation and enforcement, 
     including assistive technology-supported access and access 
     to assistive technology itself;
.    Support broad-based technical assistance on assistive 
     technology and its significance to access and full 
     citizenship, including other civil rights such as 
     voting/polling place accessibility.


XII. TECHNOLOGY-RELATED ASSISTANCE FOR INDIVIDUALS WITH 
     DISABILITIES ACT OF 1988 ("The Tech Act")
 
[29 USC 2201-2271]
 
A.   Background 

The Technology-Related Assistance for Individuals with 
Disabilities Act of 1988 (P.L. 100-407) was enacted to increase 
access to assistive technology for individuals with disabilities, 
including the promotion of access to financing.  Its three 
purposes are (1) to provide financial assistance to the states to 
help each state develop and implement a consumer-responsive 
statewide program of technology-related assistance for 
individuals of all ages with disabilities; (2) to facilitate the 
identification of federal policies that facilitate payment for 
assistive technology and those that impede such payment, and the 
elimination of inappropriate barriers to such payment; and (3) to 
enhance the ability of the federal government to provides the 
states with technical assistance, information, training, public 
awareness programs, and funding for model demonstration and 
innovation projects. 
 
The legislation was enacted in recognition that for

     "(S)ome individuals with disabilities, assistive technology 
     is a necessity that enables them to engage in or perform 
     many tasks...[and] to have greater control over their own 
     lives; participate in and contribute more fully to 
     activities in their home, school, and work environments, and 
     in their communities; interact to a greater extent with 
     nondisabled individuals; and otherwise benefit from 
     opportunities that are taken for granted by individuals who 
     do not have disabilities."

The Act also references underserved groups, defined as "any group 
of individuals with disabilities who, because of disability, 
place of residence, geographic location, age, race, sex, or 
socioeconomic status, have not historically sought, been eligible 
for, or received technology-related assistance." 
 
A comprehensive definition of assistive technology is used, to 
include services that help individuals select, acquire, and use 
assistive technology devices as
well as the devices themselves. 
 
Title I of the Act established a program of federal grants to the 
states.  Development grants are provided for a three-year period, 
with a possible two-year extension grant. 

The first round of grants in FY 1989 provided grants to nine 
states, followed by fourteen additional states in FY 1990, and 
eight more in FY 1991, to a total of thirty-one currently.  As of 
the FY 1991 awards, all states have submitted applications, and 
thirty-one have received grants.  An additional ten are expected 
to receive funding in FY 1992.  The minimum grant award is 
$500,000.

Some extension grants are expected to be awarded in FY 1992 on a 
competitive basis.  To be eligible, states will have to have 
demonstrated significant progress in implementation, based in 
part on a federal on-site review during the third year of state 
grants. 
 
Although no specific activities are required, NIDRR has made it 
clear that states are expected to engage in the activities 
suggested in the legislation.  The Act defines the purpose of 
financial assistance to the states to develop assistive 
technology systems that: 

--   are consumer-responsive; 
--   are responsive to individuals with disabilities of all ages; 
--   increase awareness of the needs of individuals with 
     disabilities for assistive technology; 
--   increase awareness of policies, practices, and procedures 
     that facilitate or impede the availability or provision of 
     assistive technology; 
--   increase the availability of and funding for the provision 
     of assistive technology for individuals with disabilities; 
--   increase awareness and knowledge of the efficacy of 
     assistive technology among individuals with disabilities, 
     the families or representatives of individuals with 
     disabilities, individuals who work for public agencies and 
     private entities that have contact with individuals with 
     disabilities (including insurers), employers, and other 
     appropriate individuals; 
--   increase the capacity of public and private entities to 
     provide technology-related assistance, particularly 
     assistive technology devices and assistive technology 
     services, and to pay for the provision of assistive
     technology;
--   increase coordination among state agencies and public and 
     private entities that provide technology-related assistance; 
     and  
--   increase the probability that individuals of all ages with 
     disabilities, to the extent appropriate, will be able to 
     secure and maintain possession of assistive technology 
     devices as such individuals make the transition between 
     services offered by human services agencies or between 
     settings of daily living. 

B.   Financing Assistive Technology 
 
Grants to the states are focused on the development of state 
systems rather than as financing mechanisms in themselves, 
however, they are used in some states as a financing resource.

Activities are expected to include

--   the provision of and payment for assistive technology as 
     well as needs assessment;
--   identification and coordination of resources;
--   information dissemination, training and technical assistance 
     to individuals with disabilities, family members, insurers, 
     employers, and individuals in all relevant public and 
     private agencies;
--   public awareness programs focused on the efficacy and 
     availability of assistive technology;
--   assistance to statewide and community-based organizations 
     that provide assistive technology services;
--   support to public-private sector collaboration; the 
     development and application of personnel standards;
--   the compilation and evaluation of program data; and
--   the establishment of procedures for the active involvement 
     of people with disabilities, family members, and other 
     appropriate individuals in the development and 
     implementation of the state's assistive technology program, 
     with special emphasis on the involvement of assistive 
     technology users.

Additional strategies that can be funded through Title I grants 
include the development of model delivery systems, encouragement 
to support groups, a public information system, and inter-state 
agreements. 

Applications must describe the involvement of people with 
disabilities in the development of the application and provisions 
for continuing involvement, results of a preliminary needs 
assessment, and expected outcomes.  States must assure that the 
grant funds will supplement and not replace funds from other 
sources.  Applications for extension grants must include a plan 
to assess people's satisfaction with the assistive technology 
system as well as demonstrate significant progress in the 
statewide program that has been developed, in line with the 
purposes of state development grants defined in the legislation.  
The federal monitoring program includes an on-site monitoring 
visit in the third year of the development grant as well as 
annual progress reports. 
 
C.   State Flexibility 
 
States have considerable flexibility in their use of Title I 
grants; wide variety is reported in the design and implementation 
of state systems.  As noted above, however, NIDRR has indicated 
to states that they are expected to include the activities found 
in the legislation, and most participating states are reported to 
do so.  States also have flexibility in their decision to apply 
for grant funding, however, no states have chosen not to apply at 
least once. 

D.   Current Policy Issues 
 
A national evaluation of the Title I program is planned by the 
National Institute of Disability and Rehabilitation Research 
(NIDRR), the administering agency.  The evaluation will focus on 
the effects of the program on the lives of individuals with 
disabilities and will be used in a report to Congress on 
implementation of the legislation, due October 1, 1992.  In 
conjunction with the evaluation, NIDRR will develop an 
information system.  As defined in the legislation, it is to 
include a qualitative and quantitative description of the impact 
of the state assistive technology systems on the lives of people 
with disabilities and on public agencies, the fiscal resources 
committed to assistive technology, community-based organizations, 
and employers.  Program monitoring currently includes site 
visits, informal communication, and annual reports from the 
participating states. 
 
NIDRR has funded a comprehensive technical assistance program to 
the states receiving Title I grants, being provided by RESNA.  
Activities have included resource information on federal 
financing sources as well as individually designed technical 
assistance. 
 
Title II of the Act authorizes four components: 
 
.    A study by the National Council on Disability on the 
     financing of assistive technology, to produce 
     recommendations to the Congress and the President regarding 
     federal laws, policies and procedures that facilitate or 
     impede states in developing consumer-responsive assistive 
     technology programs; federal and state laws, policies and 
     procedures that facilitate or impede access to assistive 
     technology for individuals with disabilities; policies, 
     practices, and procedures of insurers and other private 
     entities that facilitate or impede such access; and 
     alternative strategies for acquiring or paying for assistive 
     technology.  This report is part of the required study. 
 
.    A feasibility study on the establishment of a national 
     information and referral network on assistive technology 
     (currently being conducted for NIDRR by the University of 
     South Carolina Center for Developmental Disabilities, with  
     implementation to be determined by the results of the study.

.    Training and public awareness projects, including consumer 
     training; efforts to increase assistive technology awareness 
     among consumers, family members, and the general public; and 
     grants to institutions of higher education for professional 
     training in technology-related careers. 

.    Demonstration and innovation projects, such as model service 
     delivery, technology research and development, and assistive 
     technology loan demonstrations. 
E.   Facilitators
 
The legislation includes a series of clear policy statements on 
the importance of access to assistive technology; its central 
purpose is to promote such access, including effective and 
coordinated financing systems.  It includes a comprehensive 
definition of assistive technology that has served, in turn, as a 
model for IDEA and other legislation that affects access.  The 
focus on consumer responsive systems is significant, as well as 
the requirement that states include mechanisms for the 
involvement of individuals with disabilities in the design and 
ongoing implementation of the systems that are developed.  The 
target population includes all those with disabilities who need 
assistive technology, regardless of age.  In addition, the Act 
suggests that states attend to the assistive technology needs of 
those who are members of underserved groups. 
 
Virtually all of the suggested activities and purposes in the 
Title I program address the kinds of barriers that have been 
identified in the analysis of federal programs and policies, 
including poor coordination, limited knowledge, and gaps at 
transition points.  There are some indications that participating 
states have enjoyed varying degrees of awareness building, 
networking and consortium development, and consumer involvement.  
The Act also provides for a system of knowledge dissemination and 
technical assistance at the federal level. 
 
F.   Barriers
 
Because the Act is focused on systems development, it is not a 
primary financing resource in itself, and does not address 
concerns in many states that current resources for financing are 
insufficient.  States which use Title I funds to pay for 
assistive technology also run the risk of helping other programs 
continue to avoid their assistive technology financing 
responsibilities.  In addition, federal appropriation levels do 
not permit all states to receive development and extension 
grants.  There has also been some concern that the use of grant 
awards at or near the $500,000 minimum has been particularly 
inadequate in states with large populations. 
 
It is too early to know what role the programs authorized by the 
Act have played in the improvement of access to financing.  Some 
questions have been raised about the possible need to strengthen 
federal monitoring and leadership to
the states on effectiveness in systems development. 

G.   Suggestions for Reform  

FEDERAL LEVEL:
EXECUTIVE
.    Establish authorization for funding on a formula basis for 
     all states that guarantee a minimum allocation of $500,000 
     and take into account the needs of large population states 
     for additional funding;
.    Establish a multi-year discretionary grant program for 
     communities on a local level that target interagency 
     collaboration, consumer responsiveness and systems change to 
     stimulate expanded funding and access to assistive 
     technology;
.    Provide start up funding for states to establish a revolving 
     low interest loan fund for purchase of assistive technology 
     with authorization of a minimum allocation of five million 
     dollars per state that must be matched by participating 
     states on a one-to-one basis;
.    Authorize the funding of a national legal and advocacy 
     clearinghouse and resource center that specializes in 
     individual and systems support on financing of assistive 
     technology.  The Center would assist individuals, agencies 
     and states with accessing public funding for and protecting 
     the right to assistive technology for individuals with 
     disabilities across age and type of disability;
.    Require participation of selected state agencies at a 
     funding roundtable discussion on a quarterly basis to 
     encourage and promote interagency coordination.

XIII.     TELECOMMUNICATIONS ACCESSIBILITY
          ENHANCEMENT ACT OF 1988 
          [40 USC 762]

and       TELECOMMUNICATIONS FOR THE DISABLED ACT OF 1982
          [47 USC Section 610 et seq.]

A.   Background 

Public Law 100-542, the Telecommunications Accessibility 
Enhancement Act of 1988, directs the Federal telecommunications 
system be fully accessible to
individuals who are hearing and speech impaired, including 
Federal employees. The intent of the law is to ensure that all 
Federal agencies provide telecommunications accessibility to all 
individuals with hearing and speech impairments who either work 
for or do business with the Federal Government.  

The Act requires the General Services Administration (GSA) in 
consultation with the Architectural and Transportation Barriers 
Compliance Board (ATBCB), the Interagency Committee on Computer 
Support of Handicapped Employees, the Federal Communications 
Commission and affected Federal agencies to assure that the 
Federal telecommunications system is fully accessible to 
individuals who are hearing and/or speech impaired.   

The Telecommunications for the Disabled Act of 1982, (P.L. 
97-410) for the first time established as national policy a right 
to persons with impaired hearing to have reasonable access to 
telephone services.  The Act established three specific 
requirements for the purpose of attaining hearing aid 
compatibility.  First the Act required the Federal Communications 
Commission (FCC) to (1) establish regulations for uniform 
technical standards for hearing aid compatibility; (2) require 
telephones in certain locations designated as essential phones, 
to be equipped for use with hearing aids; (3) establish specific 
requirements for informational labeling on telephone equipment by 
the FCC.  Toward this end, in 1983 the Commission issued a Rule 
requiring that every telephone offered to the public on or after 
June 1, 1984, contain on the surface of its package a statement 
whether or not it is hearing aid compatible.

Congress defined "essential phones" to include coin-operated 
telephones, telephones provided for emergency use, and telephones 
frequently needed by individuals with impaired hearing.  In 1984, 
the FCC clarified each of these categories.  First the Commission 
defined coin-operated telephones to include those telephones 
found in public or semi-public locations, such as drugstores, gas 
stations, or private clubs.   Second, the FCC divided "telephones 
provide for emergency use into three categories: (1) telephones 
in isolated locations such as elevators, tunnels, and highways, 
(2) telephones with direct lines to emergency authorities such as 
the police and fire departments, and (3) telephones needed to 
signal life-threatening or emergency situations in confined 
settings such as hospitals or prisons.  The final category 
defined in the rules as "essential" are those which are 
frequently needed by individuals who are hearing impaired.

Essential phones are: (1) telephones for use with credit cards 
only (unless a hearing aid compatible coin operated telephone is 
located nearby), (2) telephones in the workplace which are 
necessary for the performance of the employee's duties, (3) 
telephones found in buildings in which visits by the public are 
reasonable expected, e.g., lobbies of hotels and apartment 
buildings, stores, and public transportation terminals, (4) 
telephones available for a minimum of ten percent of the rooms in 
any given hotel, and (5) telephones in locations, such as 
hospitals and prisons, where and individual may be confined, but 
which are not needed to signal the presence of a life-threatening 
situation.  The FCC required that all essential telephones 
installed on or after January 1, 1985 be hearing aid compatible.   
Moreover, the new rules mandated that essential phones that are 
either coin operated or used for emergency use be retrofitted or 
replaced for the purpose of making them hearing aid compatible by 
January 1, 1985.  

B.   Financing Assistive Technology 
 
All Federal agencies regulated by the Federal Information 
Resources Management Regulation (FIRMR) must ensure full access 
to Federal telecommunications within their agency and with those 
agencies with whom they do business.  FIRMR requires the 
performance of determinations of need and requirements analyses 
to identify specific deficiencies to ensure that agency 
telecommunications facilities are fully accessible.  Agencies 
must develop telecommunications accessibility specifications in 
solicitation documents where necessary.  

C.   State Flexibility

There is no state flexibility.

D.   Current Policy Issues

The passage of ADA may increase the interest of federal agencies 
in carrying out their responsibility to accommodate to 
individuals with disabilities.  Furthermore, the Final Rule for 
Title IV, Telecommunications, of the Americans With Disabilities 
Act, sets very specific standards for operating relay services, 
which will expand federal government response to calls.  

E.   Facilitators 

The primary facilitator is that this P.L. 100-542 has a clear 
policy on access to Text Telephones (TTs) (formerly, 
Telecommunication Devices for the Deaf --TDDs -- including 
portable TTs).  The General Services Administration assumes 
responsibility for publishing a directory of TTs and other 
devices used by Federal agencies with access numbers for TT's and 
other devices in Federal telephone directories.  A standard logo 
has been adopted to indicate the presence of TT equipment in 
buildings. 

GSA, in conjunction with the FCC must promote research to reduce 
the costs and improve the capabilities of equipment for providing 
telecommunications accessibility for those with hearing and 
speech impairments.  The regulations require the GSA to consider 
technological improvements in telecommunications accessibility 
for individuals with hearing and speech impairments. 

The Telecommunications for the Disabled Act of 1982, P.L. 97-410, 
for the first time, establish as national policy the right of 
persons with hearing impairments to have reasonable access to 
telephone services.

F.   Barriers

To date, the FCC has done little to regulate telecommunication 
services for persons with disabilities as mandated by the 
Telecommunications Accessibility Enhancement and the 
Telecommunications for the Disabled Acts.   

Most federal and states efforts are focused on improving 
telecommunications access for individuals who are deaf and 
hearing impaired.  Little has been done to ensure access for 
persons with speech, mobility and visual impairments and other 
disabilities. 

There continues to be a lack of awareness by federal agencies of 
the requirements of the law compounded by a lack of awareness by 
Federal agencies of where to seek solutions for accessibility 
problems. 

Much of the TT equipment still in use in Federal agencies is 
outdated and is TDD based.  For example, there is the continual 
and widespread use of the Baudot format despite usage of ASCII as 
the preferred format for its speed, capabilities and is generally 
the standard for today's computer terminals using communications 
software.  

Staff training on equipment for federal agency staff has been 
inadequate and in many cases is nonexistent.  

As many as thirty-six states have de-tariffed specialized 
equipment; yet programs to provide such equipment at reduced 
rates have sprung up in only twenty-five (1989 statistic) states.   
The majority of individuals with disabilities are not covered by 
many of these programs. Additionally, most of these programs 
provide no specific funding for the research and development of 
new technologies in specialized customer equipment.

G.   Suggestions for Reform 

FEDERAL LEVEL:
EXECUTIVE    
.    Establish as a national priority a telecommunications policy 
     that states all benefits of the technological revolution 
     will be made available to all individuals with disabilities; 
.    Improve enforcement by the Federal Communications Commission 
     to increase compliance requirements with the two Acts;
.    Take initiatives to integrate the technology and 
     accessibility needs of individuals with sensory impairments 
     with all specialized equipment offerings;
.    Encourage states to take a more active role in ensuring 
     telecommunications access;
.    Encourage ASCII as a standard because of its speed, but 
     Baudot must still be made available because of the large 
     embedded base of Baudot-only TDDs.  Combination Baudot-ASCII 
     TDDs can be the norm for institutional use where 
     communication might be by either format, depending upon the 
     deaf/speech-impaired user's need.

LEGISLATIVE
.    Protect the interests of individuals with disabilities 
     regarding equal and universal access to all 
     telecommunications services, including enhanced offerings.  
     Note:  A separate report will be authored on 
     telecommunication issues which will examine both hardware 
     and software needs and provide recommendations that define 
     access to network features as part of the evolving concept 
     of universal access.

.    Amend telecommunication acts to include a definition and a 
     right to
     communications accessibility as follows:

     (A)  COMMUNICATIONS ACCESSIBILITY - means making all 
          expressive and receptive communications accessible to 
          persons with disabilities, and recognizes that every 
          individual is (1) capable of communicating, and (2) 
          knows best how to convey his or her thoughts to others;  
          and (3) extends the same basic common courtesies of 
          interacting with people with disabilities that are 
          extended to others in receiving the goods, services, 
          facilities, privileges, advantages, or accommodations 
          offered by an entity providing such services by;

     --   Affording such individuals with the necessary 
          opportunity, auxiliary aids and supports to effectively 
          communicate with others.  In determining what type of 
          auxiliary aid is necessary, an entity shall give 
          primary consideration to the requests of the individual 
          with disabilities.

     --   Providing a communications environment which allows and 
          encourages persons  with motor, cognitive, hearing, 
          speech or vision disabilities to effectively express 
          themselves, understand others, and/or receive or send 
          information and signals over public alert, public 
          address and telecommunications systems and networks;

     --   Providing individuals with disabilities the assistive 
          technology, interpretive services and personal 
          assistance each needs to communicate effectively with 
          others.

     --   Recognizing communications access as an issue that 
          impacts individuals with a variety of disabilities 
          other than hearing impairment and therefore to expand 
          any definition of access with an added reference to 
          "augmentative communication devices, computer modem 
          access via the telephone lines, or other effective 
          methods of making communication available to 
          individuals with hearing or speech impairments" 
          whenever TTDs/TTs are listed as a device.

     --   Including an explanation of communications 
          accommodation as follows:

     (B)  Accommodation by an entity means taking the time to 
          communicate to a person with limited speech or who is 
          using a manual communication board or assistive device;  
          speaking and responding directly to such an individual 
          rather than any third party unless directed otherwise 
          (to the extent practical, this should apply to children 
          and adults);  not hanging up on or refusing telephone 
          inquiries from such individuals or not forcing someone 
          to write everything out on a note pad if he or she does 
          not want to communicate in this fashion;  or not 
          inferring or implying that just because an individual 
          has limited natural speech that he or she also has 
          limited or impaired intelligence, hearing or judgment.

     --   Including examples of assistive devices that could be a 
          reasonable accommodation to someone with cerebral palsy 
          or other severe physical disabilities as follows;

     (C)  The following lists examples of assistive technology 
          devices that could be a reasonable accommodation to 
          someone with cerebral palsy or other severe physical 
          disability and includes but is not limited to:

          Remote control switches for use of computers and other 
          office equipment;  adaptive switches to turn on/off 
          lights;  telephone adaptations such as speaker phones, 
          headsets, modems, TDDs or TTs;  reachers; simple 
          adaptions/fixtures for using office machines;  
          magnifiers;  adjustable furniture;  adaptive computer 
          software;  page turners;  lever door handles;  access 
          to a regular computer or typewriter to fill out forms;  
          communication boards;  telephones with audio and data 
          transmission capability;  telephones with wireless 
          audio and data communication capabilities;  
          augmentative communication devices;  automated 
          interpreters;  computer and computer modem access in 
          commonly used access forms such as ASCII; voice 
          recognition systems;  voice activated telephones;  
          pointing and typing aids such as headpointers and 
          mouthsticks;  alternative switches to control lights 
          and elevator doors and other access devices;  
          electronic equipment which can be activated by sipping, 
          puffing,  movement of the eye, head, wrist, finger, or 
          by remote or wireless means;  alternative keyboards;  
          keyguards;  large button telephones;  automatic 
          dialing, and other effective and
          efficient methods of assuring reasonable accommodation 
          and access to telecommunication networks, switching 
          services and similar services that allow an individual 
          with a disability to enjoy the same benefits and 
          privileges of services that are made available to 
          individuals without speech, mobility or manual 
          dexterity impairments.

.    Require all new phones purchased (not just those designated 
     as "essential") as hearing aid compatible;
.    Eliminate the present inconsistencies among states in the 
     provision, cost, availability and repair of specialized 
     telephone equipment;
.    Alleviate the costs of "communication aids" designed to 
     substantially reduce or eliminate sensory disabilities 
     (deafness, hearing impaired; blindness, visual impairment, 
     inability to communicate vocally).

STATE LEVEL:
.    Encourage enactment of legislation that protects the 
     interests of individuals with disabilities regarding equal 
     access to vital telecommunications services;
.    Encourage state utility commissions to require local 
     carriers to provide Specialized Customer Premises Equipment 
     (SCPE) and Value-Added Services (VAS) or "enhanced services" 
     at affordable rates with a variety of finance options, e.g., 
     tax credits or deductions, loan guaranty programs or general 
     tariffs;
     SCPE is defined as any equipment needed by persons with 
     disabilities to access a communication network without 
     assistance, or needed by nondisabled for the purpose of 
     communication with persons with hearing, speech, vision or 
     mobility-related disabilities;
     VAS is defined as any offering over the telecommunications 
     network which is more than a basic transmission service.  
     The term enhanced service shall refer to services, offered 
     over common carrier transmission facilities, which employ 
     computer processing applications that act on the format, 
     content, code, protocol or similar aspects of the 
     subscriber's transmitted information;  provide the 
     subscriber additional, different or restructured 
     information;  or involve subscriber interaction with stored 
     information. 

SECTION V.     IMPLICATIONS FOR POLICY REFORM AND
               FEDERAL INITIATIVES

All of the federal programs reviewed for this analysis include 
some features
that facilitate access to financing for assistive technology.  It 
is also true, however, that no program is without some barriers.  
Six kinds of barriers were found across the majority of programs:

A.   Lack Of Knowledge or Inadequate Knowledge Among 
     Professionals;

B.   Difficulties in the Approval Process;

C.   Eligibility Limits;

D.   Limitations in Coverage;

E.   Limited Individual Choice; and

F.   Inadequate Funding.


All of the barriers are compounded by the general lack of 
knowledge of assistive technology and its benefits among 
individuals with disabilities, family members, and the general 
public, including professionals in the service system.  Each 
barrier is discussed more fully below.  A summary table, Table 2 
-- Financing of Assistive Technology:  Barriers and Facilitators, 
appears on the next page.

A.   Inadequate Knowledge Among Professionals

Lack of or inadequate knowledge among professionals was 
identified as a barrier in virtually every program, with the 
possible exception of the Technology-Related Assistance Act that 
includes an emphasis on knowledge promotion and dissemination.  
Even within this program, lack of knowledge exists among some of 
those who are attempting to implement the program at the state 
level.  The problem of inadequate knowledge of appropriate 
technology solutions to respond to individualized needs is 
compounded by the rapidity with which the assistive technology 
field is growing.

                              TABLE 2
Several programs have the potential to address this barrier 
through existing federal requirements for qualified personnel 
(e.g., IDEA, Medicaid) and legislative provisions for federally 
supported training and technical assistance (e.g., VR, IDEA).  
Some agencies have begun to use these provisions to increase 
knowledge of assistive technology, but there is a large gap 
between actual knowledge expansion and the potential for 
well-informed professionals.

B.   Difficulties in Approval Process

Approval process barriers were found in nearly all programs.  
There is no consistent standard across federal programs that 
defines need for assistive technology services and devices.  This 
barrier is further compounded by differences of interpretation by 
decisionmakers within individual programs.  There are major 
differences between the access standards of educational, 
vocational and medical necessity. These barriers have been 
reduced in some programs through clear policy statements (in the 
legislation, by regulation, or by policy guidance) that clarify 
an individual with a disability's right to assistive technology 
or the appropriateness of financing assistive technology for 
eligible individuals.

A prime example of such clarification is the letter from the 
Director of the Office of Special Education of the U.S. 
Department of Education clarifying that assistive technology must 
be provided to IDEA Part B children when needed to receive a free 
and appropriate public education and to benefit from special 
education.  (See Appendix C for complete text of letter.)  In 
1990, further clarification was provided when the definitions of 
assistive technology devices and services were added to IDEA Part 
B.

C.   Eligibility Limits

Eligibility limits to individuals were found across most 
programs, including criteria established in federal legislation, 
barriers permitted at the state level, and barriers occurring at 
the state or local level that seem to conflict with federal 
legislative provisions.  Poor coordination compounds the problem 
of eligibility barriers, especially when people with disabilities 
move from one program to another as their age or situation 
changes.

Some barriers are compounded also by the lack of knowledge of 
assistive technology applications to make people, especially 
those with severe
disabilities, more able to fully participate in the community.  
Enhanced function as a result of assistive technology challenges 
the appropriateness of decisionmaking that says an individual is 
not capable of employment and thus ineligible for rehabilitation 
services.  The interface between technology utilization and an 
eligibility standard defined by functional capabilities is not 
yet understood or fully accepted by many professionals.

D.   Limitations in Coverage

Limitations in coverage of assistive technology are found to be a 
barrier in nearly all programs, including dollar caps. Such 
limitations include amount, scope, duration, location, and 
purpose, lack of coverage of customization, maintenance, repair, 
replacement, and other support services.  Limits are frequently 
based primarily on cost containment, but cost containment as a 
barrier is often compounded by lack of knowledge of appropriate 
assistive technology solutions.

Federal policy that transfers decisionmaking authority to the 
states is particularly significant in permitting states to place 
limits that act as barriers.  For example, state Medicaid 
programs are routinely permitted to set limits through 
definitions of medical necessity and amount, scope and duration 
of services that become significant barriers to assistive 
technology access.

E.   Limited Individual Choice

Emphasis on individual choice in and control of assistive 
technology access and funding is conspicuously lacking in most 
programs.  Although some promising federal policy has been 
established in this area, meaningful participation by people with 
disabilities regarding the identification of appropriate 
technology and individualized program planning is a concept in 
its infancy.  The viability of an individualized empowerment 
model is further diminished by the knowledge and awareness gap of 
potential technology users at the present time.

F.   Inadequate Federal Funding 

The problem of inadequate federal funding levels includes poor 
predictability and inefficient use of available funding as well 
as inadequate dollar amounts.  Given the realities of federal 
budget concerns, the emphasis should be on re-targeting federal 
resources rather than on increased appropriations. 
Programs frequently mentioned in connection with re-targeting 
include Medicaid and Vocational Rehabilitation.

Overall, however, the strongest consensus is that many of the 
programs that finance assistive technology are underfunded, 
including IDEA Parts B and H, the Centers for Independent Living, 
the Medicaid Community Supported Living Arrangements program, the 
Maternal and Child Health Block Grant/Services for Children with 
Special Health Care Needs, and the Older Americans Act.

There is also strong anecdotal information that financing 
assistive technology is cost effective for both individuals and 
for programs.  Assistive technology financing is seen to have the 
potential of reducing longterm costs through promotion of 
employment of individuals with disabilities, reduction of their 
dependency, prevention of secondary disability(ies), and their 
improved health status. There is a need to explore more fully 
research on the cost benefits/cost effectiveness of assistive 
technology to buttress support for expanded federal funding of 
assistive technology.

3.   Suggestions for Reform

All federal programs which currently finance assistive technology 
can be improved in their effectiveness.  Specific opportunities 
for legislative and administrative reforms at the federal level, 
and ways to improve the use of federal programs at the state 
level, are described in the last section of each program profiled 
in Section IV, Profiles of Individual Programs.

Concerns have been raised regarding a 'tinkering' approach to 
assistive technology financing reform, that is, an approach that 
fails to reform the entire system of supports to people with 
disabilities.  Supporters of reform believe that the goals should 
reflect new ways of thinking about disability and should include 
the viewpoint of people who experience disability.  Such an 
approach would build on the concepts underlying the Americans 
with Disabilities Act to assure that everyone with a disability 
is entitled to opportunities for maximum independence, 
productivity, and community participation, and that the public 
and private sectors share in the responsibility to support those 
opportunities.

The goal is a truly consumer responsive system, including pooling 
funding for assistive technology from existing assistive 
technology financing resources, creation of a program of tax 
credits and subsidies for people with disabilities to
lease and purchase assistive technology and other supports to 
maximize participation.  Another goal is the development of 
assistive technology or community support agents who work with 
and on behalf of people with disabilities rather than the current 
service delivery system.  It is important that the pros and cons 
of piecemeal reform are debated over the coming months as more 
information is uncovered on access to assistive technology.

In the meantime, however, consideration of ways to improve the 
effectiveness of individual programs in financing assistive 
technology, and the implications for reform across federal 
programs is most important.  Nine types of reform strategies 
emerged from this analysis, as described below:

A.   Have Clear Policy On Assistive Technology

A clear policy statement on assistive technology is significant 
in access to financing, and should be included in all relevant 
programs.  The policy should include recognition of the 
importance of assistive technology to individuals with 
disabilities and should also include clarification that assistive 
technology:

.    Supports the purposes and goals of the legislation or 
     program;
.    Should (or at least can) be financed through the program, as 
     appropriate to the individual; and
.    Should be considered as part of the determination of 
     eligibility.

Policy should include a comprehensive definition of assistive 
technology, preferably the definition used in the 
Technology-Related Assistance Act (see Appendix D).  This should 
state that assistive technology services are included, as well as 
assistive technology devices.  Efforts should be continued to 
include this definition in all relevant programs.

Federal program policy should be explicit in all relevant 
provisions about the need for minimum competencies in the 
identification, assessment of need provision, training, and 
maintenance of assistive technology devices.  Such competencies 
could be a requirement in personnel training and quality 
assurance and oversight efforts. 

B.   Provide Systematic Support For Increased Knowledge Of 
     Assistive Technology

Federal programs and policies must do more to increase knowledge 
of assistive technology among professionals, vendors and other 
service providers, and those responsible for the education and 
training of professionals and other personnel, quality assurance 
staff, individuals with disabilities, family members, and 
advocates.  Specifically, federal programs should include:

.    Stronger federal guidelines and requirements that include 
     knowledge of assistive technology in personnel 
     qualifications;
.    Increased federal support for assistive technology knowledge 
     development and dissemination activities to all target 
     audiences; 
.    Increased federal support for identifying and refining 
     assistive technology competencies for providers and 
     potential users;  and
.    A requirement for an identified lead expert on assistive 
     technology funding  policies and practices at the federal 
     and state levels.

C.   Set Fewer Limits And Restrictions On The Assistive 
     Technology That Can Be Financed

Two actions are called for:
(1)  broader coverage in federal programs, and
(2)  a review of state flexibility regarding limits imposed by 
     the states. 

Definitions of assistive technology in federal policy statements 
should be comprehensive enough to include both assistive 
technology devices and services, as well as supports such as 
customization, training, maintenance, repair, and replacement.  
The definition in the Technology-Related Assistance Act is 
recommended (in Appendix D).

The concept of medical necessity should be broadened to include 
rehabilitation, secondary prevention, longterm gains, and health 
promotion in the holistic sense, including the promotion of 
independence, productivity, and community integration.  Concepts 
of educational and vocational necessity should similarly be 
broadened.  There should be a thorough review of state 
flexibility regarding medical necessity, amount, scope, duration, 
and related limits and their effects on people's access to 
assistive technology, including the long term cost effectiveness 
of such limits.

D.   Increase Access To Individual Programs

Eligibility barriers that adversely affect access to the 
financing of assistive technology should be reduced or eliminated 
in federal programs.  Examples of specific reforms include:

.    Increased SGA limits in the initial determination of SSI and 
     SSDI eligibility level, at least to the level for people 
     with blindness and to include annual cost-of-living 
     increases;
.    Elimination of the 209(b) provision for Medicaid categorical 
     needy  eligibility determination by the states;
.    Reform of the central Vocational Rehabilitation eligibility 
     determination concept to one that assumes that all 
     individuals with disabilities are capable of employment if 
     provided appropriate supports -- which includes assistive 
     technology;
.    Review of Social Security disability benefit eligibility, 
     with an eye toward reforms that would not require people to 
     prove that they are unable to work in order to obtain 
     benefits; and
.    Elimination or reduction of the 24 month waiting period for 
     Medicare eligibility for SSDI beneficiaries.

E.   Increase Outreach

Outreach, especially to those who have traditionally been 
underserved, needs to  be increased in all the federal programs 
that finance assistive technology.  Federal policies should 
require outreach at the state and local level as well  as 
conducting outreach initiatives at the national level.  Outreach 
programs should be monitored to see that they are producing 
measurable results. Such an outreach mandate could be made as an 
additional state plan requirement. 

F.   Improve Coordination

A continuing look at ways to minimize fragmentation, program 
eligibility gaps, and conflicting and duplicative administrative 
procedures is needed which is then translated into concrete 
changes in policy.  Federal leadership on coordination should be 
strengthened, including:

.    Interagency collaboration initiatives at the federal level 
     that can be used by the states to improve coordination, 
     technology funding and service delivery;
.    Mandated requirements for coordination in funding and 
     service delivery
     with documentation of effective outcomes in reporting 
     requirements;
.    Evaluation of last payer requirements and the impact on 
     individuals and agencies, including loss of time and 
     resources; and
.    The use of a common definition of assistive technology (as 
     found in the Technology-Related Assistance Act) and a common 
     standard to justify need.

G.   Increase Focus On Individual Choice And Control

The challenge for the entire disability field, especially the 
professional service providers, is to agree to ways to share 
control over information and decisions with potential technology 
users.   The federal government can exert significant leadership 
in the promotion of individual choice and control in assistive 
technology and other supports to people with disabilities.  For 
to be truly consumer-responsive, assistive technology financing 
programs need to:

.    Require a significant role for the individual with the 
     disability (or the family, as appropriate) in all federal 
     regulations and guidelines on the selection of assistive 
     technology and the development of the individual program 
     plan;
.    Ensure that individual choice and control is promoted 
     systematically through the financing mechanism, the approval 
     or authorization process, and program monitoring;
.    Cover customization and individual training;
.    Disseminate information on appropriate assistive technology 
     solutions to individuals with disabilities and family 
     members;
.    Support research on the assistive technology preferences of 
     individuals with disabilities and on alternative 
     decisionmaking models to the medical or professionally 
     driven approach; (peer mentoring and individual choice);
.    Incorporate user satisfaction in quality assurance 
     requirements and in the certification of assistive 
     technology devices and services.

At the systems level, the federal government should involve 
assistive technology users in policy development and program 
evaluation, and require similar involvement at the state and 
local levels. Programs also should consider vouchers or similar 
mechanisms that give choice and control to individuals, at least 
on a demonstration basis.

H.   Improve Federal Monitoring

Federal monitoring of access and the right to assistive 
technology must be expanded and improved across virtually all 
financing programs.  Although monitoring is an ongoing need, it 
is particularly critical at the present time when assistive 
technology provisions are relatively new and knowledge levels are 
undeveloped.  Knowledge gaps identified through the monitoring 
process should be used to target federal initiatives in technical 
assistance and in knowledge development/dissemination activities.  
Access to assistive technology devices and services as an 
entitlement must be enforced.
     Data collection by federal guidelines must be established to 
provide state and local reporting of funding of 
technology-related assistance.  Such reporting would be enhanced 
by agreement across federal agencies of a common taxonomy for 
different types of technology assistance (mobility, 
communication, aids for daily living, computer access and use).

I.   Target More Federal Resources To Assistive Technology

There are many ways additional federal resources can be targeted 
to assistive technology to ensure that assistive technology is 
available as needed by individuals with disabilities.

Clear reference to assistive technology in federal policy, 
especially when given visibility as a new requirement or 
initiative, can promote such targeting within federal, state, and 
local programs.  The federal government can target discretionary 
grant funds that support training, research and technical 
assistance activities to assistive technology.  It can require 
inclusion of assistive technology access as an outcome in grant 
priorities coordinated between federal agencies and departments.

Personnel resources at the federal level also can be targeted to 
assistive technology, to ensure that an appropriate level of 
expertise is available in policy development and program 
monitoring.  Where overall increases in federal funding are 
needed to promote access to assistive technology financing, 
federal decisionmakers should work with a coalition of assistive 
technology users, suppliers, and payers to see that any new or 
additional resources are targeted to where they will be most 
effective and result in improved financing.  The knowledge base 
on the cost benefits/cost effectiveness of assistive technology 
should be expanded and publicized to support increased allocation 
of
resources to assistive technology.

Incentives should be developed to stimulate state and local 
funding of assistive technology devices and services.  Many of 
the federal programs analyzed provide federal funding to states 
if matched by varying percentages of state dollars.  States could 
be rewarded with an improved federal matching ratio if expanded 
assistive technology funding is made available.

SECTION VI.    SEVEN SUGGESTIONS FOR FURTHER RESEARCH

Lack of awareness and knowledge of appropriate assistive 
technology solutions and funding options among individuals with 
disabilities, family members, and advocates as well as 
professionals and providers, continues to be identified as a 
major barrier to access.  The suggestions that follow focus on 
policy research that recognizes the interrelationship between the 
knowledge gap and the current shortcomings of the federal policy 
maze.

1.   Assistive Technology Applications:  Significance In People's 
     Lives

More information is needed on how different types of assistive 
technology affect the lives of people with disabilities.  The 
Office of Special Education has recently funded some of the first 
studies on the efficacy of assistive technology for children with 
disabilities.  The need is to learn more about the impact of 
assistive technology on the education of children with 
disabilities in less restrictive environments.  There has been 
limited applied research on the efficacy of assistive technology 
for adults with disabilities and individuals who are aging.  The 
need is to learn more about the impact on health status, 
independence, productivity and prevention of secondary 
disabilities.  Expanded knowledge about the impact of assistive 
technology in people's lives should favorable influence 
policymakers and funding decisionmakers at a state and local 
level who are faced with the difficulty choices of resource 
allocation and diverse unmet needs.  Access to technology 
solutions must be understood as an educational, vocational and 
medical necessity rather than as an optimum approach or luxury.

2.   Cost Benefits/Cost Effectiveness Of Assistive Technology

Almost no research has been conducted to date on the cost 
benefits and cost effectiveness of assistive technology, other 
than the current research of this project and the few examples 
identified in the recent literature review (NCD, 1991a).  
Information is needed as background for decisions on financing 
policy and in particular on the relationship between assistive 
technology and the consumption of other services.  The role of 
assistive technology should be reviewed in relation to:

(a)  income maintenance vs. employment;
(b)  hospitalization/nursing homes/institutional care vs. living 
     at home in the
     community;
(c)  full-time home health and personal assistance services vs. 
     intermittent or assistance that phases down;
(d)  short-term vs. long-term outcomes.

Research on cost benefits and cost effectiveness must relate back 
to quality of life issues for individuals with disabilities and 
their satisfaction with the services being provided.  Such 
research must not be limited solely to dollar issues.  The 
National Council on Disability, working closely with the National 
Institute on Disability and Rehabilitation Research would be an 
appropriate partnership to conduct this type of research.

3.   Individual Choice and Control

Demonstrations should be conducted on voucher programs and other 
mechanisms that give maximum choice and control to individuals 
with disabilities, and to their families, as appropriate.  One 
approach is to compare individual outcomes, including user 
satisfaction, in voucher vs. more traditional assistive 
technology financing programs.

Research should be conducted also on the effectiveness of peer 
support and self-advocacy in increasing access to financing of 
assistive technology, and on strategies to focus on individual 
choice and control within existing individual program planning 
mechanisms. 

4.   Selection and Funding Approval

For the potential technology user with disabilities, nothing is 
more difficult than the sense of powerlessness in a third party 
funding system that has unpredictable and inconsistent standards 
for assistive technology devices and services selection and 
funding approval.  New research is needed to explore possible 
approaches to improve knowledgeable decisionmaking that is more 
predictable and consistent within individual and across federally 
funded programs.

Research is needed also to identify and test the impact of 
competency-based personnel standards for providers, professionals 
across multiple disciplines and the third party funding 
decisionmakers. Finally, such an approach should be evaluated for 
consumer responsiveness and user satisfaction.
5.   Policy Research On State Flexibility

The examination of federal programs that finance assistive 
technology points up the need for research on the policies that 
govern the nature and degree of state flexibility and the 
difficulty of defining an appropriate level of flexibility. 
Perspectives on maximum state flexibility in financing assistive 
technology can be summarized as follows:

A.   PRO:

.    States can design systems to reflect their own priorities 
     and needs.
.    States are in the best position to determine the proper 
     configuration of services and the specific coordination 
     mechanisms needed.
.    States have varying capabilities to fund assistive 
     technology at the state and local level.
.    Flexibility permits states to participate despite differing 
     infrastructures, mixes of public and private resources, and 
     stages of evolution of their service system.
.    States should be able to continue to establish their own 
     regulations for insurance, for amount/scope/duration (or 
     equivalent) in joint federal/state programs, and for 
     state-certified personnel (e.g., education, health care) 
     based on the individual state's determination of what is 
     appropriate, even if within general federal guidelines.
.    States are in the best position to monitor predominantly 
     federally funded programs and enforce federal policy at the 
     local level.

B.   CON:

.    National public policy on disability and access to assistive 
     technology can be thwarted if states impose restrictive 
     definitions that limit access or eligibility.
.    State eligibility limits (e.g., 209(b) states in the 
     Medicaid program) can severely affect access for all but the 
     most low income individuals with disabilities.
.    Few states have implemented effective outreach programs to 
     underserved populations.  Improved access increases a 
     state's cost at a time of budget austerity
.    Although federal policy changes could do more to influence 
     state personnel standards and training, state flexibility on 
     personnel standards
     results in  virtually no references to assistive technology.
.    State flexibility on administrative procedures, in 
     combination with weak coordination requirements, has led to 
     different, cumbersome, and conflicting procedures across 
     states and across federal programs.
.    State flexibility on enforcement means that the level of 
     monitoring and enforcement of federal policies varies 
     dramatically across the states.
.    Access to assistive technology financing is unpredictable 
     and inconsistent across the country despite federal funding 
     and mandates.

Policy research is needed on options to achieve a delicate 
balance between states' rights and individual rights to 
independence and productivity as they are currently defined in 
federal legislation.  Access to appropriate technology solutions 
is a proven means to achieve the federal public policy goals of 
maximum independence and productivity.  The imposition of federal 
mandates, and the appropriate federal role in monitoring and 
enforcement are critical issues for the effective design of a 
system that achieves consistent access to technology services and 
devices for individuals with disabilities of all ages. 

6.   Telecommunications Access

The rapidly changing field of telecommunications raises important 
issues for persons with disabilities.  New technologies offer 
opportunities for speech input and output and the availability in 
one's home of a vast array of information and other services.  
Functional limitations need not be a barrier to access.  
Additional research is needed to define what is needed to make 
the telecommunications network more accessible and affordable for 
a person with a disability.  The National Council on Disability 
in concert with the Federal Communications Commission should take 
a lead role in such a research effort.  Recent court rulings and 
pending legislation make it a critical time to define universal 
access for all Americans.

7.   Research On Public Policy Goals And Financing Strategies

Whenever advocates gather to discuss disability policy issues, 
there is likely to be a debate on radical vs. incremental 
reforms.  There is considerable consensus on the ultimate goals 
of maximum independence, productivity, community inclusion, 
empowerment, and quality of life.  There is consensus that 
current public policies are not working effectively in supporting 
people with disabilities to reach these goals.

There is less consensus on the change strategies that will be 
most effective, in particular the value of piecemeal, program by 
program reforms vs. creation of a new set of strategies that 
replaces those currently available.  Such strategies would 
replace concepts of medical necessity and employability, for 
example, with concepts that include supports for maximum 
independence and participation.  Other strategies would give 
priority to financing mechanisms that include maximum involvement 
of people with disabilities and choice. 

On the other hand, a more radical reform could change disability 
public policy at the roots, that is, from a third party system 
with professional decisionmaking to a system driven by 
individuals with disabilities making their own decisions.

In 1982, the Office of Technology Assessment raised many of the 
same implications for reform of federal policies and programs 
that have been addressed in this report.  Systematic analysis of 
policy options must be brought to bear on these issues as a basis 
for action to avoid repetition of this exercise in the year 2002.

                            APPENDICES



ÀÀ APPENDIX A:  INFORMATION SOURCES


ÀÀ APPENDIX B:  INDIVIDUALS PROVIDING INFORMATION/PERSPECTIVES 
     ON PROGRAMS


ÀÀ APPENDIX C:  SAMPLE POLICY DOCUMENTS


ÀÀ APPENDIX D:  DEFINITIONS OF ASSISTIVE TECHNOLOGY


ÀÀ APPENDIX E:  A MEDICARE CARRIERS MANUAL -- ABBEY FOSTER 
     MEDICARE SCREENING LIST

ÀÀ MEDICARE REFERENCES













                            APPENDIX A
                        INFORMATION SOURCES




   











                            APPENDIX B
         INDIVIDUALS PROVIDING INFORMATION/PERSPECTIVES ON
                             PROGRAMS


Patricia Beattie
     RESNA Technical Assistance Project, 1101 Connecticut Avenue, 
     N.W. Suite 700 Washington, D.C. 20036.
Betsy Brand
     Assistant Secretary, Office of Adult and Vocational 
     Education 400 Maryland Avenue, S.W. Washington, D.C. 
     20202-7100.
Betty Bristol
     Budget Services, Department of Veterans Affairs, 810 Vermont 
     Avenue, N.W. Washington, D.C. 20420.
Nell Carney
     Commissioner, Rehabilitation Service Administration 
     Department of Education Switzer Building - Room 3030  330 C 
     Street, S.W.  Washington, D.C. 20202.
Ron Castalde
     Chief, State Administration Branch, Office of Adult and 
     Vocational Education, 400 Maryland Avenue, S.W. Washington, 
     D.C. 20202-7100.
Carol Cohen
     Technical Assistance Program Officer, National Institute on 
     Disability and Rehabilitation Research, U.S. Department of 
     Education, 400 Maryland Avenue, S.W.  Washington, D.C. 
     20202-2645.
Carol Crecy
     Director, Division of Community-Based Systems 
     Implementation, Administration on Aging, 330 Independence 
     Avenue, S.W. - Room 4745 Washington, D.C. 20201.
Frederick Downs
     Director, Prosthetic and Sensory Aids Service, Department of 
     Veterans Affairs 810 Vermont Avenue, N.W., 542 Techworld, 
     Washington, D.C. 20420.
Mary Jean Duckett
     Chief, Home and Community Based Waiver Branch, Division of 
     Coverage Policy, Medicaid Bureau Health Care Financing 
     Administration, Room 400 EHR 6325 Security Boulevard, 
     Baltimore, Maryland 21207.
Joseph Dulany
     Medicaid Coverage Policy Branch, Medicaid Bureau Health Care 
     Financing Administration, Room 400, EHR 6325 Security 
     Boulevard, Baltimore, Maryland 21207.
Karen Franklin
     Director, RESNA Technical Assistance Project, 1101 
     Connecticut Avenue, N.W. Suite 700 Washington, D.C. 20036.
Victor Galloway
     Director, Title VII - Parts B and C, Rehabilitation Service 
     Administration Department of Education, Switzer Building - 
     Room 3316, 330 C Street, S.W.  Washington, D.C. 20202.
Holly Allan Grayson
     Assistant Director, Association of MCH Programs, 2001 L 
     Street, N. W. -308 Washington, D.C. 20036.
Vincent Hlinovsky
     Paralyzed Veterans of America, 801 18th Street, N.W., 
     Washington, D.C. 20006.
Terrill Hyde
     Tax/Legislative Counsel, Department of the Treasury, 15th 
     and Pennsylvania Avenues, N.W., Washington, D.C. 20220.
Fred Isbister
     Director, Supported Employment Program, Rehabilitation 
     Service Administration, Department of Education Switzer 
     Building - Room 3028  330 C Street, S.W.  Washington, D.C. 
     20202.
Terese Klitenic
     Medicaid Coverage Policy Branch, Medicaid Bureau Health Care 
     Financing Administration, Room 400, EHR 6325 Security 
     Boulevard, Baltimore, Maryland 21207.
Laurie Kohn
     Coordination and Review Section, Civil Rights Division, 
     Department of Justice, Box 66118 Washington, D.C. 
     20035-6118.
Celane McWhorter
     Director, Government Relations, The Association for Persons 
     with Severe Handicaps (TASH), 1600 Prince Street, 
     Alexandria, VA 22314.
Michael Morgan
     Deputy Commissioner, Rehabilitation Service Administration, 
     Department of Education, Switzer Building - Room 3030, 330 C 
     Street, S.W.  Washington, D.C. 20202.
Larry Rickards
     Assistant Director, National Association of Area Agencies on 
     Aging, 1112 16th Street, N.W. - Suite 100 Washington, D.C. 
     20036.
Cindy Ruff
     Medicaid Coverage Policy Branch, Medicaid Bureau Health Care 
     Financing Administration, Room 400 EHR, 6325 Security 
     Boulevard, Baltimore, Maryland 21207.
Judy Schrag
     Director, Office of Special Education Programs, U.S. 
     Department of Education, Switzer Building - Room 3086, 330 C 
     Street, S.W.  Washington, D.C. 20202.
John Schwab
     Chief, Bureau of Habilitation Services, Maternal and Child 
     Health Bureau, Parklawn Building - Room 11A-30 5600 Fishers 
     Lane, Rockville, Maryland 20857.
Cynthia Sherk
     Senior Program Analyst for ICF/MR HSQB/OSC, Health Care 
     Financing Administration, 2D2 Meadows East, 6325 Security 
     Boulevard, Baltimore, Maryland 21207.
Eugene Steuerle
     The Urban Institute, 2100 M Street, N.W., Washington, D.C. 
     20037.
Dora Timeouri
     Director, Title VII - Part A, Rehabilitation Service 
     Administration, Department of Education, Switzer Building, 
     330 C Street, S.W.  Washington, D.C. 20202.
Margaret Truntich
     Chief, Regulation Branch, General Services Administration, 
     Washginton, D.C. 20405.
Robert Wardwell
     Director, Division of Coverage Policy, Medicaid Coverage 
     Policy Branch, Medicaid Bureau Health Care Financing 
     Administration, Room 400 EHR 6325 Security Boulevard 
     Baltimore, Maryland 21207 
Bill Wolf
     Deputy Director, Office of Special Education Programs, U.S. 
     Department of Education Switzer Building - Room 3086  330 C 
     Street, S.W.  Washington, D.C. 20202









                            APPENDIX C
                                 
                    SAMPLE POLICY DOCUMENTS   



APPENDIX D

1.   DEFINITION OF ASSISTIVE TECHNOLOGY AS FOUND IN THE 
     TECHNOLOGY RELATED ASSISTANCE ACT OF 1988

The comprehensive definition of assistive technology found in 
P.L. 
100-407 and referred to throughout the review and analysis, is as 
follows: 
 
     Assistive technology device:  Any item, piece of 
     equipment, or product system, whether acquired 
     commercially off the shelf, modified, or customized, that 
     is used to increase, maintain, or improve functional 
     capabilities of individuals with disabilities. 
 
     Assistive technology service:  any service that directly 
     assists an individual with a disability in the selection, 
     acquisition, or use of an assistive technology device.  
     Such term includes 
 
     (A)  the evaluation of the needs of an individual with 
          a disability, including a functional evaluation of 
          the individual in the individual's customary 
          environment; 
 
     (B)  purchasing, leasing, or otherwise providing for the 
          acquisition of assistive technology devices by 
          individuals with disabilities; 
 
     (C)  selecting, designing, fitting, customizing, 
          adapting, applying, maintaining, repairing, or 
          replacing of assistive technology devices; 
 
     (D)  coordinating and using other therapies, 
          interventions, or services with assistive technology 
          devices, such as those associated with existing 
          education and rehabilitation plans and programs; 
 
     (E)  training or technical assistance for an individual 
          with disabilities, or, where appropriate, the family 
          of an individual with disabilities; and 
 
     (F)  training or technical assistance for professionals 
          (including individuals providing education and 
          rehabilitation services), employers, or other 
          individuals who provide services to, employ, or are 
          otherwise substantially involved in the major life 
          functions of individuals with disabilities.
          (P.L. 100-407). 
2.   DEFINITION OF ASSISTIVE TECHNOLOGY AS FOUND IN THE 
     INDIVIDUALS WITH DISABILITIES EDUCATION ACT


Assistive technology device is defined as 
     any item, piece of equipment, or product system, whether 
     acquired commercially off the shelf, modified, or 
     customized, that is used to increase, maintain, or improve 
     functional capabilities of individuals with disabilities.

Assistive technology services is defined as 
     any services that directly assists an individual with a 
     disability in the selection, acquisition or use of an 
     assistive technology services.  Such term includes:
     
(a)  the evaluation of needs...including a functional evaluation 
     ... in the individual's customary environment;
(b)  purchasing, leasing or otherwise providing for the 
     acquisition of assistive technology devices...;
(c)  selecting, designing, fitting, customizing, adapting, 
     applying, maintaining, repairing, or replacing of assistive 
     technology devices;
(d)  coordinating with other therapies, interventions, or 
     services with assistive technology devices, such as those 
     associated with existing education and rehabilitation plans 
     and programs;
(e)  training or technical assistance for an individual with 
     disabilities, or, where, appropriate, [his/her] family...;
(f)  training or technical assistance for professionals 
     (including individuals providing education and 
     rehabilitation services), employers, or other(s) who provide 
     services to, employ, or are otherwise. substantially involve 
     in the major life functions of individuals with 
     disabilities.

     [20 U.S.C. Sections 1401 (a) (25); and (a) (26)].












              APPENDIX E:  A MEDICARE CARRIERS MANUAL


              -- ABBEY FOSTER MEDICARE SCREENING LIST
                            References


Health Care Financing Administration, DME Reference List, 
Medicare and Medicaid Guide, Commerce Clearing House, Chicago, 
Illinois, Section 27,221, pp. 9301-9308.

Health Care Financing Administration, Medicare Part B Coverage, 
Section 3144, Medicare and Medicaid Guide, Commerce Clearing 
House, Chicago, Illinois, pp. 1122-1140.; (this can also be found 
in Section 2100.1B1 of the Medicare Carriers Manual.)

Health Care Financing Administration, Medicare Carriers Manual 
(Section 2100.1(B)(2),

Office of Inspector General, Medicare Coverage of Power-Operated 
Vehicles, Office of Analysis and Inspections, Washington, D.C., 
OAI-02-88-01110, July 1989).

Office of National Health Statistics, Health Care Financing 
Administration, "National Health Expenditures, 1990", Health Care 
Financing Review, Fall 1991, Vol. 13, No. 1, Table 12, pp. 51-52.  

Committee on Ways and Means, U.S. House of Representatives, 
Overview of Entitlement Programs: 1991 Green Book, U.S. 
Government Printing Office, Washington, D.C., p. 168-169.

U.S. General Accounting Office, Durable Medical Equipment: 
Specific HCFA Criteria and Standard Forms Could Reduce Medicare 
Payments, GAO/HRD-92-64, Washington, D.C., June 1992.











Section Three:







Selected States Perspective and Analysis of Public Program 
Funding























NATIONAL COUNCIL ON DISABILITY 


STUDY ON FINANCING OF ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR FOR INDIVIDUALS WITH DISABILITIES






Selected States Perspective and Analysis of Public Program 
Funding 







Contractor:    United Cerebral Palsy Associations, Inc.
1522 K Street, N.W., Suite 1112
Washington, D.C.   20005
March 18, 1992




The purpose of this report is to describe the effectiveness of 
various funding sources to pay for different types of assistive 
technology devices and services for children, adults and seniors 
with disabilities in nine states.  The states are Arkansan, 
Illinois, Maine, Maryland, Minnesota, New Mexico, North Carolina, 
Oregon, and Utah.  Effectiveness refers to the types of assistive 
technology devices and services which are covered, the range of 
age groups and disabilities who receive the assistive technology, 
and the outreach capacity of the funding sources to reach persons 
with disabilities including minorities and persons in rural 
areas.  The report consists of six sections:


Section I -    Summary

Section II -   Effectiveness of Public Funding in Financing 
               Assistive Technology

Section III -  Public Funding for Assistive Technology Devices 
               and Support Services


Section IV  -  Funding of Assistive Technology 
               Support Functions


Section V  -   Facilitators to the Financing of Assistive 
               Technology


Section VI -   Barriers to the Financing of Assistive Technology







                              Summary


Early Periodic Screening, Diagnosis and Treatment (EPSDT) 
For children with disabilities, both preschool and school-age, 
the states consistently ranked EPSDT as a program which is 
effective in the financing of assistive technology.  Although 
EPSDT is not a likely funding source in terms of a wide variety 
of assistive technology, ESPDT is likely to cover of variety of 
support functions, including: assessment of need; training of 
consumer; customization; maintenance; repair and replacement.  No 
consensus was found in the area of facilitators for the program;  
however, all states agree that cumbersome application and an 
unpredictable prior authorization process are significant 
barriers to the effective financing of assistive technology 
through this program.  Several states emphasized that assistive 
technology purchased through EPSDT must demonstrate medical 
necessity of the device and service.

Medicaid  
For working-age individuals with disabilities and seniors, the 
states consistently ranked Medicaid as an effective source in the 
financing of assistive technology.  However, for preschool and 
school-age children with disabilities, notable differences exist 
between the states.  Half the Medicaid programs were described as 
effective while the others were ranked ineffective.  No single 
category of assistive technology is likely to be funded by 
Medicaid in all states.  Here again, states emphasized that 
anything purchased through Medicaid must be justified by "medical 
necessity."  States consistently indicated that Medicaid is 
required or likely to cover support services including: 
assessment of need; customization; maintenance; repair; and, 
replacement.  No single facilitator is consistently found in all 
states.  On the contrary, several barriers were listed in every 
state Medicaid program including: restrictive definition of 
medical necessity; prohibitive or no coverage for training, 
customization, maintenance, etc.; cumbersome application process 
for individuals; unpredictable prior authorization process; and, 
burdensome reimbursement process.

Medicare Part B  
For working age individuals with disabilities and seniors, all 
states agree that the Medicare Part B program is generally 
effective as a funding source for assistive technology.  No one 
category of assistive technology is likely to be funded by 
Medicare in all states.  Medicare does not consistently pay for 
any support functions.  The availability of an appeals process is 
the only common facilitator found in all states.  A majority of 
states listed restrictive definition of "medical necessity" and, 
prohibitive or no coverage for training, customization, 
maintenance, and other support services as barriers to the 
effective financing of assistive technology through Medicare Part 
B. 
Maternal and Child Health Services
For preschool and school-age children with disabilities, MCH 
programs for children with special needs are considered on 
average an effective source of financing assistive technology.  
No single category of assistive technology is required or likely 
to be paid for consistently in all states.  However, states agree 
that MCH state programs will cover key support services 
including: assessment of need; training of consumer; 
customization; repair; and replacement.  No common facilitators 
were found throughout all state programs.  All states indicate 
that restrictive eligibility requirements is a common barrier to 
the programs effective financing of assistive technology.  

Special Education 
For school-age children with disabilities, states were unanimous 
in finding special education programs as an effective source of 
financing of assistive technology.  However, Part H consistently 
ranked among the lowest in all states as an ineffective source of 
funding for assistive technology for pre-school children with 
disabilities.  States unanimously agree that special education 
programs are required or likely to pay for two categories of 
assistive technology: computer access and use; and, vision and 
reading technology.  A majority of states agree that special 
education programs will pay for two additional categories of 
assistive technology--hearing and speech.  For coverage of 
support services, states agree that Special Education is required 
or is likely to cover: assessment of need; training of consumer; 
maintenance; and, replacement.  
     All states indicated the existence of several facilitators 
in their special education programs: broad coverage of 
individuals; coverage of support services; individualized plan 
required; availability of an appeals process; and, coordination 
among funding sources.  However, a majority of states listed 
common barriers including: limits on other uses of assistive 
technology; incentives for lowest cost; lack of informed 
professionals; limited outreach; and, limited funding. 

Vocational Rehabilitation 
For working-age individuals with disabilities, states agree, VR 
Basic States Grants and Independent Living Services are an 
effective source of financing assistive technology. In addition, 
VR's Independent Living Part A is, on average, the most effective 
source of financing assistive technology for seniors with 
disabilities.  With the exception of two categories of assistive 
technology--environmental access and recreation--states indicated 
that Vocational Rehabilitation programs are required or likely to 
pay for all other categories of assistive technology.  States 
agree that VR is required or likely to pay for the different 
support services which are necessary for the effective use of 
assistive technology.  All states indicated the following 
facilitators in their VR programs: coverage of a wide range of 
assistive technology and coverage of support services; 
individualized plan required; availability of appeals process; 
and coordination among funding sources.  A majority of states 
listed the following barriers:  restrictive eligibility 
requirements; and limited funding in the program.

VR Supported Employment  
For working-age individuals with disabilities, supported 
employment as a funding source for assistive technology is 
somewhat effective.  No common facilitator is found throughout 
all the state programs; however, the majority of states listed 
seven or more facilitators.  Common barriers to effective 
financing were noted by a majority of states including: 
restricted eligibility requirements and limited funding.  No 
single category of assistive technology is likely or required to 
be funded by all states. Two support functions are likely to be 
funded--assessment of need and training of consumer.

Vocational Education  
States ranked Vocational Education as somewhat effective in the 
financing of assistive technology for school-age children with 
disabilities.  No single category of assistive technology or any 
support service is consistently paid for by Vocational Education 
in every state.  The majority of states had no information 
regarding the facilitators or barrier to the effective financing 
of assistive technology through this program.

Job Training Partnership Act (JTPA)  
States unanimously agreed that this program is not an effective 
source of financing assistive technology for working-age 
individuals with disabilities.  No single category of assistive 
technology nor any support service is consistently paid for by 
JTPA in every state.  The majority of states had no information 
regarding the facilitators or barriers to effective financing of 
assistive technology through this program.

Veterans Administration (VA) 
States consider the VA as somewhat  effective for financing 
assistive technology for working-age individuals with 
disabilities and generally effective for elderly individuals with 
disabilities.  The VA does not consistently pay for any one 
category of assistive technology devices or support services. 
              RESULTS OF THE NINE STATE STATUS REPORT


Section II

  Effectiveness of Public Funding in Financing Assistive 
Technology

     Section II analyzed the effectiveness of different funding 
     sources to pay for assistive technology.  Public/private 
     funding sources were ranked from those considered most 
     effective by the states in the financing of assistive 
     technology to those funding sources considered ineffective.  
     An analysis was conducted on four age groups of individuals 
     with disabilities including: preschool; school-age; 
     working-age; and, elderly individuals.    The following 
     scale was used to rate the effectiveness of each funding 
     stream:

NA - Not applicable/does not exist
0  - Don't know
1  - Not effective
2 -  Somewhat effective (e.g. for 1-3 disability groups, or 1-3 
     types of services/devices)
3 -  Generally effective (e.g. for 4 or more disability groups, 
     or 4 or more types of services/devices)
4 -  Most effective (e.g. for the full range of disabilities, and 
     types of services/devices


Summary 

     For preschool children with disabilities, the Medicaid  
programs in the states of Maine and Minnesota were ranked as the 
most effective source of financing assistive technology followed 
by EPSDT and Title V of the Maternal and Child Health Block 
Grant. With the exception of Maine, Minnesota, and the Medicaid 
waiver program, all other state Medicaid programs were ranked 
among the lowest.  Part H and Head Start, two programs which are 
specifically targeted to this age group, also ranked among the 
lowest.  Sixty-seven percent of programs for this age group fell 
below 3 indicating that the programs are somewhat effective or 
ineffective in the financing of assistive technology for 
preschool children with disabilities. 
     For school-age children with disabilities, Minnesota's 
Medicaid program ranked the highest followed by the Technology 
Related Assistance grants and EPSDT.  Special Education ranked 
fourth.  Sixty-one percent of programs fell below 3 indicating
that the majority of programs for this age group are somewhat 
effective or ineffective as a funding source for assistive 
technology.
     For working-age individuals with disabilities, Minnesota 
Medicaid; Vocational Rehabilitation (VR) State Grants; and, 
VR-Independent Living; ranked the highest.  Medicare Part B 
ranked fifth.  Here again, sixty percent of programs for this age 
group fell below 3. 
       Vocational Rehabilitation (Independent Living Part A); 
and, the Veterans Administration were listed as the most 
effective for elderly individuals with disabilities.  
Eighty-seven percent of programs available to elderly individuals 
with disabilities fell below 3 indicating that a large majority 
of the programs available to this age group are somewhat 
effective or ineffective in the financing of assistive 
technology.


The following list of public/private funding streams are ranked 
from most effective to least effective in the financing of 
assistive technology.  Average scores of effectiveness follow 
each program.

IIa.      Preschool Children with Disabilities
1. Medicaid TEFRA (ME)                      4
2. Medicaid CADI (MN)                       4
3. Medicaid CAD/MR (NC)                     4
4. Medicaid CAC (MN)                        4
5. EPSDT                                    3.2
6. MCH                                      3.2
7. Medicaid Waiver                          3
8. Tech Act                                 3
9. Service Clubs                            2.75
10. VR - Independent Living                 2.75
11. State Services for the Blind            2.66
12. Special Education                       2.4
13. 89-313                                  2.4
14. State Services for the Deaf             2.28
15. Equipment Loan Programs                 2.27
16. State Funds for Technology          2.25
17. Private Volunteer Organizations         2.25
18. Medicaid-Medically Fragile  (NM)       2
19. Medicaid-Developmentally Disabled (NM)      2 
20. Head Start                              1.75
21. Monetary Loan Program                   1.5
22. Part H                                  1.4
23. Medicaid/Physically Handicapped (NM)        1
24. Medicaid/Case Management  (ME)         1

IIb.       School-age Children with Disabilities 
1. Medicaid CAC, CADI (MN)                  4
2. Tech Act                                 3.8
3. EPSDT                                    3.3
4. P.L. 94-142                              3.28
5. Medicaid Waiver-TEFRA                    3.2
6. VR - Title VII - Independent Living  3.14
7. Medicaid MR/MC                           (MN)3
8. Medicaid CAP/C   (NC)                    3
9. Medicaid CAP/MR                          (NC)3
10. State Funds for Technology             3
11. MCH                                     2.85
12. 89-313                                  2.83
13. Service Clubs                           2.7
14. State Services for the Blind        2.66
15. Vocational Education                    2.65
16. VR Title I State Grants                 2.6
17. Equipment Loan Funds                    2.54
18. Medicaid - Developmentally Disabled (NM)    2.5
19. Medicaid ICF/MR                         2.3
20. State Services for the Deaf         2.28
21. Medicaid - Medically Fragile  (NM)     2
22. Head Start                              2
23. Private organizations                   2
24. JTPA                                    1.83
25. Monetary Loan Program                   1.8
26. VR Title VI-C                           1.8

IIc.      Working-age Individuals with Disabilities  
1. Medicaid- CAD/CADI  (MN)                 4 
2. VR Title I Basic State Grant          3.7
3. VR Independent Living                    3.42
4. Medicaid                                 3.16
5. Medicare Part B                          3.16
6. Medicaid BMR Waiver (ME)                 3
7. Medicaid Phy. Handicapped/Elderly (NM)  3
8. Medicaid CAP/DA  (NC)                    3
9. Medicaid CAP/MR  (NC)                    3
10. ICF/MR                                  3
11. Veterans Administration                 2.83
12. Medicaid Waiver                         2.75
13. Tech Act                                2.71
14. State Services for the Blind        2.66
14. State Services for the Deaf         2.66
16. Equipment loan Program                  2.6
17. Vocational Education                    2.4
18. Service Clubs                           2.33
19. Private Volunteer Organizations     2.27
20. State Funds for Technology          2.25
21. Supported Employment                    2.16
22. Medicaid - Personal Care Services (ME)      2
23. Title XX                                1.8
24. PWI                                     1.66
25. JTPA                                    1.66


IId.      Elderly Individuals with Disabilities
1. VR Independent Living Part A         3.28
2. Veterans Administration                  3.2
3. Medicaid                                 3.166
4. Medicare                                 2.85
5. Equipment Loan Fund                      2.77
6. State Funds for Technology                  2.6
7. Tech Act                                 2.5
8. State Services for the Deaf           2.5
9. State Services for the Blind         2.33
10. Private Volunteer organizations     2.30
11. Nursing Homes - SNI                     2.28
12. Nursing Homes                                  2.25
13. Nursing Homes - ICI                                   2
14. VR Title I                                            2
15. VR Title VII-B Centers                                2
16. VR Title VII-C IL for Older Blind      2
17. Community Development Block Grant           2
18. Service Clubs                                         1.83
19. Older Americans Act                                   1.66
20. Monetary Loan Programs                                1.66
21. Monetary Loan Program                   1.66
22. Title XX                                1.5
23. VR Title VII-C Supported Employment         1.2



Section III  

Public Funding for Assistive Technology Devices and Support 
Services

Section III examines the types or assistive technology and the 
types of support functions for assistive technology most likely 
to be funded by different public funding sources.  Thirty-eight 
types of assistive technology were identified in nine categories.  
States were asked to describe how the funding source is likely to 
cover different types of assistive technology.  Each funding 
source is followed by the percentage of state responses received.  
States were asked to use the following scale for each funding 
source.   States were asked to use the following scale:

R= Required 
L= Likely   
U= Unlikely 
X= Cannot   
?= Don't Know

Summary 
Listed below are the nine categories of assistive technology 
followed by the public funding programs that are "required" or 
"likely" to pay for them based on receiving 70% or more of state 
responses.  Each public funding stream is followed by the 
percentage of state responses received. 

Activities of Daily Living 
Vocational Rehabilitation (88%) Independent Living (98%)

Environmental Access
     -0-

Control and Manipulation
Vocational Rehabilitation (72%)

Mobility
Vocational Rehabilitation (89%)
Independent Living (72%)

Computer Access and Use
Special Education (100%)
Vocational Rehab. (100%)
State Operated Programs (71%)
State Serv. for the Blind (92%)




Hearing
Special Education (74%)
State Operated Programs (71)%
Vocational Rehabilitation (96%)
Independent Living (97%)

Vision and Reading
Special Education (100%)
State Operated Programs (84%)
Vocational Rehabilitation (86%)
Independent Living (71%)
State Serv. for the Blind (100%)

Speech
EPSDT (79%)
Special Education (82%)
Vocational Rehabilitation (91%)
Independent Living (100%)

Recreation
  -0-
 
     
Section IV

     Funding of Assistive Technology Support Services

This section examines the coverage of different support functions 
which are necessary for the effective use of assistive 
technology.  These include: (1) assessment of need; (2) training 
of consumer; (3) customization; (4) maintenance; (5) repair; and, 
(6) replacement.  The following support services are followed by 
the public funding sources that are "required" or are "likely" to 
pay  for the service based on having received over 70% of the 
state responses.  

I. Assessment of Need
EPSDT (100%)
Medicaid (72%)
MCH (100%)
Special Education (100%)
State Operated Programs (86%)
Medicare (72%)
Vocational Rehab. (100%) Supported Employment (72%)
Independent Living (86%)
State Serv. for the Blind (86%)
Vocational Education (83%)

II. Training of Consumer
EPSDT (100%)
MCH (71%)
Special Education (100%)
State Operated Programs (86%)
Vocational Rehabilitation (85%)
Supported Employment (71%)
Independent Living (86%)
State Serv. for the Blind (71%)

III. Customization
EPSDT (100%)
Medicaid (86%)
MCH (85%)
State Operated Programs (71%)
Medicare (85%)
Vocational Rehab. (100%)
Independent Living (86%)



IV. Maintenance
EPSDT (100%)
Medicaid (86%)
Special Education (85%)
Vocational Rehab. (100%)
Independent Living (87%)

V. Repair
EPSDT (100%)
Medicaid (100%)
MCH (86%)
Medicare (85%)
Vocational Rehab. (100%)
Independent Living (71%)
State Serv. for the Blind (71%)


VI. Replacement
EPSDT (86%)
Medicaid ((86%)
MCH (85%)
Special Education (71%)
Vocational Rehabilitation (85%)
Independent Living ((85%)
State Serv. for the Blind (85%)

Section V and VI  

Facilitators and Barriers to the Financing of Assistive 
Technology

Section V and VI provide information on specific state laws, 
policies and practices which increase the effectiveness 
(facilitators) or reduce the effectiveness (barriers) of 
different funding sources for assistive technology.


Summary  

EPSDT   
No single  facilitator is consistently found in all states.  One 
state responded "no facilitator exists".  The majority of states 
cited two or fewer facilitators.   The following barriers in the 
EPSDT program are found in every state: cumbersome application 
process; and, unpredictable prior authorization process.  A 
majority of states listed six or more barriers. 

Medicaid  
No single facilitator is consistently found in all states. One 
state indicated "no facilitator exists" while another state 
listed only one.  The following barriers are found in all states: 
restrictive definition of "medical necessity"; prohibitive/no 
coverage for training, customization, maintenance, etc.; 
cumbersome application process for individuals; unpredictable 
prior authorization process for specific AT; burdensome 
reimbursement process for vendor or individual.   A majority of 
states listed 8 or more barriers with two states listing 11 
barriers to the financing of assistive technology.

Medicare Part B  
All states listed the availability of an appeals process making 
it the only common facilitator.  The greatest number of 
facilitators were found in Utah and North Carolina while the 
majority of states listed four or fewer facilitators.  A majority 
of states listed restrictive definition of "medical necessity"; 
and, prohibitive/no coverage for training, customization, 
maintenance, etc.  One state listed Medicare as uncooperative in 
pursuit of information.  
  
Maternal and Child Health No single facilitator is consistently 
found in all states.  The majority of states listed four or fewer 
facilitators.  All states indicated that restrictive eligibility 
requirements  is a barrier to the programs financing of assistive 
technology. The majority of programs listed five or more 
barriers.


Special Education  
All states listed the following facilitators: broad coverage of 
individuals; coverage of support services; individualized plan 
required; availability of appeals process; and, coordination 
among funding sources promoted.  A majority of states listed the 
following barriers: other limits on approved uses such as 
purpose/location of AT; incentives for lowest cost AT; lack of 
informed professionals such as case managers or service 
providers; limited outreach to under-represented groups;  and, 
limited funding in the program that could pay for AT. 

Vocatinal Rehabilitation State Grants   
All states listed six or more facilitators, with two states 
listing 12 or more.  The following facilitators were found in all 
state VR programs: coverage of a wide range of assistive 
technology; coverage of support services; individualized plan 
required; availability of appeals process; and, coordination 
among funding sources.  A majority of states listed the following 
barriers: other limits on approved uses such as purpose/location 
of AT; lack of informed professionals such as case managers or 
service providers; and limited funding in the program that could 
pay for AT. 

Vocational Rehabilitation Supported Employment   
No single facilitator is consistently found in all states; 
however, the majority of states listed seven or more 
facilitators.  A majority of states listed the following 
barriers: restrictive eligibility requirements; and limited 
funding in the program that could pay for AT. 

Vocational Rehabilitation Independent Living  
The following facilitators were found consistently in all states: 
broad coverage of individuals; coverage of a wide range of AT; 
coverage of support services; individualized plan required; 
individual choice supported; availability of appeals process; 
coordination among funding sources promoted.  All states 
indicated limited funding in the program that could pay for AT as 
a barrier to the financing of assistive technology.   

Vocational Education  
The majority of states had no information regarding the 
facilitators and barriers to financing assistive technology 
through this program.

JTPA  
No single facilitator is found consistently in all states.  The 
majority of states indicated no facilitators.  Of the two states 
that responded, both indicated that limited funding in the 
program that could pay for AT, and lack of informed personnel 
were barriers to financing through this program.  


Veterans Administration  
There are no facilitators found consistently in all states.   
     All states indicated that restrictive eligibility 
requirements is a barrier to the financing of assistive 
technology through this program.
Section V  

Facilitators to the Financing of Assistive Technology

(1)  clear policy statement on access to AT;
(2)  broad coverage of individuals in terms of age, income, and 
     disability;
(3)  coverage of a wide range of AT;
(4)  coverage of support services for AT including training, 
     customization, maintenance, repair, and replacement;
(5)  individualized plan required;
(6)  individual choice supported;
(7)  availability of appeals process;
(8)  coordination among funding sources promoted;
(9)  requirements for outreach strategies to promote awareness of 
     the advantages of AT among potential consumers, especially 
     under-represented groups such as low-income persons, 
     minorities, and persons living in rural areas;
(10) provision for qualified support personnel through funding 
     availability;, certification standards for providers, and 
     inservice training, etc.;
(11) performance standards for assistive technology to qualify 
     for funding;
(12) sufficient level of funding in terms of adequacy and 
     predictability;
(13) appropriate level of state flexibility.


EPSDT
No one facilitator is consistent in all states.
One state responded, "no facilitator exist."
Two state programs listed broad coverage of individuals.
The majority of states listed 2 or fewer facilitators. 

Medicaid
One state listed no facilitators exist.  One state listed only 
one facilitator exists.  The majority of states listed the 
following facilitators:
o    broad coverage of individuals; 
o    individual plan required;
o    availability of appeals process;
 

Medicare Part B
Two states listed two of fewer facilitators.  Two states listed 
over nine facilitators. All states listed as a facilitator: the 
availability of an appeals process.  In addition, a majority of 
states listed the following facilitators:
o    coverage for support services for AT;
o    individualized plan required;


MCH Programs for Children with Special Health Care Needs
One state listed no facilitators.  The majority of states listed 
the following facilitators:
o    individualized plan required;
o    coordination among funding sources promoted;


Special Education
All states listed the following facilitators:
o    broad coverage of individuals;
o    coverage of support services;
o    individualized plan required;
o    availability of appeals process;
o    coordination among funding sources promoted;

In addition, a majority of states listed the following 
facilitators:
o    clear policy statement on AT;
o    coverage of a wide range of AT;
o    individual choice supported;
o    provision for qualified support personnel;
o    appropriate level of state flexibility.

Vocational Rehabilitation (State Grants)
All states listed six or more facilitators. Two states listed 12 
or more facilitators.  All states listed the following 
facilitators:
o    coverage of a wide range of AT;
o    coverage of support services;
o    individualized plan required;
o    availability of appeals process;
o    coordination among funding sources promoted.

A majority of states listed the following as facilitators.
o    broad coverage of individuals;
o    individual choice supported;
o    provision for qualified support personnel;


Vocational Rehabilitation (Supported Employment)
The majority of states listed seven or more facilitators.
One state responded, "does not apply".  The majority of states 
listed the following facilitators:
o    broad coverage of individuals;
o    coverage of a wide range of AT;
o    coverage of support services;
o    individualized plan required;
o    individual choice supported;
o    availability of appeals process;
o    coordination among funding sources promoted;
o    provision for qualified support personnel;
o    sufficient level of funding in terms of adequacy and 
predictability;
o    appropriate level of state flexibility.


Vocational Rehabilitation (Independent Living)
All states listed six or more facilitators.  The majority of 
states listed nine or more facilitators. All states listed the 
following facilitators:
o    broad coverage of individuals;
o    coverage of a wide range of AT;
o    coverage of support services;
o    individualized plan required;
o    individual choice supported;
o    availability of appeals process;
o    coordination among funding sources promoted;

In addition, a majority of states listed as a  facilitator, clear 
policy statement on access to AT.

Vocational Rehabilitation
A majority of states indicated no facilitators exist.  Two states 
listed the following facilitators:
o    broad coverage of individuals;
o    individualized plan required;
o    coordination among funding sources promoted;
o    provision for qualified support personnel;

JTPA
A majority of states indicated no facilitators exist.
Two states listed as a facilitator:
o    coordination among funding sources. 

Veterans Administration
The majority of states listed the following facilitators:
o    coverage of a wide range of AT;
o    coverage of support services;
o    performance standards for AT to qualify for funding;
o    appropriate level of state flexibility.
Section VI 

Barriers to Financing Assistive Technology


(1)  restrictive eligibility requirements (e.g. age, income, 
     disability, level of severity) pre-existing condition;
(2)  restrictive definition of "medical necessity";
(3)  other limits on approved uses such as purpose/location of 
     AT;
(4)  prohibitive or missing coverage for training, customization, 
     maintenance, repair, or replacement of AT;
(5)  incentives for lowest cost AT;
(6)  inappropriate caps on amount of coverage (dollar limits or 
     service limits);
(7)  last payor requirement;
(8)  cumbersome application process for individual (e.g. long 
     time delays in processing application, arbitrary time limits 
     imposed for submitting new documentation, and unnecessary 
     administrative complexity often duplicative of other 
     applications which the consumer has already made);
(9)  unpredictable prior authorization process for specific AT;
(10)  burdensome reimbursement process for vendor or individual;
(11) lack of informed professionals such as case managers or 
     service providers, etc. who are knowledgeable about 
     potential advantages of AT for persons with disabilities;
(12) limited outreach to under-represented groups such as low 
     income persons, minorities, or persons in rural areas;
(13) limited funding in the program that could pay for AT. 

EPSDT
A majority of states listed six or more barriers. All states 
listed the following barriers:
o    cumbersome application process for individuals;
o    unpredictable prior authorization process for specific AT;

In addition, a majority of states listed the following barriers:
o    restrictive definition of "medical necessity";
o    burdensome reimbursement process for vendor or individual;
o    lack of informed professionals knowledgeable about AT;
o    limited outreach to under-represented groups;

Medicaid
The majority of states listed 8 or more barriers with two states 
listing 11 barriers to the financing of assistive technology.
All states listed the following barriers:
o    restrictive definition of "medical necessity";
o    prohibitive/no coverage for training, customization, 
     maintenance,    etc.;
o    cumbersome application process for individuals;
o    unpredictable prior authorization process for specific AT;
o    burdensome reimbursement process for vendor or individual;

A majority of states listed the following barriers:
o    inappropriate caps on amount of coverage;
o    lack of informed professionals such as case managers or 
     service providers;
 

Medicare Part B
A majority of states listed four or more barriers to the 
financing of assistive technology.  One state indicated that the 
regional Medicare office was uncooperative in seeking information 
about the program.  A majority of states listed the following 
barriers:
o    restrictive definition of "medical necessity";
o    prohibitive/no coverage for training, customization, 
     maintenance, etc.;


MCH Programs for Children with Special Health Care Needs (Title 
V)
The majority of programs listed 5 or more barriers.  All states 
responding listed the following barrier:
o    restrictive eligibility requirements;

A majority of states listed the following barriers:
o    lack of informed professionals such as case managers or 
     service providers;
o    limited funding in the program that could pay for AT. 

Special Education
A majority of states listed five or more barriers with one state 
listing 10.  A majority of states listed the following barriers:
o    other limits on approved uses such as purpose/location of 
     AT;
o    incentives for lowest cost AT;
o    lack of informed professionals such as case managers or 
     service providers;
o    limited outreach to under-represented groups;
o    limited funding in the program that could pay for AT. 

Vocational Rehabilitation (Special Grants)
All states listed three or more barriers.  The majority of states 
listed the following barriers:
o    other limits on approved uses such as purpose/location of 
     AT;
o    lack of informed professionals such as case managers or 
     service providers;
o    limited funding in the program that could pay for AT. 


Vocatinal Rehabilitation (Supported Employment)
The majority of states listed three or more barriers.
One state responded, "does not apply".  A majority of states 
listed the following barriers: 
o    restrictive eligibility requirements;
o    limited funding in the program that could pay for AT. 


Vocational Rehabilitation (Independent Living)
All states listed three or more barriers.  All states indicated 
limited funding in the program that could pay for AT as a 
barrier. 

A majority of states listed the following barrier:
o    lack of informed professionals such as case managers or 
     service providers;


Vocational Education
The majority of states had no information regarding the financing 
of assistive technology through this programs.   Of the two 
states that responded, the following barrier was indicated in 
both responses:
o    limited funding in the program that could pay for AT. 

JTPA
The majority of states had no information regarding the financing 
of assistive technology through this programs.  Of the two states 
that responded, two barriers were indicated in both responses:
o    limited funding in the program that could pay for AT; 
o    lack of informed personnel.  

Veterans Administration
All states responding indicated that restrictive eligibility 
requirements was a barrier to the financing of assistive 
technology for this program.














                                            
     
                            APPENDIX A


                          Summary Tables 
Percentages of Assistive Technology Devices and Related Support 
Services Financed Through Various Public Programs

















Section Four:







The Role of Private Health Insurance Coverage of Assistive 
Technology 























NATIONAL COUNCIL ON DISABILITY 


STUDY ON FINANCING OF ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES






The Role of Private Health Insurance Coverage of Assistive 
Technology 







Contractor:    United Cerebral Palsy Associations, Inc.
1522 K Street, N.W., Suite 1112
Washington, D.C.   20005
August 24, 1992
            Private Insurance and Assistive Technology

Introduction

Private health insurance is primarily funded through voluntary 
annual contracts, mostly with employers, to cover the health 
related needs of employees and their dependents.  This fact, and 
the historical origins of private insurance having been developed 
by hospitals to finance the care they can provide, has resulted 
in an acute care orientation to health insurance in the U.S. 
(Access to Health Care, December 1988-March 1989).  This acute 
care orientation, which has been institutionalized through the 
role of physicians as the gatekeepers in the health care system, 
has tended to slight prevention and rehabilitation, even though 
almost half of the U.S. population has chronic health conditions. 
(Word from Washington, May/June 1991).  One consequence of the 
acute care orientation of health insurance is the restrictive 
funding for assistive technology.  Removing obstacles to the 
financing of assistive technology is part of the larger challenge 
of redefining the concept of health from the absence of disease 
and impairment to the management of chronic conditions to 
maximize functional capacity to participate as fully as possible 
in society.  

Findings:

1.Assistive technology is mostly paid for out-of-pocket.  

According to the Health Care Financing Administration, 67.3% of 
the total health care expenditures for durable medical equipment 
and vision products were paid by out-of-pocket payments in 1990 
(Health Care Financing Review, Fall 1991). Private health 
insurance paid for only 10.4% of expenditures for durable medical 
equipment, while public funds paid for 22.3%. (This estimate of 
the contribution of public sources for durable medical equipment 
is actually understated because all Medicaid payments for durable 
medical equipment were included within other categories.)   

     Data from the 1987 National Medical Expenditure Survey 
     (NMES) also provided similar information.  According to a 
     recent analysis of NMES, 66.2 percent of DME expenditures 
     came from out-of-pocket payments, 13.8 percent came from 
     Medicare, 3.9 percent came from Medicaid, 10.7 percent came 
     from private insurance, and 5.4 percent came from other 
     sources among the 5.1 million adults with disabilities who 
     reported using assistive technology (Altman, B., 1992) 

2.   Many people with disabilities need assistive technology 
     which they cannot afford.  A recent analysis of the 1990 
     National Health Interview Survey on Assistive Devices 
     revealed that at least 2.5 million persons in the 
     noninstitutionalized population have an unmet need for 
     assistive technology
     devices.  These include 1.2 million persons of working-age, 
     between 25-64 years.  The types of assistive technology 
     which were measured by this survey included: prosthetics and 
     orthotics, mobility devices (e.g. cane, walker, wheelchair, 
     scooter), hearing devices (e.g. hearing aid, TDD/TTY, 
     special alarm), vision devices, speech devices, and other 
     types of assistive technology (e.g. adapted computer, 
     adapted automobile).

     Over 61 percent of those who reported that they need 
     assistive technology which they do not have explained that 
     they cannot afford them (Hendershot, G., LaPlante, M., and 
     Moss, A. 1992.)  This survey also confirmed that nearly 
     one-half of persons with assistive technology devices say it 
     was paid for by themselves or their families with no 
     assistance from third party payers, and more than 
     three-fourths of persons with home accessibility features 
     say they were paid for entirely by themselves or their 
     family.  Although more than half of poor people with 
     assistive technology devices had the help of a third party 
     payer in obtaining devices, poor people were about twice as 
     likely as nonpoor people to say they needed a device they 
     did not have.

3.   Many people with disabilities who have private insurance do 
     not get it to pay for assistive technology.

     Approximately two-thirds of persons with disabilities have 
     private health insurance according to the National Health 
     Interview Survey. (National Center for Health Statistics, 
     1987).  A consumer survey of 724 working-age persons with 
     disabilities or chronic illness who were members of various 
     national voluntary health associations revealed that, among 
     those who reported using various types of "durable medical 
     equipment or other assistive devices (e.g. wheel chair, 
     respirator, blood glucose meter, insulin pump, therapeutic 
     shoes)" in 1989, only 39.3% of persons with health insurance 
     reported that their health insurance covered this equipment 
     without any limitations and a co-payment of 20% or less.  
     Another 23.3% reported that their health insurance made a 
     smaller contribution to their durable medical equipment, and 
     16.7% reported that their health insurance did not cover 
     their use of durable medical equipment at all.  
     Unfortunately, 20.7% of the respondents reported that they 
     did not know whether their health insurance covered the 
     durable medical equipment which they used. (Griss, B. and 
     Hanson, S., 1990)

Literature review on private insurance and assistive technology:

Although approximately two-thirds of persons with disabilities 
have some private health insurance,  (National Center for Health 
Statistics, 1987) few studies have attempted to examine what 
types of assistive technology private health insurance pays for.  
Nor have many studies tried to identify the conditions under 
which
private insurance will pay for certain types of assistive 
technology.

Some studies have attempted to measure the contribution of 
private health insurance to assistive technology for selected 
populations.  For example, a Paralyzed Veterans of America (PVA)  
survey examined the health care costs for spinal cord injury 
among a random sample of persons with spinal cord injury around 
the country. (Berkowitz, Harvey, Greene, and Wilson, 
forthcoming).  Among the needs which they estimated annual costs 
for were adaptive equipment which varied from $1,874 for a 
"complete quadriplegic" to $449 for an "incomplete paraplegic" 
for average annual costs.  Private health insurance accounted for 
approximately 16.2 percent of these adaptive equipment costs.  
Although the survey asked questions about the current health 
insurance status of persons with spinal cord injury, the survey 
did not seek comparable information about their health insurance 
status since the spinal cord injury that would enable one to 
accurately measure the contribution of different sources of 
payment to DME costs since their spinal cord injury.  

Another study in progress on persons with spinal cord injury is 
being conducted by Denise Tate at the University of Michigan's 
Department of Physical Medicine and Rehabilitation to examine the 
impact of insurance benefits coverage on independent living 
outcomes (Tate, D. 1992).  This research is collecting data on 
about 300 persons treated for spinal cord injury at two 
rehabilitation centers in Michigan.  By comparing persons with 
spinal cord injury who are covered by four different types of 
insurance (e.g. no fault auto insurance, Workers Compensation, 
private health insurance, and Medicaid) the study is examining 
the services which they get and the progress that they are making 
toward independent living.  In the second year of this study, 
they are finding that type of insurance did not seem to affect 
access to DME as much as it has affected access to housing, 
personal assistance services, and transportation which have a 
significant effect on Independent Living outcomes.

A recent study on consumer abandonment has focused attention on 
the selection process through which persons with disabilities 
acquire assistive technology.  In a recent survey at the National 
Rehabilitation Hospital in Washington, D.C. it was found that 
equipment purchased through third party payers is more likely to 
be abandoned than equipment purchased out of pocket.  This 
exploratory study used a small sample (N=227) and combined 
persons with different types of disabilities using different 
types of assistive technology which made it difficult to isolate 
the factors which led to an "abandonment" of different forms of 
assistive technology (Phillips, 1992).  Nevertheless, this type 
of study when properly refined has the potential of calling 
attention to the financing advantages of improving the selection 
process for assistive technology.

Survey of insurers in nine states:

Viewing access to assistive technology as an important component 
of health, this
study examined how different types of private insurance choose to 
cover different types of assistive technology.  The study 
consisted of: (1) surveying insurers in each of nine states 
selected among the early state Tech Act programs; (2) inviting 
insurers and others to report on insurance coverage at the three 
regional forums, and (3) conducting interviews with 
representatives of insurers, rehabilitation professionals, and 
DME vendors.

Nine states were selected by the National Council on Disability 
from the original Tech Act states.  These included: Arkansas, 
Illinois, Maine, Maryland, Minnesota, New Mexico, North Carolina, 
Oregon, and Utah.  The funding specialist in each of these Tech 
Act states was asked to survey five types of insurers in their 
state to learn about their coverage policy for specific types of 
assistive technology.  The five types of insurers were: (1) Blue 
Cross-Blue Shield, (2) a commercial or for-profit insurer, (3) a 
health maintenance organization (HMO), (4) a self-insured 
employer, and (5) a Workers Compensation carrier.  To increase 
the comparability of data across states and to maximize the 
representativeness of the results, the Tech Act programs were 
asked to target among the largest insurers within each category 
of insurance identified through the State Department of 
Insurance.  The state employee benefits plan was selected in each 
state as a  representative of self-insured employers.  

Most state Tech Act programs found it very difficult to get the 
cooperation of private insurance companies to provide information 
about the types of assistive technology covered by their 
insurance plans.  One state was not able to find any private 
insurers to provide the requested information.  Other states had 
difficulty in finding certain categories of insurers.  Some Tech 
Act funding specialists encountered difficulties until they 
finally found someone who was knowledgeable and willing to answer 
their questions.  Some insurers chose to fill out the survey 
themselves; others were willing to provide the information to the 
Tech Act funding specialists who were able to ask clarifying 
questions in filling out the survey.  Unfortunately, these 
variations in the methodology of collecting the data may have 
compromised the reliability of some of the information.  In 
addition, many insurers insisted on anonymity in responding to 
the survey.  For all these reasons, the analysis of the insurance 
survey which follows is more general than we would prefer.  
However, it provides an overview that is generally absent from 
the literature, and offers some valuable insights into the 
variations by which private health insurance covers assistive 
technology. 

Workers Compensation/casualty insurance 

Workers Compensation insurers were selected as a point of 
comparison with private health insurers because they often look 
at persons with the same types of disabilities and because the 
Workers Comp carriers are sometimes part of the same insurance 
company.  However, the decisions of the Workers Comp carriers are 
often different from the decisions of the private health insurers 
because they have
different requirements and different incentives.  The Workers 
Comp. carrier is supposed to do whatever they can to get a worker 
who has been injured on the job back to work.  This includes 
funding assistive technology that promotes independence in the 
home and rehabilitation in the workplace as well as getting to 
the workplace.  Health insurers, on the other hand, have a fiscal 
incentive to restrict their coverage to acute care needs since 
they have annual contracts with the employer who has an incentive 
to minimize the employer's premium contribution.
 
A major problem with the Workers Compensation system is that many 
of the players in the system (e.g. employers, insurers, 
attorneys, physicians, and workers) have financial incentives to 
go for a large lump sum settlement in the short run rather than 
for rehabilitation over the long run.  This problem which is not 
the subject of this paper is leading to rising costs in the 
Workers Comp system which, ironically, is resulting in political 
pressure to restrict rehabilitation benefits in certain states.

Among the services which some Workers Comp insurers identify as 
necessary to provide if needed are prosthetics/orthotics, walking 
aids, manual and power wheelchairs, hearing aids, braille aids, 
personal care aids, bathroom equipment; eating/feeding aids; 
transfer equipment; home modification; van modification and 
driving aids (see Table 1).  States differ in how comprehensive 
their Workers Compensation laws are and Table 1 reveals the great 
variations among Workers Compensation carriers for the same type 
of assistive technology. 

In contrast to health insurance, Workers Comp. carriers are 
likely to pay for home modification; van modification and driving 
and transportation aids; car or van purchase in recognition of 
importance of transportation to getting to work; computer access 
and use; and various aids for hearing and vision.  Surprisingly, 
Workers Comp. is unlikely to cover most recreation aids and is 
less likely to cover speech aids, certain alarm/emergency call 
systems, personal care aids, adapted clothing and personal 
robotics. Some Workers Comp. carriers appeared to be more likely 
to cover personal assistance services than assistive technology 
to enable a person to meet their Activities of Daily Living (ADL) 
needs more independently.  Not surprisingly, Workers Comp. was 
unlikely to pay for school modification or public accommodations.

There are other types of casualty insurance that could have been 
examined in this study.  Among them are auto insurance, 
disability insurance, product liability insurance, and 
malpractice insurance.  Some of these forms of casualty insurance 
make a major contribution to the rehabilitation process and 
provide coverage for different forms of assistive technology.  
For example, approximately half of all persons with a traumatic 
brain injury are injured in a motor vehicle accident (Rice, D. 
and MacKenzie, 1989).  Their access to rehabilitation and 
assistive technology would often depend more on the automobile 
casualty insurance that they have or
that the person who hit them carries than on their own health 
insurance plan.  An examination of these other forms of insurance 
would reveal other interesting contrasts with the function of 
private health insurance.  Moreover, it also raises the public 
policy question whether the American public is being well served 
by this patch-work quilt of over-lapping insurance coverages, 
operating with different incentives and looking differently at 
the needs of the individual.  Ultimately, the question is whether 
the American public is best served by having access to different 
types of benefits not based on their health care needs but based 
on whether an injury occurs at the work place, over the weekend, 
in an automobile, or in one's home. 

Another kind of private insurance which was also not examined in 
this study is long term care insurance.  This is currently used 
by less than __ percent of the population, and is often purchased 
for nursing home coverage but sometimes provides for home care 
when it serves as a lower cost alternative for persons who would 
otherwise be placed in a nursing home.

The rest of this chapter will focus on different forms of private 
health insurance including: HMOs, commercial insurers, Blue 
Cross-Blue Shield, and self-insured employers.  Private health 
insurance is a bit of a misnomer because there is a substantial 
public tax subsidy in it (approximately 25 percent) when it is 
provided through an employer.  This estimate was derived from the 
Joint Committee on Taxation estimate of $32.6 billion for tax 
expenditures related to exclusions of employer contributions for 
medical insurance premiums and medical care in the Ways and Means 
Committee 1990 Green Book, (p. 807) and the Health Care Financing 
Administration's estimate of $139.1 billion in 1990 for employer 
contributions to private health insurance premiums reported in 
the Health Care Financing Review, Winter 1991, Vol. 13, No. 2, 
(p. 86).  Moreover, private insurance is usually oriented to 
medical services rather than to health care needs, and it 
generally functions as a mechanism to pay for health care 
services used by a specific employer group rather than for 
spreading risk throughout the population. 

HMOs:

HMOs are likely to provide some DME coverage as part of their 
comprehensive benefit package, but the DME coverage is likely to 
be strictly limited.  Unlike traditional insurance plans that 
impose a deductible and a copayment to discourage unnecessary 
utilization, HMOs generally provide first dollar coverage.  They 
also depend on organizational policies that are designed to 
rationalize health care delivery for their average users rather 
than for persons with disabilities.  Some HMOs impose a dollar 
cap on DME like $500-1000 per benefit period (maximum one year) 
which is inadequate for many types of DME.  Many HMOs also limit 
the number of visits for rehabilitation therapies to 60 days per 
year.  This cap was actually introduced as a minimum requirement 
for federally qualified HMOs in the Federal HMO Act of 1973.  
Some HMOs actually impose a coverage limit to a 60
day period from the time of an injury or from the time of 
discharge from a hospital.  This limitation is subject to a 
subjective judgment that the individual will be able to make 
substantial progress within a limited period of time.  Some HMOs 
have been known to not honor their obligation to provide the 
minimum benefit if the HMO decides that the individual would not 
make substantial progress within a limited time period.  This 
requirement discriminates against persons with chronic 
degenerative conditions unless the HMO recognizes as progress the 
prevention of expected deterioration.

HMOs were most likely to provide coverage for seating and 
positioning, walking/standing aids, manual and power wheelchairs, 
and prosthetics/orthotics (see Table 2).  Some HMOs also provided 
coverage for some ADL aids, functional electrical stimulation, 
TDD equipment, adaptive listening aids, low-vision aids, and oral 
speech aids, and adapted exercise aids.  None of the HMOs which 
were reported on provided coverage for home modification, 
personal robotics, environmental control devices, van 
modification, car or van purchase, or computer access, adaptive 
toys or adaptive sports. Some HMOs were even unlikely to cover 
any ADL aids, prosthetics/orthotics, mobility aids, vision aids, 
or speech aids. A few HMOs provided coverage for hearing aids as 
an optional benefit which was available for an additional 
premium.  The most comprehensive HMO offered coverage for: 
functional electrical stimulation, personal robotics, power 
wheelchair, hearing aids, and low vision aids.

Commercial insurers:

Commercial health insurers varied considerably in the assistive 
technology that they covered (see Table 3).  The most likely 
items to be covered were prosthetics/orthotics, a manual 
wheelchair and walking/standing aids. One commercial insurer 
indicated that it was required to provide an oral speech aid if 
needed.  Some commercial insurers reported covering: bathroom 
equipment; adaptive furniture, transfer equipment; seating and 
positioning, and power wheelchair.  Other commercial insurers 
reported covering alarm/emergency call system, eating aids, home 
modification; environmental control devices, hearing aids, and 
even an augmentative communication device.  At the other extreme, 
one commercial insurer did not cover orthotics and some did not 
even cover any mobility aids.  No commercial insurer reported 
covering personal robotics, van modification; driving aids; car 
or van purchase; or computers; and most commercial insurers did 
not cover: aids for daily living, environmental controls, 
hearing, vision, speech aids or any recreation aids.

Blue Cross-Blue Shield:

Like commercial insurers, Blue Cross-Blue Shield will generally 
not cover ADL aids, home modification, environmental control 
devices, van modification, driving aids, car or van purchase, 
computer access, aids for hearing (other than hearing aids),
visual aids, augmentative communication devices or recreation 
aids (see Table 4).  There seemed to be a little more uniformity 
in coverage policies among the Blue Cross-Blue Shield plans than 
among the commercial insurers, but commercial insurers in two 
states were more likely to report being required to provide some 
assistive technology when needed.  The most likely types of 
assistive technology to be covered are: prosthetics and 
orthotics, walking aids, manual or power wheelchairs, and oral 
speech aids.  Augmentative communication devices were reportedly  
covered on a case-by-case basis in one Blue Cross-Blue Shield 
plan.  Some Blue Cross-Blue Shield plans also were likely to 
cover functional electrical stimulation, mobility aids for visual 
impairment, seating and positioning, and hearing aids, adaptive 
furniture, transfer equipment, personal robotics, and adaptive 
exercise aids.

Self-insured employers:

Large self-insured employers are supposed to have a more 
comprehensive benefit plan than small employers who seek to 
self-insure primarily to avoid state regulation.  The state 
employee benefits plan was thought to be representative of large 
self-insured employers.  Nevertheless, this survey found that 
state employee benefits plans were less likely to cover assistive 
technology than Blue Cross-Blue Shield or commercial health 
insurers (see Table 5).  Like other forms of private health 
insurance, the state employee benefit plans were most likely to 
cover prosthetics and orthotic devices, walking/ standing aids, 
adaptive furniture, transfer equipment, and oral speech aids.  
Surprisingly, two of the three state employee benefit plans 
reported on did not appear to provide coverage for manual or 
power wheelchairs.  However, state employee benefit plans were 
unlikely to include coverage for: alarm/emergency call system, 
adapted clothing, home modification, functional electrical 
stimulation, personal robotics, environmental control devices, 
van modification, driving aids, car or van purchase, mobility 
aids for visual impairment, computer access, any hearing or 
visual aids, augmentative communication devices, or any 
recreation aids.  

Methodological problems with the grid:

The methodology of comparing types of insurers on whether they 
cover different types of assistive technology has certain 
problems.  One problem relates to the representativeness of the 
insurance companies.  This problem was minimized by encouraging 
the Tech Act funding specialist to try to target the largest 
companies based on premium information available from the State 
Department of Insurance.  Another problem of representativeness 
involves the persons who are reporting on their insurance 
companies.  Many of the Tech Act program staff had difficulty 
obtaining the cooperation of the insurance companies and may have 
obtained information from persons in the company who were not 
sufficiently knowledgeable about the scope of the benefits 
package.  Some insurers chose to complete the grid themselves; 
others provided information to the Tech Act program which
completed the grid.  In some cases, information came from an 
insurance agent when the company refused to provide it directly.  
And in one state information on two insurance companies was 
actually provided by consumers who had health insurance through a 
specific company.  

A third problem involves the subjectiveness of the judgments 
about coverage policy.  Although an effort was made to identify 
39 types of assistive technology, these types were not specified 
in sufficient detail.  For example, transfer equipment could 
include a seat lift chair or a Hoyer lift or a stairway elevator 
each with different purposes and considerably different prices.  
Another problem is that the survey did not specify the 
characteristics of the individual needing the assistive 
technology, such as the type of disability or level of severity 
which might have a bearing on the coverage decisions.  For 
example, the Workers Compensation carriers often made the 
assumption that a person had a catastrophic injury, while health 
insurers are likely to make different assumptions about the level 
of need.  

The survey did not clarify the nature of the assistive technology 
which might also affect the coverage decision.  While a standard 
power wheelchair can cost $5,000, a customized power wheelchair 
with individual modifications can cost $10,000-$25,000.  Without 
specifying the type of the assistive technology, the 
characteristics of the individual, and the price of the 
equipment, it is difficult to compare coverage policies among 
different plans.  These problems are accentuated by the fact that 
most decisions about coverage for assistive technology are made 
by insurance companies on a "case-by-case" basis.  

In addition to these problems, the survey asked informants to 
report whether the insurance coverage was required, likely, or 
unlikely for different types of assistive technology.  Some of 
the informants expressed the view that there is a fine line 
between "required" and "likely", and even between "likely" and 
"unlikely".  Others avoided the question by reporting that 
coverage policy would be based on medical review without 
specifying the criteria or the standards for review, while others 
offered a question-mark.  It is not clear to the researchers 
whether the question-mark represents the limited knowledge of the 
informant or the ambiguity of the question.  Is the difference 
between likely and unlikely based on the informant's personal 
knowledge of whether a specific coverage decision has ever been 
made, or based on the possibility that the insurance plan could 
ever cover a specific type of assistive technology, or based on 
the probability that the insurance plan would cover the device in 
a particular hypothetical situation.  These differences would 
need to be further clarified to more accurately measure coverage 
policy.

Although these problems can interfere with quantifying the 
coverage decisions of different types of insurers, this survey 
has identified certain coverage patterns that can begin to be 
addressed in public policy even before they are measured more 
accurately. Even if the subjectivity of judgments could be 
eliminated, a survey on coverage policy still does not reveal 
many of the criteria that private insurers use in
determining medical necessity.

Difficulty collecting information from insurers:

Many Tech Act programs had great difficulty getting insurance 
companies to respond to questions about their coverage for 
different types of assistive technology.  Many insurers did not 
want to provide any information even with the promise of 
confidentiality.  There seemed to be two main fears.  One was the 
fear of adverse selection.  An insurer does not want to be viewed 
as having a very comprehensive benefit plan compared to other 
insurers for fear that they would attract persons who are more 
likely to be high risk.  This could have the effect of increasing 
health care costs which would force the insurer to raise their 
premiums and reduce their competitive position in the health 
insurance marketplace.  The second fear  which cannot be 
protected by the cloak of anonymity is the fear of generating 
public pressure for increasing mandates to cover certain 
services.  In a voluntary insurance system, state mandates could 
have the effect of driving insurers out-of-state to states where 
mandates do not exist, or driving employers to self-insure to 
avoid state mandates.  This is why it is necessary for mandates 
to exist at the federal level for all insurers and self-insured 
employers.

Unless all insurers operate in a system which requires a 
comprehensive level of benefits, there are likely to be greater 
financial incentives to compete by avoiding risk rather than by 
spreading risk among all persons with insurance.  Moreover, there 
is likely to be an incentive to calculate profits in the short 
run rather than the long run.  Cost-effectiveness from an 
insurer's point of view will be different from a cost-benefit 
analysis from a public policy point of view (see Cost-Benefit 
chapter).


II.  Analysis: Conditions under which insurers may not pay for 
covered services 

Much of the literature on health insurance coverage of assistive 
technology emphasizes the importance of the insurance contract 
(Reeb, K., 1987).  However, the insurance contract generally does 
not list most forms of assistive technology which are to be 
covered.  Insurers utilize other criteria which may or may not be 
known by the user of the health insurance or by the employer who 
contracts for the health insurance to decide the conditions under 
which to pay for covered services.  Based on the health insurance 
booklets which the funding specialists were able to obtain from 
certain insurance companies, the three regional public forums on 
assistive technology conducted by the National Council on 
Disability, and interviews with insurers, rehabilitation 
professionals, DME suppliers, and consumers with disabilities, 
this section will describe the conditions which affect whether an 
insurer may pay for assistive technology.  Among the excuses 
which private health insurers may use to avoid paying for 
assistive technology, even
when it is a covered service, are the following: 

(1) device or service is explicitly excluded by the insurance 
policy;  many plans contain a list of excluded services such as: 
"eyeglasses, contact lenses and their related fittings; services 
provided by an audiologist and hearing aids (including cochlear 
implants), devices to improve hearing and related fittings; 
services that are not medically necessary; personal comfort item 
or convenience items; air conditioners and humidifiers; dental 
braces, except as covered for cleft lip and palate".  Some 
insurers may refuse to cover appliances not an integral part of 
the body such as artificial limbs, hearing aids, crutches, etc.  
One plan claimed that "The fact that a doctor may prescribe, 
order, recommend, or approve a service or supply does not, of 
itself, make it a Covered Service or Medically Necessary, even 
though it is not specifically listed as an exclusion."  Coverage 
often depends on how effectively the consumer can make the case 
during the appeals process that the assistive technology which he 
or she is seeking coverage for falls within the contract language 
of the insurance plan.  One insurer limited coverage to durable 
medical equipment which "is currently approved under Medicare".

(2) person is ineligible for the device because the condition may 
have occurred before the person was covered by this insurance 
plan; one insurer defined pre-existing condition as "An injury, 
illness, or medical condition you had-- whether or not the 
diagnosis was known to you-- before you applied for this 
coverage."  Many insurance plans consider a condition to be a 
pre-existing condition if it was diagnosed or treated within 3-12 
months prior to the effective date of the current insurance 
policy.

(3) condition was not caused by an illness, disease, injury or 
congenital anomaly covered by the plan; some insurers have 
claimed that they are only responsible for the rehabilitation of 
conditions caused by illness or injury rather than for 
habilitation for congenital conditions; some insurers have tried 
to avoid paying for rehabilitation services on the grounds that 
the actual cause of the condition was not determinable.  

(4) private insurer will not cover services which the insured 
person could be eligible for from other public or private payers; 
this is understandable in the case of Workers Compensation where 
a private Workers Compensation carrier has a clear responsibility 
to cover work-related injuries, but it is much more problematic 
in the case of public programs like services identified in a 
child's Individualized Educational Plan (IEP) or public insurance 
programs like Medicare.  There are many problems based on the 
interaction effects of private insurance and public programs.

(5) service or device was not provided by a licensed specialist 
or the person was not referred to the licensed specialist by an 
appropriate physician; the greater use of managed care for cost 
containment purposes is tightening the prior authorization 
requirements which private insurers can impose before deciding 
whether to pay for
covered services; this is highly problematic for persons with 
disabilities when the gatekeeper is not knowledgeable about 
rehabilitation or has incentives to under-serve.
 
(6) insurer claims that service is not considered "reasonable and 
necessary" for that condition; insurer reserves the right to 
determine medical necessity; the greatest obstacle to coverage of 
assistive technology by private health insurers is based on the 
insurer's determination of what is "reasonable and necessary" for 
a specific condition.  "Medical necessity is defined in as many 
ways as there are insurance companies"; "care recommended for you 
by a professional may be appropriate for your illness or 
condition, but may not meet our definition of medical necessity"; 
many insurers use Medicare's definition of durable medical 
equipment (e.g. not useful to a person in the absence of illness, 
injury or disease); letter of medical necessity is generally 
required to be signed by a physician prior to rendering of the 
service; documentation must generally include: patient's 
diagnosis, type of equipment to be rented or purchased; patient's 
prognosis; estimated duration of need for the equipment; 
instructions for the use of the equipment; patient's or other 
family member's ability to operate equipment; indication that the 
equipment is either new, used, or replaced; reason equipment is 
being replaced or cannot be repaired;

(7) device is not primarily used to serve a medical purpose;  
some insurers explicitly exclude coverage for maintenance or 
basic daily care concerned with maintaining a functional level of 
living in one's home-- such as activities assisting with daily 
living; in defining the meaning of "medical purpose", insurers 
often use an acute care definition of health; this allows them to 
exclude coverage for maintenance or basic daily care concerned 
with maintaining a functional level of living in one's home -- 
such as through the assistance of an environmental control unit; 
reflecting a home-based definition of need, health insurers often 
try to avoid coverage for health related services that occur in 
other settings such as school or workplace or community life.

(8) insurer decides that there is not a "reasonable expectation" 
that the device will result in restoration or improvement of lost 
functions within a specific period of time; one HMO is currently 
resisting covering rehabilitation services on the grounds that 
the condition is "life-long"; special features are covered only 
if they serve a therapeutic function and are not primarily a 
convenience for the patient or family; HMOs often impose a 
"reasonable expectation of progress" test of 60 visits for 
rehabilitation services, or 60 calendar days since an injury or 
discharge from a hospital.  Insurers may try to discriminate 
against persons with chronic degenerative conditions by ignoring 
that rehabilitation can reduce the deterioration of a condition 
or can enable a person to maintain their level of function; some 
insurers will try to deny coverage if rehabilitation will not 
restore a lost function even if it will enable a person to 
improve their functioning inspite of an impairment;

(9) device may not fall within the allowable cost limits;  (e.g. 
one HMO is reported to have an annual cap of $500 for DME per 
year; insurer may also determine when a device must be purchased 
or rented, and may require that the rental not exceed the total 
cost of purchase; insurer may require prior approval for DME 
costs in excess of a certain amount (e.g. $100);

(10) specific device is not on an approved list of the insurer's 
which is not included in the "Certificate of Coverage"; one 
insurance contract stated that it excludes from coverage 
"services or supplies that are not specifically mentioned in this 
Certificate".  Another contract stated that the insurance will 
not cover any services that are not covered by Medicare.

(11) provider or vendor is not on an approved list of the 
insurer; insurers may try to limit reimbursement to an approved 
list of providers or vendors in order to maximize the insurer's 
leverage over prices.  Insurers may try to steer policyholders to 
providers with whom the insurer has negotiated a discount price 
even though the provider may not be the choice of the 
policyholder.

(12) policy does not pay for repair, maintenance, training or 
replacement even if it covers the device and assessment of need;
some policies cover only the initial purchase of an external 
prosthesis which is needed because of a condition occurring when 
the insurance plan was in effect; these policies may not cover 
repair, maintenance, training or replacement; many private 
insurers will cover replacement due to changes in the person's 
condition but not due to loss or damage of the equipment. 

(13) policy may not pay for duplicates; many insurance plans will 
avoid paying for duplicates or even for assistive technology that 
approximates the functions of a more cost effective alternative;

(14) insurer requires person to meet certain deductible and 
copayment requirements (e.g. consumer may be required to pay a 
copayment of between 20%-50%; by capping the DME benefit at a 
specified amount, the insurer is in effect requiring a copayment 
of 100%).

(15) insurer may offer coverage for certain types of assistive 
technology for an additional premium; hearing aids were the most 
common type of assistive technology available as an optional 
benefit; some insurers offer DME as an optional benefit.

(16) insurer may refuse to pay for device which has not been 
approved by a specific governmental agency (e.g. Food and Drug 
Administration) which would certify that the technology results 
in improved health outcomes for a specified diagnosis; one 
insurer limited coverage to assistive technology to durable 
medical equipment which "is currently approved under Medicare";
     
(17) insurer decides what is cost-effective; a power wheelchair 
may be covered if the physical condition prevents the use of a 
manually-operated wheelchair in one's home; otherwise, a power 
wheelchair may not be covered even if it is necessary for 
mobility at one's workplace or in the community. 

While private insurers can legally avoid paying for assistive 
technology that is not covered by the contract, they frequently 
are willing to go outside the contract in order to cover 
assistive technology which will reduce their liability for more 
expensive covered services like hospitalization or 
institutionalization.  Private insurers often resort to medical 
case management for high cost cases which may require greater 
flexibility in benefits than was built into the insurance 
contract.  Insurers often point to medical case management as an 
example of their flexibility in responding to unique needs.  

These examples reinforce the notion that it may be strategic to 
convince private insurers that rehabilitation and assistive 
technology can be extremely cost-effective in general. 
(Mendelsohn, S. and DeWitt, J., 1992)  In an assessment of 
alternative funding strategies for private health and disability 
insurance, Mendelsohn and DeWitt suggest that the state should 
conduct a demonstration project designed to help insurers 
discover the cost savings created by the use of assistive 
technology.  Among the potential cost savings are: (1) prevention 
of additional illness or injury; (2) prevention of job 
performance stress; (3) job retention; and (4) facilitation of 
return to work.  The problem with this strategy for demonstrating 
the cost-effectiveness of assistive technology is that private 
health insurers do not calculate cost-effectiveness from the 
perspective of the individual or of society.  Unless the 
regulatory structure for health insurance changed, health 
insurers are likely to continue to be concerned with their short 
term profits in their short term contracts with employers.

Rather than have to convince an insurer of the effectiveness of 
assistive technology, an insurance representative explained that 
an insurer is willing to cover whatever the employer is willing 
to pay for.  From the insurer's perspective, it does not matter 
whether the service is medically effective.  Nor does it matter 
that assistive technology can increase the person's independence, 
get the person back to work, or increase the quality of life. 
This is a major problem associated with employment-linked health 
insurance as well as with private insurers who have no stake in 
whether a person with disabilities becomes a productive citizen.
   
Among the other ways that private insurers and self-insured 
employers can limit their liability in the health insurance 
marketplace are:

(1) life time caps:; 79% of employer-sponsored health insurance 
plans limit an insurer's liability to a lifetime maximum; 42 
percent had a lifetime cap of at least $1 million in 1989, 
according to the Bureau of Labor Statistics; services which
exceed the lifetime cap will not be reimbursed by the private 
insurer or self-insured employer.  A 1990 survey of working-age 
persons with disabilities in various voluntary health 
associations found that 26.1 percent of persons with serious 
mental illness and 13.7 percent of persons with spinal cord 
injury had exceeded the lifetime cap on their private insurance 
plans (Griss, B. and Hanson, S., 1990).

In a 1988 case involving Jack McGann v. the H & H Music Company 
in Houston, Texas, a federal District Court in Texas and Court of 
Appeals in New Orleans have decided that an employer can change 
the life time cap of an employer-sponsored health insurance plan 
for AIDS related services in order to reduce the employer's 
liability. This case which has recently been appealed to the 
Supreme Court may affect whether employers can change the 
lifetime caps in their insurance plans for various high cost 
medical conditions whether cancer, stroke, diabetes, etc.  (N.B. 
This kind of behavior by an employer would not be legal since 
July 26, 1992 under the Americans with Disabilities Act.)

Some insurers impose a lifetime cap on certain services.  For 
example, some policies will cover only one wheelchair per 
individual per lifetime even though most people will need to 
replace their wheelchairs when the wheelchair wears out or their 
needs change.

(2) annual limits: insurance contracts may limit the dollar 
amounts, hours, or units of service that persons can receive for 
certain covered services; approximately 11.1 percent of persons 
with disabilities reported exceeding annual maximums in their 
private health insurance plans (Griss, B. and Hanson, S., 1990).  
Persons with disabilities in HMOs are especially vulnerable to 
annual limits on DME coverage since HMOs provide first dollar 
coverage in exchange for a capitated payment without resorting to 
deductibles or copayments to discourage unnecessary utilization.

(3) pre-existing condition exclusions: approximately 16 percent 
of persons with disabilities have a permanent pre-existing 
condition exclusion on their private health insurance plans 
according to the 1990 BPA/WID Consumer Survey (Griss, B. and 
Hanson, S., 1990); a much higher percentage are subject to 
waiting periods for pre-existing conditions which can be repeated 
every time there is a change in insurer; many insurance plans 
impose a pre-existing condition exclusion on any conditions for 
which there was a diagnosis or treatment during some period (3-12 
months) prior to the effective date of the current health 
insurance plan.

(4) premium increases based on group or individual "experience" 
which exceed threshold of affordability and lead to reduction in 
benefits or policy cancellation; insurers can adjust the premiums 
in an individual or group plan to reflect the actuarial 
experience of whatever "block of business" that the insurer 
chooses to assign a particular individual or group to.  The 
insurer can assign some individuals or groups to a "block of 
business" which is in an upward spiral of costs resulting in
an increase in premiums beyond the insured's threshold of 
affordability.  This situation frequently leads to a reduction in 
benefits or a policy cancellation when the insured individual or 
group can no longer afford the premium increases.

The list of conditions under which health insurers will pay for 
covered services defies generalization other than to say that: 
"It all depends".  

Importance of medical documentation:

There is a growing literature on how to provide medical 
justification for insurance coverage of assistive technology as a 
medical necessity.  One example is the Prentke Romich Company's 
"How to Obtain Funding for Augmentative Communication Devices" 
(Prentke Romich, revised 1989) which describes the critical terms 
that must be used (e.g. medical necessity) and others that should 
be avoided (e.g. educational or vocational benefits) and provides 
an outline for and successful examples of letters to document 
medical necessity.  

Recognizing that most insurance plans do not explicitly refer to 
a specific type of durable medical equipment, it is necessary to 
show how the type of assistive technology which is sought fits 
under such covered benefits in the insurance policy such as 
durable medical equipment, prosthetics, or orthotics.  For 
example, Prenthke Romich suggests referring to an augmentative 
communication device as a speech prosthesis which replaces the 
function of a malfunctioning body part, i.e. the larynx.  

In order to emphasize how an augmentative communication device is 
medically necessary, Prenthke Romich suggests that specific 
examples be given from the individual's personal life which show 
how the use of a communication device could have or did improve 
communication with medical personnel and rehabilitation personnel 
resulting in more effective and more timely medical treatment.  
The emphasis should be on the impact of the equipment on the 
individual's physical and mental health care needs.  

In addition, the medical documentation should emphasize the cost 
savings to the insurance company from reducing the individual's 
medical care costs and the evidence that the specific type of 
assistive technology which is being sought is the least expensive 
device which will adequately serve the needs of the individual.  
Supportive documentation is necessary from the individual's 
physician(s) and from rehabilitation professionals who can 
explain: (1) the medical history and diagnosis of the condition 
which has led to the need for the assistive technology, (2) the 
prognosis for the individual's functioning without the assistive 
technology, and (3) evidence of the individual's ability to use 
the assistive technology.  This information can often be 
effectively  communicated with photographs of the individual, 
with a detailed description of the assistive technology, through 
the use of a videotape of the individual using the equipment, and 
with any information
about the individual's experience with the equipment during a 
trial period.  In a memorable newsletter referred to below, Anna 
Hofmann described how a twenty-nine year old woman with cerebral 
palsy was able to get Medicare to reverse its denial of coverage 
for an augmentative communication device. (Hofmann, 1987).
Unable to get the Medicare carrier to recognize that an 
augmentative communication device was not a "personal comfort 
item", she arranged to visit in person the local offices of her 
Congressional members to demonstrate that this assistive 
technology actually replaced a function of the body enabling her 
to be understood. 

The Prentke Romich guide identifies a critical role for the 
"Client Advocate" who coordinates the collection of the 
supportive materials which is sent to the Funding Coordinator of 
the equipment manufacturer or distributor before it is submitted 
to the insurance company.  The funding guide begins with the 
claim that "Funding success is 100% dependent upon the 
perseverance of the client advocate" and that "Funding is always 
available!". 

Although health insurers want to keep coverage decisions as much 
up to their discretion as possible, it is possible to build an 
"institutional memory" by sharing experiences of how different 
insurers have decided that it was medically necessary to cover 
certain types of assistive technology.  Building this 
"institutional memory" is also essential to changing the criteria 
of medical necessity that health insurers can be made publicly 
accountable for using.  

There are various ways that an "institutional memory" can be 
generated in the area of reimbursement for assistive technology.  
One example is Anna Hofmann's monthly newsletter called "The Many 
Faces of Funding" which is sponsored by Phonic Ear.  This 
collection of newsletters is organized into different sections.  
One section provides an overview of Federal/State, Educational, 
Insurance, and Private Funding programs. The second section 
addresses strategies for knowing your patient, assembling 
supportive documents, and building awareness/credibility for the 
assistive technology.  The third section provides a brief 
synopsis of selected case histories relating to Medicare, 
Medicaid, and Insurance companies from Monthly Newsletters since 
1981.  Also included are summaries of various federal and state 
programs that provide precedents for justifying coverage of 
different forms of assistive technology.

Another example of sharing experiences among rehabilitation 
professionals is Janet M. Gritz's "Third Party Reimbursement for 
Speech-Language Pathology and Audiology Services" (Gritz, J., 
1990).  Produced for the Maryland Speech-Language-Hearing 
Association, this report provides an analysis of how 86 third 
party payers (private and public) operating in the Washington, 
D.C. metropolitan area cover speech-language pathology and 
audiology services.  The information was obtained from actual 
records of claims covered or denied by insurance carriers, 
correspondence with insurers, and an examination of Federal 
Employees Health
Benefits Program brochures which needs to be periodically 
updated.  

An "institutional memory" can also be built through keeping track 
of the DME coverage policies of different insurance plans by 
systematically sharing experiences among rehabilitation 
professionals, parents of children with disabilities, and persons 
with disabilities.  Lou Golinker is trying to organize health 
insurance registries to monitor coverage denial excuses of third 
party payers for specific types of assistive technology 
(Golinker, 1992).  Golinker suggests that these health insurance 
registries can expose arbitrary and inconsistent decisions of 
third party payers and lead to greater responsiveness to people's 
needs for assistive technology.

Cost containment pressures among third party payers (both private 
and public) have accentuated the tendency for insurers to become 
more restrictive in their eligibility criteria based on medical 
underwriting and more restrictive in the health benefits which 
they offer.  Contrary to the assumption that competition in the 
health insurance marketplace encourages private insurers to offer 
more generous benefits to attract more consumers, cost 
containment pressures actually discourage insurers from covering 
assistive technology in order to avoid what they regard as 
"adverse selection".

Coverage depends on not only on the type of insurance chosen, but 
the location of the event which necessitates the use of assistive 
technology.  For example, if you have a spinal cord injury, it 
makes a big difference if you have it in an automobile accident 
or on the job than if you have it on a weekend falling off your 
roof; instead of people getting what they need to get back to 
work they get what the insurer agreed to provide in advance.  
With health insurance, which is usually a contract between an 
employer and an insurer, the needs of the consumer may be easily 
overlooked.  A disability perspective on health care reform 
considers not what it takes to maximize profits for private 
health insurers but what is good public policy for coverage of 
assistive technology. 

III. Recommendations:

1.   Establish comprehensive health care as a federal right for 
     all persons which is not dependent on income, employment 
     status, geographical area, age, or presumed quality of life, 
     etc.  If this cannot be achieved within the logic of a 
     voluntary private health insurance system, then public 
     policies should be established which can finance the 
     comprehensive health care needs of all persons and 
     distribute those costs equitably throughout the population.

2.   Establish Federal minimum benefit standards for health 
     insurance.  These should be based on the kind of health care 
     services that people need and not be limited to the 
     financial capacity of employers or the financial incentives 
     of insurers to pay for these services.

3.   Broaden the definition of medical necessity to include 
     health and safety needs and Activities of Daily Living (ADL) 
     needs.  Health insurance should cover all assistive 
     technology which improves the function of malfunctioning 
     body parts (whether replaced or remaining in the body) that 
     is expected to improve health, safety, or promote 
     independence in meeting ADL needs.  This includes 
     environmental control devices, safety equipment, and 
     communication devices that can facilitate interaction with 
     medical personnel, can assist in an emergency situation, and 
     can reduce mental health problems related to barriers to 
     communication. 

4.   Require insurers to recognize treatment billing codes from a 
     rehabilitation perspective which reflect the evaluation 
     services provided by rehabilitation professionals who need 
     to assess functional deficits in order to develop effective 
     treatment plans to address functional impairments.  It is 
     not adequate to rely on diagnostic treatment codes from a 
     clinical perspective that is principally concerned with 
     identifying the underlying medical conditions.  

5.   Develop collaborative strategies with the health insurance 
industry for educating private insurers to the health related 
aspects of assistive technology.

6.   To avoid the consumer suffering from the competition among 
     private and public payers to be "payer of last resort", 
     private insurers should be required to provide funding for 
     assistive technology as a covered service under its health 
     insurance policy, and then try to collect from the 
     government program.

7.   Require insurers to guarantee consumer choice and control in 
     the selection of assistive technology in order to maximize 
     the effectiveness of assistive technology and minimize the 
     inefficiencies associated with consumer abandonment of 
     assistive technology.

8.   Develop legal procedures for establishing precedents for 
     coverage of assistive technology by private insurers to 
     reduce the discretion which private insurers currently have 
     to avoid paying for health related assistive technology.  

9.   Build an institutional memory among providers, vendors, and 
     consumers to reduce the arbitrary discretion which private 
     insurers currently exercise.

10.  Require the Department of Labor/Bureau of Labor Statistics 
     to request information about health insurance coverage of 
     DME from the more than 4000 employers who they survey 
     annually for the Employee Benefits Survey.  This information 
     would also be useful to the Department of Labor to promote
     the employment objectives of ADA.

11.  Encourage universal design of products so that costs for 
     assistive technology can be shifted from health insurance to 
     the general costs of products.


IV.  Future research:

1.   Design and conduct studies of cost-effectiveness of 
     assistive technology from the perspective of employers, 
     insurers, different levels of government, and consumers 
     taking into account the potential for increases in 
     productivity, independence, and integration as well as a 
     reduction in secondary disabilities.

2.   Develop studies of the actuarial implications of extending 
     coverage for assistive technology.  Instead of asking only 
     how would health insurance premiums be affected by the 
     incidence of disability and the estimated use of assistive 
     technology also take into account the reduction in acute 
     care utilization attributable to enhanced functional 
     capacity.

3.   Examine the knowledge base of claims reviewers of third 
     party payers who decide what assistive technology private 
     insurers should pay for.

4.   Examine the impact and administration of assistive 
     technology coverage in various Canadian provinces (e.g. 
     Ontario and Alberta), as well as Sweden, as models for 
     covering assistive technology through the health care system 
     in the U.S.

5.   Extend analysis of private insurance coverage of assistive 
     technology:

     [A]  Examine claims processing experience of DME vendors 
          with different types of third party payers.  A 
          systematic survey of a representative sample of vendors 
          of DME through a trade association like the National 
          Association of Medical Equipment Suppliers (NAMES) or 
          through selected manufacturers or distributors of 
          specialized assistive technology like augmentative 
          communication devices, could identify the facilitators 
          and obstacles to coverage in different types of 
          insurance plans.  This research could contribute to the 
          building of an "institutional memory" where yesterday's 
          exceptions become tomorrow's rule. learn their 
          experience with different types of insurers.

     [B]  Recommend that the Social Security Administration 
          should study the adequacy of rehabilitation benefits 
          for SSDI beneficiaries during the two year waiting 
          period for Medicare.

     [C]  Expand survey on the adequacy of health insurance for 
          persons with disabilities to measure how effectively 
          different forms of private and public health insurance 
          are meeting their health care needs.










                           Bibliography

Access to Health Care, "Strategies for Adapting the Private and 
Public Health Insurance Systems to the Health Related Needs of 
Persons with Disabilities or Chronic Illness," Vol. I, Nos. 3-4, 
December 1988-March 1989, pp. 3-11., United Cerebral Palsy 
Associations, Washington, D.C.

Altman, Barbara M., Preliminary estimates prepared for National 
Council on Disability by Agency for Health Care Policy and 
Research, February 1992.

Berkowitz, Monroe, Harvey, Carol, Greene, Carolyn G., and Wilson, 
Sven E., The Economic Consequences of Traumatic Spinal Cord 
Injury, Demos Publishers, forthcoming.

Golinker, Lou. Personal correspondence submitted to the Prentke 
Romich Corporation (PRC's) "Current Expressions", June 1992.

Griss, Bob and Hanson, Stuart, Accessibility, Adequacy, and 
Affordability of Health Insurance for Persons with Disabilities 
or Chronic Illness, unpublished draft, Chapter 3, submitted to 
the National Institute on Disability and Rehabilitation Research, 
July 1990.

Gritz, Janet M., "Third Party Reimbursement for Speech-Language 
Pathology and Audiology Services", Maryland 
Speech-Language-Hearing Association (MSHA) Hospital and Clinical 
Affairs Committee, 200 Kimblewick Drive, Silver Spring, MD 20904.

Health Care Financing Review, Fall 1991, Vol. 13, No. 1, Table 
12, pp. 51-52.

Hendershot, Gerry E., LaPlante, Mitchell P., and Moss, Abigail 
J., "Assistive Technology Devices and Home Accessibility 
Features: Prevalence, Payment, Need, and Trends", Advanced Data 
on Vital and Health Statistics, No. 217, Hyattsville,
MD, National Center for Health Statistics, 1992.

Hofmann, Anna. "The Many Faces of Funding...", March 15, 1987, 
Phonic Ear, Inc., 3880 Cypress Drive, Petaluma, CA, 94954-7600.

Mendelsohn, Steven and DeWitt, John C., "Assistive Technology in 
Maryland: Existing Options and Alternative Strategies Under 
Federal/State Funded Programs, State-Based and Private 
Initiatives," April 1992, pp. 40-41.

National Center for Health Statistics, Health Care Coverage by 
Sociodemographic and Health Characteristics, United States, 1984: 
Data from the National Health Survey, Vital and Health 
Statistics, Series 10, No. 162; November 1987, DHHS Publication 
No. (PHS) 87-1590; Tables 4, 6, 9, 13, 18.

Phillips, Betsy, "Technology Abandonment: From the Consumer Point 
of View", National Rehabilitation Hospital, Rehabilitation 
Engineering Center, Washington, D.C., 1992.

Reeb, Kenneth, G., "Private Insurance Reimbursement for 
Rehabilitation Equipment", Electronic Industries Foundation, 
Washington, D.C., July 1987.

Rice, Dorothy P. and MacKenzie, Ellen J., The Cost of Injury in 
the United States: A Report to Congress. San Francisco, CA: 
Institute for Health and Aging, University of California and 
Injury Prevention Center, The Johns Hopkins University, 1989, p. 
163.

Tate, Denise, "The Effects of Insurance Benefits Coverage on 
Independent Living Outcomes for Persons with Spinal Cord Injury", 
Field-Initiated Research Continuation Proposal to the National 
Institute on Disability and Rehabilitation Research, January 
1992.

Word from Washington, "Health Insurance At Risk", United Cerebral 
Palsy Associations, Washington, D.C., May/June 1991, pp. 13-16.









Section Five:






Alternative Funding Programs for Assistive Technology 























NATIONAL COUNCIL ON DISABILITY



STUDY ON FINANCING ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES


Alternative Funding Programs
for Assistive Technology 








Contractor: United Cerebral Palsy Associations, Inc.
1522 K Street, N.W., Suite 1112
Washington, D.C.  20005

February 12, 1992
                             Introduction

A variety of alternative funding programs exist for the purchase 
of assistive technology equipment and devices.  These funding 
sources are "alternative" in that they are generally smaller, 
more targeted funding sources available to people with 
disabilities who typically are denied funding by the more 
traditional funding sources.  Eligibility and program formats 
vary widely, but in most cases, these funding sources provide 
less stringent eligibility requirements and certifications than 
the traditional funding sources.  The fourteen alternative 
funding programs looked at here have a wide variety of policies 
and objectives.  Many are "payors of last resort," places to turn 
when all other traditional private and public sources have been 
pursued, and adequate funding has not been obtained for the 
desired piece of equipment.  With almost every program, there are 
more applications than there are funds, and particularly for 
those programs with liberal eligibility requirements and the most 
flexible terms, the waiting lists of already approved 
applications are long.

These alternative funding programs are operated and supported by 
state governments, local and national agencies who serve people 
with disabilities, manufacturers of assistive technology devices, 
manufacturers of equipment which can be adapted for use by people 
with disabilities, and one federal government employer.  These 
alternative funding programs include a variety of loan programs, 
manufacturer's discounts, reimbursements for adaptations made to 
equipment, and outright grants made for the purchase of assistive 
technology devices and accommodations.  Some funds are available 
only for the purchase of specific types of equipment, while other 
programs will fund virtually any type of assistive technology.

These programs receive funding from a variety of sources, from 
state or federal government appropriations and federal grants to 
private corporate contributions or manufacturer support.  One 
innovative program is generating funds through a state income tax 
check-off contributions, and another proposed state government 
program will generate funds from fees charged in convictions of 
motor vehicle and traffic violations.  

The single greatest common problem of these alternative programs 
is lack of sufficient funds to meet all requests, (with one 
exception), with limited funding thus affecting the extent of
information dissemination about the funds' availability to 
potential technology users.   In many cases, very limited 
information dissemination occurs within the target audiences 
regarding funding availability, and in one case funds are only 
available to individuals at the program staff's specific 
suggestion, without any publicity to the general service 
population of the program whatsoever.  Either because funding is 
so limited, or because the program is new, or because there is no 
simple way to spread the word, many potential technology users 
may never learn about an alternative funding source for which 
they are qualified.  The manufacturers typically do not heavily 
promote their own discount or loan programs, and there are no 
national, or even regional clearinghouses which offer information 
and referral about alternative funding sources.  In researching 
these programs, an example was given by a local private service 
agency of how their loan fund will assist a sight impaired woman 
purchase a particular device for which she could not obtain 
enough funding through traditional sources.  The local service 
agency was completely unaware that the manufacturer of that exact 
device operated their own low-interest loan program with a 
sizable discount and flexible repayment terms.  The lack of 
information exchange and coordination even between the existing 
alternative programs is staggering.  Many of the programs are 
designed to in some way serve as a demonstration model for other 
like programs, and staff are eager to share information about 
their projects for purposes such as this study.  Again due to 
limited funding however, their information dissemination to other 
potential alternative funding providers is limited.  

While their specific goals and target audiences may differ, each 
program has in common its desire to ease the availability and 
accessibility of assistive technology for people with 
disabilities.  The majority of applications of these alternative 
funding sources are "user-friendly," though many do require an 
extensive financial credit evaluation.  Most of the alternative 
funding sources offer a variety of support services in addition 
to funding, including information about assistive technology 
options, needs assessment, local resources, training, education, 
and information for a variety of individuals, with and without 
disabilities.  
The following pages provide one-page summaries of thirteen 
different alternative funding programs, followed by a list of 
options to enhance and increase alternative funding sources.

Type of Program: Revolving Loan Fund  (State Government 
Funded/Private Service Agency Operated)
Program Name:       Adaptive Equipment Loan Program
Operated By:        Alpha One
                    85 E Street
                    Suite #1
                    South Portland, ME  04106
                    (207) 767-2189           
Contact:            Kathy Adams
Program Operation:  The Adaptive Equipment Loan Program is a $5 
million loan fund that makes low-interest, long term loans 
available to individuals with disabilities and businesses for 
assistive technology devices.  Maine citizens and businesses may 
apply for loans to purchase technology which will enhance an 
individual with a disability's independence in the home, work 
place or community.  Virtually any type of assistive technology, 
high or low tech, may be purchased with the loan funds, for 
individual or site accommodation use.  Individuals may finance up 
to 100% of the cost of their equipment, and businesses may borrow 
up to 50% of costs, with a $50,000 maximum.  Interest rates vary 
from 0% to the current prime rate in Boston.

Funding Eligibility:  Any individual, disabled or non-disabled, 
community organization, or business may apply for a loan to 
purchase adaptive equipment, as long as the equipment assists one 
or more persons with a disability to improve their independence, 
quality of life, or become more productive members of the 
community.

Funding Caps/Restrictions:  Individuals may borrow enough to 
cover 100% of their adaptive equipment costs, businesses may 
borrow up to 50% of their costs.  The maximum amount which may be 
borrowed is $50,000, depending on the individual or businesses' 
credit worthiness and ability to repay.

Program History:   The Adaptive Equipment Loan Fund was 
established by a bill ratified through the state legislature and 
a ballot referendum in 1988, creating a sizable revolving loan 
fund.  A board was appointed by the Governor in the spring of 
1989, to oversee program operations and loan awards.  Alpha One, 
in conjunction with the Finance Authority of Maine (FAME), 
established the guidelines of the program and began 
implementation.  Over 210 loans have been awarded since the 
program's beginning, totalling over $1.6 million.  The loans have 
ranged from $200 to $50,000, with an average interest rate 
recently under 6% for four years.  

Program's Funding Source:  Maine State Legislature appropriation 
of $5 million.  The loan fund is revolving, so repayments 
maintain the level of available funding.

Program Strengths:  The flexibility and broad scope of the 
program is unique.  The program is more comprehensive than any 
other loan program, even including businesses and persons without 
disabilities in its eligibility guidelines.  The repayment terms 
are favorable and flexible, and the maximum ceiling is favorable 
to purchasers of
sophisticated technology systems.  The program also provides 
assessment, education and a variety of support services for 
borrowers.  This program is on e of the first of its kind, and a 
model for future programs.

Program Weaknesses: The application is long and requires a great 
deal of financial information. 
Type of Program:    Revolving Loan Fund (State Government Agency)

Program Name:       Equipment Loan Fund for the Disabled
Operated By:        New York State Department of Social Services
                    Office of Financial Management - 13D
                    40 N. Pearl Street
                    Albany, NY  12243                            
Contact:            Richard Daugherty
                    Loan Administrator

Program Operation:  The Equipment Loan Fund for the Disabled is a 
revolving low-interest loan program established through an 
appropriation of the New York State Legislature.  Disabled 
residents of New York State (and their families, spouses or other 
related care takers) may receive low-interest loans (at 8% in 
1990), repayable in two to eight years, depending on the amount 
of the loan.  The loans may be used to purchase a variety of 
assistive technology "which assists the disabled person to 
overcome barriers to daily living."  A loan committee, including 
representatives of many state agencies which serve people with 
disabilities, oversees the approval of loan applications.  The 
application must be completed by the applicant (financial 
information), physician (certification of disability), and vendor 
(preferably a vendor who conducts business in New York).

Funding Eligibility:  Residents of New York State with 
disabilities, or their parents, spouses, siblings or other family 
members who support them are eligible to receive a loan under the 
Equipment Loan Fund for the Disabled.  There are no restrictions 
regarding age or type of disability, though statistics indicate 
that the overwhelming majority of recipients are adults with 
disabilities, particularly over the age of 61.  Proof of 
disability must be certified by a licensed New York State 
physician or psychologist.

Funding Caps/Restrictions:  Loans are awarded from a minimum 
amount of $500 to the maximum of $4,000, repayable from two to 
eight years depending on the total amount borrowed. Borrowers may 
choose from a variety of repayment plans, with the interest rate 
set below market at 8% (1990).  The only restriction as to the 
type of assistive equipment which may be purchased involves motor 
vehicles--the legislature has prohibited the use of loan funds 
for motor vehicles.

Program History:  The New York State legislature first 
appropriated funds for the Equipment Loan Fund for the Disabled 
in 1985, allocating $50,000 for the program's start-up.  By the 
end of 1990, the program had loaned $395,000 to 222 individuals 
with disabilities and their families.  Currently, the program 
makes approximately 75 loans per year, averaging $1,779 per loan.  

Program's Funding Source:  From 1985 through 1990, the New York 
State Legislature has appropriated $50,000 per year to the 
Equipment Loan Fund for the Disabled.  While annual state funding 
may not continue in
future years, the program currently receives approximately $5,000 
per month in repayments, and is seeking Tech Act funding.

Program Strengths:  The repayment terms of the program are very 
flexible, and there is no penalty for paying off the entire loan 
early.  The credit check process is lenient, a benefit to many 
people with disabilities who have no credit history at all.  
Finally, the variety of assistive technology which can be 
purchased with these funds is almost limitless. 

Program Weaknesses:  Due to the flexibility of the program, there 
are many more applicants than funds available, and a long 
wait-list is maintained.  Due to a state budget crisis, the 
future funding stability of the program is in question, and the 
program currently maintains a 20% default rate.
Type of Program:    Establishment of Trust and Revolving Loan 
Fund (State Government Agency)
Program Name:       Georgia's Technology Related Assistance Trust 
Fund
Operated By:        Georgia Department of Human Resources
                    878 Peachtree Street, N.E., Room 712
                    Atlanta, GA  30309-9844
                    (404) 894-7593

Contact:            Joy Kniskern
                    
Program Operation:  This program has not yet been established, 
but is in the process of receiving the authorization of the 
Georgia State Legislature and governor. Two bills have passed the 
state Senate and are currently in the House Appropriations 
Committee, awaiting approval.  If ratified, a funding source to 
assist people with disabilities will be established via increased 
penalties and fees for convictions of motor vehicle and traffic 
violations, including driving under the influence (DUI).  The 
first bill, an amendment to the Constitution of Georgia, would 
increase speeding ticket fines by two dollars per mile over the 
limit, and allocate an additional 5% of the original fine for DUI 
and reckless driving convictions to be placed in the Technology 
Related Assistance Trust Fund.  The second bill establishes a 
governor-appointed commission to implement a revolving loan fund 
and grant program for technology devices, as well as support 
systems, education, research, public information, needs 
assessment and demonstration projects state-wide regarding 
assistive technology for people with disabilities, including 
victims of crimes.

Funding Eligibility:  The Commission will establish the specific 
program guidelines.

Funding Caps/Restrictions:  Not yet determined.

Program History:   The bills were first introduced into the state 
Senate as a result of a study of creative state and federal 
assistive technology laws.  The bill was introduced in February 
1991, and immediately passed and sent on to the House 
Appropriations Committee.  It is hoped the House will pass the 
bills this winter, and if not vetoed by the governor, will be 
placed for ratification by voters in the November 1992 General 
Election.  If ratified, the Commission would be established 
within eight months, with the fund fully operational 18 months 
after ratification.

Program's Funding Source:  Fines from criminal and minor traffic 
violations throughout the state.

Program Strengths:  The idea is very innovative, and the fund 
raising potential is strong--from $3 million to $10.8 million per 
year, according to program studies.  The terms of the technology 
related assistance program cannot yet be evaluated, as they will 
be developed by the appointed commission.  It is interesting to 
note that the nine member appointed commission will be made up to 
five individuals with disabilities, or their care takers.

Program Weaknesses:  The program faces quite a challenge to be 
ratified by the state legislature, governor and voters.
Type of Program:    Revolving Loan Fund (State Government Grant 
Funded/Private Service Agency Operated)
Program Name:       Guaranteed Collateral Loan Program
Operated By:        Assistive Technology Program
                    United Cerebral Palsy of Southern Nevada and 
the Valley Bank of NV
                    1050 East Sahara, Suite 412
                    Las Vegas, NV  89104-3204
                    (702) 798-4433
Contact:            Susan Terry
                    
Program Operation:    This new program will provide up to $5,000 
in loans to individuals with disabilities or their family members 
for the purchase of adaptive equipment and devices.  The fund is 
to be used as a last resort funding source for individuals who 
have exhausted all other means of funding the assistive 
technology they desire.  The loans require no money down, and no 
collateral, as the loans are guaranteed by the program.  The 
program hopes to coordinate with vendors and traditional funding 
sources (e.g., Medicaid) to be a consolidation source for all 
funders involved in a technology purchase.  The program would 
loan a technology purchaser the funds needed immediately, and 
then receive reimbursement from other funding sources such as 
Medicaid.

Funding Eligibility:  All residents of Nevada, regardless of age 
or type of disability, are eligible to receive a loan under this 
program for the purchase of any type of assistive technology 
equipment of device which would otherwise not be able to be 
purchased due to insufficient funding by traditional sources.
 
Funding Caps/Restrictions:  A funding cap of $5,000 is expected, 
though exceptions will be made if appropriate.  Certification of 
disability is required, but the applicant can show proof of 
disability via the state's prior determination of disability. 
(For example, if the applicant already has received funding for 
assistive technology from traditional sources.)  Loans  may be 
repaid in 12 to 36 months, no collateral or down payment is 
required, and the interest rate is fixed at 6.5%.

Program History:  The Guaranteed Collateral Loan Program was 
established in December of 1991 through a grant from the Nevada 
State Rehabilitation Division.  Additional funding is being 
sought through private donations, and funds will be maintained as 
loans are repaid.  From the grant, $140,000 is in the bank to 
serve as collateral for all loans made under the program, and the 
interest earned remains in the account.  As loans are repaid, 
these funds become available for new loans.  The Valley Bank of 
Nevada does not have locations in every county, but other banks 
in 12 rural counties have agreed to participate by assisting 
applicants with the necessary paperwork, and forwarding all 
applications to the program.  The program is thus available 
statewide on a local level, an important aspect for this rural 
state.

Program's Funding Source:  A grant from the Nevada State 
Rehabilitation Division provided the necessary funds
to begin the revolving loan fund.  Additional private donations 
are being sought, and it is expected that the program will fund 
itself as loans are repaid and interest is earned.

Program Strengths:  The program is designed to be as 
user-friendly as possible, allowing flexible certifications, 
geographically accessible application locations, assessment, 
training, and other resources, as well as liberal eligibility and 
repayment terms.  The program's desire to coordinate and 
consolidate with other funding sources is unique, and very 
favorable to the technology purchasers.  There are no 
restrictions as to the type of equipment which may be purchased.

Program Weaknesses:  The loan funds are available only to 
individuals who have exhausted all other avenues of funding for 
the technology they desire.  
Type of Program:    Revolving Loan Fund (Federal Government Grant 
Funded/Private Service Agency Operated)
Program Name:       Technology Related Loan Fund
Operated By:        National Easter Seal Society
                    70 East Lake Street, Suite 90
                    Chicago, IL  60601-5907
                    (312) 726-6200 (Voice)
                    (312) 726-4258 (TDD)
Contact:            William Watson
                    Loan Fund Officer

Program Operation:    This program was established by a two-year 
grant from the U.S. Department of Education, with the National 
Easter Seal Society providing an additional 13 percent of 
funding.  Funds are available to individuals with disabilities 
nationwide for the purchase of a variety of assistive technology 
devices, though the program tends to concentrate on computer 
technology, as that is the area of expertise of program staff.  
The project is intended to be a demonstration study in the 
viability of a nationwide direct loan fund, facilitating the 
access to assistive technology of people with disabilities.  The 
lengthy application requires several supporting financial 
documents, for an extensive credit evaluation.

Funding Eligibility:  To receive funds, the applicants must be an 
individual with disability, whose family income is lower than 
120% of the U.S. median, or $31,171. "The technology-related 
assistance which is purchased must maintain or enhance [the 
individual's] level of functioning in any major life activity."   
Certification of disability is required by a physician, as well 
as a quote from the vendor, and a $25 application fee is 
required.  
 
Funding Caps/Restrictions:  Loans are typically made for 75% of 
the cost of the purchase, though exceptions will be made, up to 
90% of the total cost; the interest rate is one percent over the 
current market rate.  Loans thus far have averaged between $1,800 
and $2,500, repayable in one to three years.  The program has no 
restrictions on the type of technology which can be purchased, 
though the program focuses on computer technology and screen 
readers for the blind.  

Program History:  The first loans were made in February of 1991.  
The program was established by a grant from the U.S. Department 
of Education, National Institute of Disability and Rehabilitation 
Research.  The program has been funded to run for only two years, 
but is intended to be a demonstration model for other similar 
programs throughout the country.

Program's Funding Source:  The National Institute of Disability 
and Rehabilitation Research, U.S. Department of Education, 
provided $144,000 total program dollars; $85,000 for loans, and 
the National Easter Seal Society contributed an additional 13%.  

Program Strengths:  This program is the first national loan fund 
of its kind.  The guidelines are intended to be flexible, and all 
cases are considered on an individual basis.  The staff of the 
program are very knowledgeable about a variety of computer 
technologies, and provide potential technology users with a great 
deal of education about technology options, usage and funding.  
Thus far, the program has received over 1800 contacts, most of 
which have been provided basic education regarding technology.

Program Weaknesses:  The program is not designed to accommodate 
first time borrowers, and a great deal of financial information 
is required of applicants.  Additionally, while the program has 
no formal restrictions as to the types of technology which may be 
purchased, the focus is on computer technology as that is the 
strength of program staff, though the guidelines are broad as it 
is a demonstration project.
Type of Program:    Revolving Loan Fund & Discount (Private 
Service Agency & Manufacturer)

Program Name:       American Foundation for the Blind Loan 
Program
Operated By:        American Foundation for the Blind Special 
Fund, Inc.
                    15 West 16th Street
                    New York, NY  100      
                    (212) 620-2117
Contact:            Sharon Rice
                    
Program Operation:  The AFB Loan Program makes loans to 
individuals who are legally blind or visually impaired for the 
purchase of the Kurzweil Personal Reader (KPR), an optical 
character recognition system which reads print and transfers it 
into synthetic speech, and just recently, loans are also 
available for the purchase of any other Kurzweil product.  The 
loans, along with a 30% discount for the KPR, are available to 
individuals who would not otherwise be able to afford the 
Kurzweil devices.  Borrowers are required to pay 10% down 
payment, and then receive a loan for the remainder of the retail 
cost, at an interest rate 5% below market, for 48 months.

Funding Eligibility:  Applicants must indicate their need for the 
Kurzweil device they request, including employment, education, 
vocational training, or community service work.  An extensive 
credit evaluation is conducted to determine the applicant's 
financial need, and ability to repay the loan.  Applicants who 
earn less than $25,000 generally need a co-signer to the loan.

Funding Caps/Restrictions:  The retail cost of the device is 
loaned, minus a 10% down payment, and a 30% discount for the KPR.  
The KPR retails between $8,000 and $12,000 depending on the 
features.  Certification of visual impairment is necessary, as is 
demonstration of need.

Program History:   The AFB Loan Fund was established in 1989 by a 
commitment from AFB and Xerox Corporation of one million dollars.  
The program works with the Bank of Boston, which approves the 
credit history and financial background of all applicants.  In 
two years, the program has maintained a 0%  default rate, which 
it hopes to maintain.  Approximately 50 applications per year are 
accepted for loans, though an additional 50 or so are rejected by 
the bank.  The bank no longer requires a dollar for dollar 
guarantee of each loan, but allows the program to maintain only 
$20,000 in the account as collateral against $100,000 in loans.  
Xerox and AFB hope to take back their initial investments in a 
few years, and additional financial supporters are being sought.

Program's Funding Source:  AFB and Xerox provided the initial $1 
million to establish the program. These funds provide the 
interest rate subsidies, and the manufacturer of the KPR provides 
a 30% discount on that device.

Program Strengths:  The loans are guaranteed by AFB through the 
Bank of Boston, so the credit evaluation terms
can be flexible.  The interest rate subsidy and discount are 
quite favorable to the borrower.  The program's 0% default rate 
makes establishment of such a program look quite favorable to 
investors.

Program Weaknesses: In order to maintain such a favorable default 
rate, the bank is not as flexible in its requirements as it could 
be.  The financial need assessment part of the application is 
elaborate, and the repayment terms are quite specific and well 
structured.  First time borrowers with no credit history are 
acceptable within the guidelines of the program, though they may 
be intimidated by the formality of the terms.  Funds are 
available only for the purchase of Kurzweil products (until 
recently, only the KPR in particular), and are not available for 
other types of assistive technology.
Type of Program:    Revolving Loan Fund (Private Service Agency)

Program Name:       Low-Interest Loans for Technology
Operated By:        National Federation of the Blind
                    Committee on Assistive Technology
                    3530 Dupont Avenue, North
                    Minneapolis, MN  55412
                    (612) 671-3131
Contact:            Curtis Chong
                    
Program Operation:  The Committee on Assistive Technology of the 
National Federation of the Blind offers very low-interest loans 
to individuals with sight impairments for the purchase of 
assistive technology devices.  A variety of computer technology 
and related devices which aid blind individuals may be purchased 
with the loans, so that individuals who are blind or have visual 
impairments may "go about the business of living a normal, 
everyday life." 

Funding Eligibility:  Any individual who is blind may qualify to 
receive a loan from NFB, for the purchase of computers and 
related technology equipment for the visually impaired.

Funding Caps/Restrictions:  The maximum loan amount is $3,000, 
repayable in four years with 3% interest.  

Program History:   The program was begun just a year ago, and has 
made loans to approximately 25 people to date.  All program 
funding is from private contributions and funds generated from 
the National Federation of the Blind's Committee on Assistive 
Technology.  The program is rather informal, and does not require 
or maintain the types of records which other programs do.  

Program's Funding Source:  Private contributions and funds 
contributed by the National Federation of the Blind.

Program Strengths:   The less formal approach to the program 
allows for greater flexibility.  Additionally, funds are 
available for a variety of equipment, as opposed to one specific 
device or manufacturer.  Finally, the subsidized interest rate is 
very favorable to the borrowers, the lowest of any of the 
revolving loan programs.

Program Weaknesses:  The program is not widely publicized, and 
even obtaining information for inclusion here was somewhat 
difficult.  
Type of Program:    Revolving Loan and Grant Fund (Private 
Service Agency)

Program Name:       Klatt Assistive Technology Fund
Operated By:        Boston Children's Hospital
                    Communications Enhancement Center
                    300 Longwood Avenue
                    Boston, MA 02116
                    (617) 735-6466
Contact:            Howard Shane


Program Operation:  The Klatt Assistive Technology Fund provides 
low-interest loans, and occasionally grants to people with 
disabilities for the purchase of assistive technology devices.  
The funding availability is not advertised, and the funds are 
available only to individuals who are provided services at Boston 
Children's Hospital's Communications Enhancement Center.  The 
program is very informal, with no strict guidelines or 
restrictions, but the funds are regarded as a last resort 
resource.

Individuals who have exhausted all other potential funding 
sources, public and private, and would not otherwise be able to 
purchase an assistive technology device, are offered funds by the 
Center from the Klatt Assistive Technology Fund.  Those 
individuals or families who are determined to have the ability to 
repay the funds are given low-interest loans; individuals or 
families who are unable to repay the funds are given outright 
grants for the purchase of the necessary equipment.

Funding Eligibility:  The funds are available to individuals with 
disabilities who are seen in the Boston Children's Hospital 
Communication Enhancement Center.  There are restrictions 
regarding age or type of disability, as long as the assistive 
technology being purchased is based on the assessment and 
recommendation of the Center.  Financial need is generally 
necessary, though there is no rigid credit check process.

Funding Caps/Restrictions:  There are no set funding caps in this 
program, for either grants or loans.  Awards are based on the 
amount of funding necessary for the purchase of the specific 
device.

Program History:  The Klatt Assistive Technology Fund was 
established in 1989, and to date has served approximately 50 
people with disabilities. (Note:  No formal records or data are 
maintained.)  The fund has purchased a variety of assistive 
technology, from full communications systems to a mouthstick.

Program's Funding Source:  The Klatt Assistive Technology Fund 
was established through a $200,000 grant from Digital Equipment 
Corporation as a one-time grant.  Currently, there are no 
concrete plans to seek other funding sources.

Program Strengths:  The informality of the program allows for a 
great deal of flexibility for the borrowers/grantees.  There are 
no strict guidelines for the assessment of an individual or 
family's credit history or income level, nor are there strict 
repayment terms.  Funding is also closely linked to extensive 
assessment, education, training and support from the staff of the 
Communications Enhancement Center. 

Program Weaknesses:  Funds are available only to those 
individuals who are served by the Communications Enhancement 
Center, and are not even widely publicized to potential 
technology users of the Center.  While there are no established 
restrictions on the type of assistive technology which may be 
purchased with the funds, typically funds are used for equipment 
and devices which are recommended by the Communications Center 
staff, e.g. communications devices.
Type of Program:    Lending library/special needs center
Program Name:       Duluth Public Library
                    Special Needs Center
Operated By:        City of Duluth
                    520 West Superior Street
                    Duluth, MN 55802
                    (218) 723-3809 (Voice or TDD) 
Contact:            Randall E. Vogt
                    Coordinator
                    
Program Operation:  The Duluth Public Library's Special Needs 
Center provides public access to computers in cooperation with 
the Computer Assisted Literacy Center (CALC).  The program 
includes special adaptations to all equipment for use by 
individuals with disabilities.  The Special Needs Center was 
established to enhance access to the Library's materials, 
programs and services.  The goal has not been to provide separate 
services, but to ensure that people with various disabilities can 
utilize the library's resources. The program serves seven 
counties in Minnesota by providing the  following services for 
people with disabilities:
A. Access to equipment for individuals with visual disabilities;
B. Adapted computer equipment for a variety of disabilities;
C. An adapted toy lending library;
D. Computer Assisted Literacy Center;
E. Sign Language Video Collection;
F. Disability Awareness Projects.

Program Eligibility:  All individuals, disabled or non-disabled 
are encouraged to use the Center and the Library as independently 
as possible.  People unable to use the Center or other Library 
services independently must be accompanied by an attendant who 
will remain with the persons while they use the Center.  During 
the initial visit to the Center, staff will meet the user to 
discuss goals and objectives for center use.

Program History:   Duluth Public Library was designed to be 
completely accessible to people with disabilities.  It is the 
philosophy of the Library that access to the library goes beyond 
getting through the front door.  As a result,  the Special Needs 
Center was established to enhance access to all the library 
services, resources, and programs. The program began with grant 
funding for the purchase of a Kurzwiel Personal Reader and grew 
to serve more individuals with a variety of disabilities through 
a range of technology.  In 1991, the Center answered 456 requests 
for information.  Of these, 179 were specifically in regard to 
assistive technology.  People with disabilities used the Center's 
computers approximately 426 hours and checked out 527 pieces of 
software.  In addition, 306 adapted toys were checked out.  

Program's Funding Source: A grant for $27,500 was initially 
secured through the Library Services and Construction
Act to purchase a Kurzweil Reading Machine and provide staff 
training.  As discussions continued, it became evident that a 
Center would need to be created to house the Kurzweil.  Staff 
time would be needed to train library patrons on how to use the 
Kurzweil and operate the Center.
     Foundation grant support was obtained for years two and 
three of operation for $25,000 each.  The grants provided 
additional equipment and covered personnel costs.  The City of 
Duluth then provided funding for Center staffing and operational 
costs in the annual Library budget beginning in 1983.   Grant 
funds have continued to be a source of funding for new and 
innovative methods of serving people with disabilities within the 
community.  During the past 10 1/2 years, the Special Needs 
Center has benefited from grant funding in the amount of 
$132,000.  Federal and State support amounts to $72,000 or 
slightly more than 50%.  

Program Strengths:  The Special Needs Center allows people with 
disabilities and members of their families to know what assistive 
technology is and what impact it could have on their lives.  
Included in this knowledge is the opportunity to try out the 
device to determine its usefulness for the individual before the 
item is purchased.  The adapted toy loan program allows parents 
to check out toys adapted with switches.  Prices for these toys 
are usually higher than toys purchased off the shelf.  It is 
beneficial for the family to know if the toy and/or adaptation is 
appropriate for the youngster before money is spent.   Likewise 
the availability of computers equipped with assistive devices in 
a library setting is also a valuable resource. 

Program Weaknesses:  Limited financial resources.

Type of Program:    State Income Tax Check Off (State Government 
Agency)

Program Name:       Illinois Assistive Technology Tax Check Off
Operated By:        IL Department of Rehabilitation Services
                    411 East Adams 
                    Springfield, IL  62701
                    (217)522-7985            
Contact:            Penni Cooper
                    Executive Director, IL Assistive Technology 
Project

Program Operation:    Beginning in the summer of 1992, Illinois 
residents with disabilities will be eligible to receive grants 
from the Department of Rehabilitation Services for the purchase 
of assistive technology devices.  The fund is being established 
through the donations of Illinois residents who choose to 
contribute one dollar or more on their 1991 state income tax 
returns.  The rules and guidelines for the program are currently 
being developed, but local programs with contracts with the IATP 
will be asked to administer and promote the fund on a local 
level.  Grant applications will be forwarded to a central 
committee of technology specialists and users for approval.

Funding Eligibility:  Any resident of Illinois with proof of a 
disability, and family income under $50,000 (not yet final), who 
has been denied funding for a particular assistive technology 
device, may receive a grant under this program.  A physician and 
vendor will provide certifications on the application, and 
financial history, proof of denied funding, and need for the 
device will also be required.
 
Funding Caps/Restrictions:   Grants will be awarded for a maximum 
of $10,000, though other funding sources may be used to cover the 
actual purchase costs of any equipment or device.  Applicants are 
encouraged to seek other funding sources.  An assessment by a 
committee appointed physician or therapist, particular for high 
tech devices, may be required.

Program History:  This is the first year that the Illinois State 
Legislature has allowed the IATP to participate in the tax check 
off program, which was first enacted in 1984.  In order for the 
program to be eligible to participate in the tax check off in the 
following year, a program must raise at least $100,000 through 
the check off.  Over $6,000 has been spent by IATP in a publicity 
campaign to generate funds on the check off as ten different 
programs are listed on the 1991 state tax return.  Tax payers may 
contribute any dollar amount they choose.  The tax check off 
program is typically quite successful, generating as much as 
$250,000 one year for a single program.  The actual details of 
grant awarding are still being worked out by program staff, with 
the first fund allocations to the program expected in June.  The 
first grants are expected to be made in late summer, 1992.

Program's Funding Source:  State of Illinois income tax payers, 
as allowed by the Illinois State Legislature.

Program Strengths:  The funds will be available as outright 
grants, available for any type of assistive technology equipment.   
Funding eligibility is expected to be based on a family income of 
$50,000 or less, with exceptions allowable (such as due to high 
medical bills).  These broad terms will likely generate very high 
numbers of applicants.  

Program Weaknesses:  The fund is competing against several 
worthwhile tax check off programs for funding this year, 
including support for individuals with AIDS and Alzheimers.  The 
funds are promoted as a payment of last resort, and the paperwork 
to support this will undoubtedly be less consumer friendly than 
some other programs.
Type of Program:    Credit Agreement (Manufacturer)

Program Name:       The Mitarai/Canon Optacon Financing Program
Operated By:        Telesensory
                    455 North Bernardo Avenue
                    Post Office Box 7455
                    Mountain View, CA  94039-7455
                    (415) 960-9064 
Contact:            Gail Zink 
                    TSI Credit Collections Department

Program Operation:    The Optacon Financing Program makes loan 
funds available only for the purchase of an Optacon II, an 
assistive technology device for the blind.  Funded by Canon 
U.S.A., the company which also helped fund the development of the 
Optacon, loans are made at a subsidized interest rate; borrowers 
pay only 4% per year.  Loans are made for up to a three year 
period, requiring a ten percent down payment, based on the retail 
cost of the Optacon.   The application requests minimal financial 
information, and the application and loan are most similar to a 
credit card application and terms.

Funding Eligibility:  Any purchaser of an Optacon II is eligible 
for credit funds, subject to a credit check.  
 
Funding Caps/Restrictions:   Credit is offered for up to 90% of 
the retail cost of an Optacon II, or approximately $3,200.  With 
a 4% interest rate, the Optacon II purchasers repay approximately 
$100 per month for 34 months.

Program History:  In an interesting personal story, the credit 
program, and the development of the Optacon were established when 
the son of the founder of Canon studied electrical engineering 
with the creator of the Optacon, the Chairman of Telesensory.   
Their continued strong relationship is the basis for this 
alternative funding program.

Program's Funding Source:  Canon, U.S.A. provides the entire 
financial support for the program.

Program Strengths:  The terms of this program are flexible and 
the interest rate is well below market.  The application process 
is brief and simple, and as the credit is offered as an Agreement 
between Telesensory and the purchaser, certifications and back-up 
paperwork are not required.

Program Weaknesses:  The credit terms are only available to 
purchasers of the Optacon II, and not any other types of 
assistive technology devices.  


Type of Program:    Reimbursement for Vehicle Adaptation 
(Manufacturer)
Program Name:       Mobility Access Program
Operated By:        Volkswagen U.S.A.
                    3800 Hamlin Road
                    Auburn Hills, MI  48326
                    1-800-444-VWUS (hotline)
                    (313) 340-5026 (program administration)
Contact:            Heidi Peter
                    Commercial & Recreational Products Group 
Coord.
Program Operation:    Volkswagen U.S.A. offers a $1500 
reimbursement to purchasers of its Vanagon, or $500 to purchasers 
of any Volkswagen passenger car who make accessibility 
adaptations to the vehicle.  With the 1993 editions of Volkswagen 
vehicles, this reimbursement will be lowered to $1000 for the new 
Eurovan, the successor to the Vanagon.  Reimbursements are based 
on the filing of a credit form which includes a copy of the 
purchase agreement and proof of disability or adaptive use 
application.  

Funding Eligibility:  Any purchaser of an new Vanagon or 
Volkswagen passenger car with need for accessibility adaptations 
is eligible to receive this reimbursement, regardless of their 
financial situation.  Reimbursements are paid to either the 
purchaser or Volkswagen dealer, according to the terms of the 
purchase agreement.
 
Funding Caps/Restrictions:   A limit of $1500 is currently in 
place for all new Vanagons, $500 for all Volkswagen passenger 
cars, and $1000 will be the limit for the 1993 Eurovans.

Program History:  Reimbursements are available to individuals who 
adapt vehicles for themselves to drive, or for adaptations made 
for family members with disabilities.  There is no record of any 
adaptations having been made for drivers to drive directly from 
their wheelchairs, (as opposed to the vehicle's seat).  Braun and 
IMS are currently studying the Eurovan to determine if a drop 
floor conversion would allow a person to drive the van directly 
from their wheelchair.  Many features of the Vanagon allow for 
accessibility without any modifications, including the door 
widths (for lifts) and floor to ceiling heights, thus adaptations 
may be less extensive and thus less costly for Vanagons than for 
other vehicles. 

Program's Funding Source:  Volkswagen, U.S.A.

Program Strengths:  Reimbursements are offered to any individuals 
who require adaptations to their new Volkswagen vehicles, 
regardless of income level.  The Vanagon, and new Eurovan have 
design features with accessibility in mind, such as the side and 
back door width, (lift accessible), and floor to ceiling height.  
The hotline offered by Volkswagen and claim application are 
user-friendly, and the availability, dependant on each particular 
dealer, of reimbursement directly to the dealer as opposed to 
purchaser is also consumer-friendly.

Program Weaknesses:  The reimbursements are obviously available 
only to Volkswagen purchasers, and are particularly targeted at 
Vanagon buyers.   The accessibility marketing literature offered 
by Volkswagen contains no mention of the reimbursements.
Type of Program:    Reimbursement for Vehicle Adaptations 
(Manufacturer)

Program Name:       Physically Challenged Assistance Program 
(P-CAP)
Operated By:        Chrysler Corporation
                    P.O. Box 19
                    Detroit, MI  48288-0159
                    1-800-255-9877 (hotline)
               
Contact:            John N. Martel
                    
Program Operation:    Individuals with disabilities, or family 
members of individuals with disabilities, can receive from 
Chrysler up to a $500 reimbursement for any necessary adaptations 
made to new Chrysler vehicles.  Adaptations may include 
modifications for the driver of the vehicle, or adaptations to 
the passenger seats for other disabled passengers.  The program 
serves as a resource for individuals with disabilities, providing 
information about vehicle accessibility and adaptations, 
referring individuals to local resources for adaptations and 
driver training.

Funding Eligibility:  All individuals with disabilities or their 
family members who make adaptations to new Chrysler vehicles are 
eligible for this reimbursement, regardless of their income 
level.
 
Funding Caps/Restrictions:  Reimbursements are made for up to 
$500 towards adaptations made on new Chrysler vehicles.

Program History:  The Physically Challenged Assistance Program 
was first established by Chrysler five years ago, in 1987.  
Though exact statistics are not available, it is estimated that 
approximately 2,000 reimbursements are made each year, totalling 
"thousands" to date.  

Program's Funding Source:  All reimbursements are provided by the 
Chrysler Corporation.

Program Strengths:  The information data base that Chrysler 
maintains of local resources for driver training and adaptations 
is unique.  The toll-free hotline was receiving over 25 calls a 
day five years ago, and the numbers have steadily grown.  

Program Weaknesses:  The reimbursement ceiling is only $500, 
while many adaptations can cost up to $12,000.  While this amount 
clearly helps, it is minimal.  
Type of Program:    Employee Accommodations Program (Federal 
Government Employer)

Program Name:       Computer/Electronic Accommodations Program 
(CAP)
Operated By:        Defense Medical System Support Center
                    U.S. Department of Defense
                    5109 Leesburg Pike, Suite 502
                    Falls Church, VA  22041-3201
                    (703)756-0976            
Contact:            Dinah Cohen
                    Director, CAP Program

Program Operation:    Beginning in FY 1990, the CAP Program was 
established to provide resources, education, training and 
assistive technology accommodations to all new and currently 
employed DoD employees with disabilities.  The program is the 
largest of its kind in the federal government, providing 
assessment, training and technology devices to DoD employees with 
hearing, vision or mobility impairments.  The CAP Program works 
closely with supervisors of every DoD department, providing 
educational seminars to promote the hiring of individuals with 
disabilities.  Additionally, the program pays for such 
accommodations as the training of sign language interpreters for 
employees.

Funding Eligibility:  Any DoD employee with a hearing, vision, or 
mobility impairment may be provided with any accommodation, 
technological or otherwise, which will enable or enhance his or 
her ability to work in the DoD community.  Everything from 
Kurzweil readers to TDDs to sign language training has been 
provided, for employees in all grade levels of the DoD.
 
Funding Caps/Restrictions:   No caps or restrictions are listed 
in any of the program's extensive materials.  The application 
process is user-friendly and brief, with the most important 
requirement appearing to be the appropriate authorizations of the 
employee's supervisors and CAP program staff.

Program History:  The program, first begun in FY 1990, has been 
allocated 10.7 million dollars through 1994.  In 1991 alone, 1.5 
million was expended on equipment and accommodations, as well as 
sign language training.  An additional $41,000 was spent on 
information dissemination, including seminars for DoD staff and 
other federal employees, videos, and printed materials.  In its 
first year, the program received 56 requests for accommodations, 
and over 850 the second year, due to extensive information 
dissemination.   Of the 850 accommodations requests, over 500 
related to hearing impairment, over 300 related to vision 
impairment, and only twenty were mobility related accommodations.  
Over 50 new employees received accommodations in FY 1991.

Program's Funding Source:  The entire 10.7 million dollar budget 
of the CAP program is supplied by the
Department of Defense. 

Program Strengths:  The extent of funding and its stability are 
unique in this program.  Employees with disabilities are being 
actively recruited and accommodated, with a great deal of program 
flexibility, and staff support.  Everything from the promotion of 
the program and education, to assessment, training and 
maintenance support make the program a highly comprehensive 
alternative funding source.

Program Weaknesses:  While not limited in any way in the program 
literature, the focus of recruitment and accommodations efforts 
appears to be for individuals who are hearing or visually 
impaired, as opposed to those with mobility impairments.  Little 
mention is made of speech impairments in particular, which are 
grouped with hearing impairments; the available hearing/speech 
impairment accommodations which are promoted do not include 
devices such as speech synthesizers, but instead all involve 
hearing impairment accommodations.
Type of Program:    Equipment Loan Program for Telephone 
Accommodations (State agency)

Program Name:       Deaf Equipment Acquisition Fund Trust 
(D.E.A.F. Trust)
Operated By:        Deaf and Disabled Telecommunications Program 
(DDTP)
                    1939 Harrison Street, Suite 420
                    Oakland, CA 94612
                    (510) 874-1410                
Contact:            Shelley Bergum
                    Executive Director   

Program Operation:    The Deaf and Disabled Telecommunications 
Program in the State of California provides telecommunications 
equipment (and services) to deaf and disabled individuals.  Any 
individual with a disability which affects his or her ability to 
use a standard telephone may loan equipment from the D.E.A.F. 
Trust, via their local telephone company.  The equipment includes 
a variety of technological accommodations, from TDDs to speaker 
phones, memory phones, amplifiers, remote control telephones, and 
more.  In all, 25 different types of equipment are available, 
free of charge, so that individuals with disabilities may access 
their basic phone service.  The program is entirely funded by a 
.3% surcharge on all intrastate telephone service for all 
residents of California.

Funding Eligibility:  Any individual with a certified disability, 
either vision, hearing or mobility related, which impairs the 
individual's ability to use a standard telephone, is eligible to 
receive adaptive equipment from DDTP.  Disability must be 
certified by a physician.

Funding Caps/Restrictions:   No caps or restrictions are listed, 
but the equipment is loaned to the customer, and remains the 
property of the D.E.A.F. Trust.  Customers must choose between 
the available 25 types of equipment.

Program History:  This program was begun initially in 1981, when 
the California Public Utility Commission (CPUC) and the 
legislature established the .3% surcharge and created the 
D.E.A.F. Trust.  At this time, the California Relay Service was 
begun, (operated also by DDTP), and TDDs were available to 
customers.  In 1987, the program was expanded to include all 
types of disabilities and a variety of other equipment.  The 
program provides maintenance and upgrades to all customers, and 
customers made trade-in their equipment for different devices, 
upgrades or repairs.  Since 1981, well over 200,000 devices have 
been loaned through the program.  This program is one of the 
largest and most comprehensive of its kind, as well as one of the 
first.  Over half of the states now operate similar, though 
typically more limited equipment distribution programs.

Program's Funding Source:  The program's approximate annual 
budget of $31 million is raised entirely via the .3% surcharge on 
all intrastate phone service, assessed each month on every 
telephone subscriber's bill. The funds are all placed in the 
general D.E.A.F. Trust, and then local phone companies are 
reimbursed for the equipment and
services they provide to individuals with disabilities.

Program Strengths:  California's program is more comprehensive 
and effective than most.  As the ADA leads to the establishment 
of relay services, often accompanied by equipment loan programs 
in all states, California continues to be a leader.  The 
continual maintenance, upgrades, and user-friendly application 
and acquisition process are all exemplary, as is the inclusion of 
all types of disabilities, not just the hearing impaired.

Program Weaknesses:  Because the equipment is loaned by the local 
phone company, moving involves much more than changing telephone 
service, and individuals who move out of state "lose" their 
equipment.   
Type of Program:    Telecommunications Devices for the Deaf (TDD) 
and Specialized Customer Premises Equipment (SCPE)

Program Name:       TDD/SCPE Distribution Program
Operated By:        New England Telephone and Telegraph Company
                    Telesector Resources Group, Inc.
                    441 Ninth Avenue
                    New York, N.Y. 10001
Contact:            Halina Malinowski
                    Associate Director
                    Purchasing
                    (212) 502-7526

Program Operation:  Beginning in 1991, the TDD/SCPE Distribution 
Program was established to provide a TDD equipment and a SCPE 
distribution service for any residential subscriber who is 
eligible.   Each common carrier must provide upon request of a 
certified subscriber, TDD or SCPE equipment to the requesting 
subscriber.  Equipment categories include: 1) TDD; 2) 
Telebraillers 3) Amplifiers; 4) Signalers; 5) Artificial 
Larynxes;  6) Telephone Sets; 7) Specialty Items (relay switches; 
misc, special assembly, headsets, large number overlays, large 
visual adjuncts for TDD).

Program History: In December 1990, the Governor of the 
Commonwealth of Massachusetts signed into law Chapter 291 of the 
Acts of 1990, which established a program to provide that every 
common carrier shall provide and maintain a TDD equipment 
distribution service and a SCPE distribution service, and shall 
make such services available to any residential subscriber who is 
eligible.  Compliance by every common carrier was required by 
July, 1992.

Funding Eligibility:  Resident of Massachusetts who are certified 
by the Massachusetts commission for the Blind as sufficiently 
visually impaired or blind to be in need of SCPE equipment, or 
certified by the Massachusetts Rehabilitation Commission as 
sufficiently disabled in need of SCPE; or residents certified by 
the Massachusetts Commission on the Deaf and Hard of Hearing as 
sufficiently deaf or hard to hearing to be in need of TDD or SCPE 
equipment.  

Funding Caps/Restrictions:  Services are provided free of charge, 
or at reduced rated if the department of public utilities first 
certifies that the subscriber is unable to afford the equipment 
at full cost.  Equipment vendors are selected by means of an RFP 
to enter into a contractual arrangement with New England 
Telephone (NET).  In addition, vendors are required to provide 
maintenance, replacement, and repair of all parts and training if 
requested by NET.

Program's Funding Source:  The program is financed by revenue 
from a surcharge on directory assistance calls.  All NET 
subscribers are charged at a rate of .35 cents per call to 
directory assistance after ten free calls.  

Program Strengths: According to program administrators, the 
program more than pays for itself.   

Suggestions


1.   Establish systems of information exchange and referral both 
     regionally and nationally for individuals with disabilities 
     seeking funding, as well as agencies and programs wishing to 
     start alternative funding programs.  Encourage existing 
     alternative funding programs to disseminate information 
     about program start-up and operation to other potential 
     alternative funding sources and interested parties.

2.   Provide central avenues of networking, and encourage 
     information exchange and  coordination between the 
     alternative funding sources, as well as with the traditional 
     funding streams.

3.   Create a funding resource for alternative funding programs.  
     Connect private corporate donors with alternative funding 
     programs, or provide start-up grants enabling the 
     establishment of revolving loan funds.  This could be a part 
     of a corporation for public technology concept.

4.   Provide federal incentives, such as matching funds, to state 
     governments to allocate state dollars for the start-up of 
     revolving loan funds with flexible terms. 

5.   Provide incentives to banks to provide loans to people with 
     disabilities without a prior credit history for the purchase 
     of assistive technology.

6.   Provide incentives to manufacturers for low-interest loans, 
     below-market rate, for the purchase of assistive technology.

7.   Offer federal and state grants for start-up of revolving 
     loan programs.

8.   Offer additional incentives for employers to operate 
     accommodations programs for
     their employees, in conjunction with the ADA.  (Department 
     of Defense Model).

9.   Encourage tax check off programs at the federal level and in 
     every state to generate funds for the funding of assistive 
     technology.







Section Six:





Lending Practices of Financial Institutions




















NATIONAL COUNCIL ON DISABILITY


STUDY ON FINANCING OF ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES



Financing of Assistive Technology:
Lending Practices of Financial Institutions

by

John De Witt
David Colson

of

De Witt & Associates, Inc.
January, 1992

                FINANCING OF ASSISTIVE TECHNOLOGY:
            LENDING PRACTICES OF FINANCIAL INSTITUTIONS


TABLE OF CONTENTS


EXECUTIVE SUMMARY                                         - iii -

OBJECTIVE                                                  Page 1

METHODOLOGY                                                Page 2

RESULTS                                                    Page 5

   TRADE ASSOCIATION SURVEY                                Page 5

      Table 1: Trade Association Tabulations               Page 6

   LENDERS SURVEY                                          Page 7

      General Results                                      Page 7

         Specific Loan Programs Offered                    Page 9

            Secured Lending (other than auto or 
              mortgage) Page 9; Unsecured Loans  Page 9; 
            Mortgage Loans  Page 10; 
            Auto Loans  Page 10

         Table 2b: Respondents That Offer Secured Loans, 
           Other Than Auto or Mortgage                    Page 12

         Table 2c:  Respondents That Offer Secured Loans, 
           Auto and Mortgage                              Page 13

      Use of Cosigner/comaker in Lending Decision         Page 14

         Table 3: Use of Cosigner/comaker by Respondent   Page 16

      Acceptance of Mitigating Circumstances              Page 18

            Loan Applicant  Page 18; 
            Cosigner/comaker  Page 19

         Table 4: Mitigating Circumstances                Page 20


TABLE OF CONTENTS, continued


      Voluntary Comments                                  Page 22

            Governmental Regulations/Programs  Page 22;          
Miscellaneous Comments  Page 23

         Table 5a: Other Voluntary Comments, Government
            Regulations/Programs                          Page 25

         Table 5b: Other Voluntary Comments, 
           Miscellaneous                                  Page 26

      Tone of Interviews                                  Page 28

         Table 6: Tone of Interviews                      Page 28

   SURVEY OF SUPPLIERS OF CREDIT SCORING SYSTEMS          Page 29

CONCLUSIONS                                               Page 30

   TRADE ASSOCIATIONS                                     Page 30

   LENDERS SURVEY                                         Page 30

   SURVEY OF CREDIT SCORERS                               Page 34

SUGGESTIONS/SOLUTIONS                                     Page 36

APPENDIX A-1: Map of U.S. Census Regions and Divisions    Page 38

APPENDIX A-2: Chart of Institutions Contacted by Census 
  Region and Division                                     Page 39

APPENDIX A-3: List of Lenders Surveyed                    Page 43

APPENDIX B: LENDER QUESTIONNAIRE                          Page 46

APPENDIX C: List of Trade Associations and Credit 
  Scoring Systems                                         Page 52

ATTACHMENTS                                               Page 53



                FINANCING OF ASSISTIVE TECHNOLOGY:
            LENDING PRACTICES OF FINANCIAL INSTITUTIONS


Executive Summary

This report supplements information being collected and analyzed 
in conjunction with the National Council on Disability's study of 
the financing of assistive technology, as mandated by Title II of 
the Technology-Related Assistance Act of 1988.  De Witt & 
Associates surveyed a broad spectrum of financial institutions 
nationwide to develop a preliminary understanding of current 
lending practices toward individuals with disabilities.  
Additional interviews with the corresponding trade associations 
as well as suppliers of credit scoring systems provided further 
perspectives on the subject.

The research found a high degree of concern and sensitivity 
within this community to the issues involved.  Often, respondents 
voiced a willingness to act favorably on mitigating circumstances 
that may disqualify an individual with a disability for a loan to 
purchase assistive technology.  However, laws, regulations, rules 
or guidelines identified in this study can interfere with this 
process.  The lending standards, that seem so daunting when one 
seeks a loan, really comes down to two basic criteria.

     Will the loan be repaid?  

     Will the loan and/or the financial institution's portfolio 
      of loans meet the applicable laws and regulations that 
      govern that lender's operations?

The results of this study led to several important suggestions 
for both private and public initiatives:

1. Work with trade associations on joint efforts to make their 
   members aware of the needs of individuals with disabilities, 
   develop a dialog on avenues to meet these needs and establish 
   model programs that members can test within their own
   organizations.

2. Investigate creative approaches such as:  special lending 
   standards for needy individuals with disabilities; financing 
   programs that manufacturers of assistive technology devices 
   can use to facilitate device purchase; and loan guarantee 
   programs through cooperative initiatives with governmental 
   entities, disability-related organizations and the financial 
   community.

3. Thoroughly investigate laws, regulations and practices that 
   have been identified as potentially facilitating or inhibiting 
   the making of loans to individuals with disabilities.  For 
   those that facilitate the process, make sure that the 
   inclusion of those with disabilities is explicit.  For those 
   that inhibit the process, seek modifications to ease the 
   granting of such loans.

4. Establish educational programs for individuals with 
   disabilities to help them understand the lending process, its 
   nuances and vagaries, and what they must do to maximize their 
   chances of being approved for the loan they require.

Implementation of these suggestions will produce a set of 
well-developed options for special broad-based lending 
initiatives to finance assistive technology devices.
                FINANCING OF ASSISTIVE TECHNOLOGY:
            LENDING PRACTICES OF FINANCIAL INSTITUTIONS


  I.Objective

This report is designed to supplement information being collected 
and analyzed in conjunction with the National Council on 
Disability's study of the financing of assistive technology, as 
mandated by Title II of the Technology-Related Assistance Act of 
1988.  De Witt & Associates has designed and conducted a 
"mini-study" to develop a preliminary understanding of lending 
practices regarding funding of assistive technology devices for 
individuals with disabilities, primarily through a survey of over 
fifty financial institutions nationwide.

Among the specific objectives of the survey were:

     to ascertain factors that facilitate or inhibit the 
      application for, obtaining of and repayment of loans by 
      individuals with disabilities for the acquisition of 
      assistive technology;

     to cover as broad a spectrum of financial institutions as 
      practicable, both in terms of type and size, as well as 
      geographic locale;

     to obtain information of both a quantitative and 
      qualitative nature from executives with responsibilities 
      for policymaking or interpretation.
 II.Methodology

A telephone survey was chosen because this technique yields a 
higher response rate than a written survey.  The survey 
instrument was designed with extensive open-ended questions to 
develop the maximum amount of information, even though this 
design makes quantitative analysis more difficult.  This was 
important because many responses could not be anticipated.  In 
the context of the study's fundamental purpose, to learn about 
policies and practices that facilitate or inhibit the financing 
of assistive technology to individuals with disabilities, 
quantitative analysis is essential.

The types of loans that an individual with a disability might 
consider for funding an assistive technology device are:

     Secured loans:     with the assistive technology device as 
                         collateral.

     Unsecured loans:   including installment loans, unsecured 
                         lines of credit, term loans, credit 
                         cards, etc.

     Mortgage loans:    home equity loans or the possibility of 
                         "cash-out refinancings."

     Auto loans:        funding specifically for a modified 
                         automobile or van.

Because banks, savings & loans and credit unions could 
potentially supply any of these kinds of financing, they 
constituted a major focus of the work.  Additionally, De Witt & 
Associates surveyed lenders specific to the mortgage market: 
mortgage companies; mortgage brokers; and the mortgage operations 
of insurance companies.  Similarly for the auto industry, 
financing subsidiaries of auto makers were also included.

Financing by manufacturers of assistive technology devices was
specifically excluded because:

     these manufacturers generally are small with limited 
      financial resources; thus, few are in a position to 
      undertake loan programs;

     extending the survey to adequately sample those few 
      manufacturers of assistive technology with loan programs 
      would have been beyond the primary focus of this 
      mini-study.

Using the parameters described above, De Witt & Associates 
developed a contact list of 57 financial institutions to survey:

     Banks/Savings & Loans:  a "large" and a "small" institution 
                              of each type from each of nine U.S. 
                              Department of Commerce Bureau of 
                              the Census divisions, producing a 
                              list of 36 institutions.

     Credit Unions:          equal numbers of "large and "small" 
                              credit unions from each of the four 
                              U.S. Department of Commerce Bureau 
                              of Census regions, adding eight 
                              more institutions.

     Mortgage Lenders:       five firms representing brokers, 
                              companies or subsidiaries of 
                              insurance companies.

     Finance Companies:      three major general purpose finance 
                              companies and two financing 
                              subsidiaries of major auto makers.

     Credit Card Companies:  Two major non-bank credit card 
                              issuers and the credit card 
                              operations of one major bank.

Additional considerations in choosing contacts for the survey 
were: to balance metropolitan and rural areas; and to include a 
broad representation of states.

Appendix A provides a map of the U.S Department of Commerce 
Bureau of Census regions and divisions; a table describing the 
geographic location of contacted lenders by city/state and Census 
division/region; and the names of lenders contacted.

In preparation for the survey, De Witt & Associates interviewed 
an extensive selection of trade associations that represent 
various components of the consumer finance industry.  As an 
additional facet of the study, three major suppliers of credit 
scoring services were interviewed to develop an understanding of 
how these systems may impact the borrowing capabilities of 
individuals with disabilities.  Appendix B provides the list of 
trade associations contacted and the names of the three principal 
firms engaged in credit scoring systems.

Appendix C provides the survey instrument, as modified based upon 
interview experience.  While this instrument appears highly 
structured, all judgmental areas on the part of the responding 
firm were asked in an open-ended style; voluntary comments were 
encouraged.


III.Results

A. Trade Association Survey

Ten of the thirteen trade associations contacted for this study 
provided interviews.  (See Table 1 on page 6.)  Most respondents 
(70%) recognized the responsibilities of their members in the 
context of provisions of the Americans with Disabilities Act 
(ADA).  Half of those interviewed had programs in place to 
disseminate information about member responsibilities under the 
Act.

Respondents showed a high level of recognition and commitment 
towards overcoming the architectural barriers posed to 
individuals with disabilities.  Conversely, most demonstrated a 
low level of recognition towards meeting the needs of individuals 
with disabilities for access to loans to fund the purchase of 
assistive technology.  Despite this, two have disseminated 
materials to members to promote the understanding of the 
borrowing needs of those with disabilities.[**]  However, none of 
the associations had programs to collect data from members 
regarding member performance in lending to individuals with 
disabilities.

In fact, only a minority of the respondents (20%) mentioned, as 
voluntary responses, the equal access/nondiscrimination 
provisions of the Equal Credit Opportunity Act (ECOA) as applying 
to individuals with disabilities.  Other voluntary comments 
regarding governmental regulation were one mention of member 
financing of building modifications to meet guidelines of the 
Department of Housing & Urban Development (HUD) for access to 
multifamily units; and one mention of concern about adverse 
rulings by bank examiners regarding new or innovative programs to 
meet special needs of individuals with disabilities for loans.


TABLE 1:    TRADE ASSOCIATION TABULATIONS


                                                Number        % 
of
                                               Reporting      
Base

TRADE ASSOCIATIONS CONTACTED (base = 13)

  Respondents:                                      10           
77
  Unreachable:                                       2           
                 15
  Disbanding:                                        1            
                 8
  Total                                             13          
100

ASSOCIATION RESPONSE REGARDING LENDING TO 
INDIVIDUALS WITH DISABILITIES (base = 10)

  Specific information about qualifying/lending:     0            
0
  Generic ECOA/nondiscrimination:                    3           
30
  ADA recognition:                                   7           
                      70
       Information/program:                              5    50
  Miscellaneous information:[***]                    1           
                                10
  None/don't know:                                   3           
                      30
  Total (>base/100% due to multiple responses):          14     
140

OBTAIN DATA FROM MEMBERS REGARDING LENDING TO 
INDIVIDUALS WITH DISABILITIES (base = 10)

  Yes:                                               0            
0
  No:                                               10          
100

TONE OF INTERVIEW (base = 10)

  Concerned/sensitive:                               7           
70
  Matter-of-fact:                                    3           
30
  Total:                                            10          
100

OTHER GOVERNMENTAL REGULATION COMMENTS  
(base = 10)

  Positive:                                          3           
30
       ECOA:                                      2           20  
       HUD accessibility:                         1           10

  Negative:                                          1           
10
       Bank examiners:                            1           10   
  Total:                                             4           
40


B. LENDERS SURVEY

1. General Results

De Witt & Associates were successful in obtaining a 90% response 
rate to the survey.  51 of the 57 financial institutions 
contacted provided interviews regarding their lending practices 
toward individuals with disabilities.  (See Table 2a on page 8.)  
None of the respondents indicated that their firms code loan 
applications to provide a basis for statistical analysis to judge 
performance regarding lending to individuals with disabilities.  
In fact, a couple of respondents questioned whether such coding 
was legal.

The majority of respondents (94%) indicated no specific written 
policies for their firms' lending practices towards individuals 
with disabilities.  A large minority of respondents (31%) 
indicated that they had generic policies dealing with 
nondiscrimination or meeting ECOA regulations that included 
individuals with disabilities.  Notably, a small minority of 
respondents (6%) were able to respond that their firms had such 
policies in place.

For the firms with no specific policies in place, the most common 
responses regarding their experience with such lending were:

     don't know of a problem or don't track (40%).
     want to make such loans (40%);
     statement of policy (40%): 
      -   not to discriminate;
      -   all loan applicants must meet the same lending 
          standards;

A sizable minority (about 20%) expressed their experience as 
requiring only:

     a demonstration of ability to repay loan;
     that loan applicants be credit worthy or qualified.
TABLE 2a:   FINANCIAL INSTITUTIONS CONTACTED

                                                Number        % 
of
                                               Reporting      
Base

FINANCIAL INSTITUTIONS CONTACTED (base = 57)

  Respondents:                                      51         90
  Uncooperative:                                     3          5
  Miscellaneous (commercial lender, 
    receivership, etc.):                             3          5
  Total                                             57        100

RESPONDENTS THAT CODE APPLICATIONS (base = 51)

  Code for disability:                               0          0
  Do not code:                                      50         98
  Do not know:                                       1          2
  Total:                                            51        100

RESPONDENTS THAT HAVE WRITTEN POLICIES FOR LOANS
TO INDIVIDUALS WITH DISABILITIEs (base = 51)

  Specific policies:                                 3          6
  Generic policies (ECOA/Nondiscrimination):        16         31
  No special policies:                              30         59
  Do not know:                                       2          4
  Total:                                            51        100

EXPERIENCE OF THOSE WITHOUT SPECIFIC POLICIES 
(base = 48)

  None/Don't know of problem/Don't track:           19         40
  Want to make such loans:                          19         40
  Desire to do "right thing":                        2          4
  Case-by-case review:                               5         10
  Don't discriminate/Same standards for all:        19         40
  Ability to repay:                                 10         21
  Credit worthy/Qualified:                           9         19
  No response:                                       6         12
  Total (>base/100% due to multiple responses)      89        186

2. SPECIFIC LOAN PROGRAMS OFFERED

   a. Secured Lending (other than auto or mortgage)

   Among lending institutions offering secured loans on assets 
   other than real estate or automobiles, large pluralities (42%) 
   either:

     affirmed that they would accept an assistive technology 
      device as collateral; or
     did not know.

   Only a minority of respondents indicated that assistive 
   technology devices would not be acceptable as security.  (See 
   Table 2b on page 12.)

   Regardless of response, a number of problems in accepting the 
   assistive technology devices as security were mentioned.  A 
   quarter of the respondents were concerned about valuation or 
   resale.  Small minorities mentioned the difficulty of 
   repossessing something so important (8%) or non-liquidity 
   (5%).  The latter preferred passbooks, certificates of deposit 
   or securities as collateral.

   b. Unsecured Loans

   All respondents that offer unsecured lending would be willing 
   to know that the funds were being utilized for assistive 
   technology.  (See Table 2b on page 12.)  In fact, many 
   respondents that offer both secured and unsecured loans 
   expressed a definite preference for making such loans on an 
   unsecured basis rather than as a secured loan with an 
   assistive technology device as collateral.

   The dollar range of loans on an unsecured basis was quite 
   broad.  A large majority (82%) of lenders offer such loans 
   (including lines of credit) beginning under $1,000.  Although 
   a large minority (41%) of lenders restricted the maximum on
   such loans to less than $5,000, the majority (59%) appeared to 
   offer higher limits with important minorities (35% and 24% 
   respectively) offering either unspecified upper limits or 
   upper limits in the range of $5,000-$20,000.

   c. Mortgage Loans

   All mortgage lenders that offer home equity loans (86%) or 
   "cash-out refinancings" (9%) had no problem with the proceeds 
   of such loans being used for the purchase of assistive 
   technology.  (See Table 2b on page 12.)  However, in Texas (5% 
   of total survey respondents), the use of mortgage financing 
   proceeds is restricted to:  purchase of property by way of a 
   first mortgage; refinancing the balance owed on the 1st 
   mortgage; or home equity loans solely for home improvements or 
   payment of taxes.

   d. Auto Loans

   A majority (62%) of lenders that finance automobiles would 
   treat a loan on a vehicle modified to meet the needs of an 
   individual with a disability the same as any other auto loan.  
   (See Table 2c on page 13.)  A small minority (11%) did not 
   know how their firm would treat such a loan.

   However, an important minority (27%) would treat such a 
   vehicle as a specialty item.  Such a designation is not 
   necessarily good nor bad:

   In some cases, such a designation means nothing more than the 
   obvious; the vehicle is different than one of similar make and 
   model.  Some lenders, in fact, may include all conversion vans 
   in such a category.

   In a very limited number of cases, such a designation may 
   connote a special loan program to the advantage of the
   borrower.[****]

   In the remainder of cases, such a designation can connote the 
   requirement for a higher down payment or a reduced lending 
   limit to reflect a feeling that the full vehicle cost 
   including the added costs of the modifications may be less 
   than market value for the modified vehicle.

TABLE 2b:   RESPONDENTS THAT OFFER SECURED LOANS, OTHER THAN AUTO 
            OR MORTGAGE

                                                Number        % 
of
                                               Reporting      
Base

RESPONDENTS THAT OFFER SECURED LOANS, OTHER 
THAN AUTO OR MORTGAGE (base = 36)

  Accept assistive technology device as security?

       Yes:                                         15         42
       No:                                           6         17
       Don't know:                                  15         42
       Total:                                       36        101

PROBLEMS VOLUNTARILY REPORTED BY RESPONDENTS

  Resale/Valuation problem:                          9         25
  Repossession problem:                              3          8
  Non-liquid (prefer passbooks/CDs/Securities):      2          5
  Total reporting problems:                         14         38

RESPONDENTS THAT OFFER UNSECURED LOANS (base = 36)

  Would fund assistive technology devices:          36        100
  Would not fund assistive technology devices:       0          0
  Total                                             36        100

REPORTED DOLLAR RANGES ON UNSECURED LENDING 
(base = 17)

  Minimum Loan        Number     %     Maximum Loan    Number  % 
ó $1,000                14       82  ó $5,000             7    41
> $1,000 -  5,000        3       18  > $5,000 - 20,000    4    24
> $5,000                 0        0    Unspecified        6    35
Total                   17      100                      17   100

                                                Number        % 
of
                                               Reporting      
Base

MAKE MORTGAGE LOANS (base = 42)

  Unrestricted use of proceeds:                     40         95
       Home equity:                              36        86
       1st mortgages/Cash-out refinancings:       4         9
  Restricted use of proceeds:
    Home equity loans (home improvements or
    taxes); 1st mortgage; cash-out
    refinancings (remaining balance only):           2          5
  Total:                                            42        100
TABLE 2c:   RESPONDENTS THAT OFFER SECURED LOANS, AUTO AND 
            MORTGAGE


                                                Number        % 
of
                                               Reporting      
Base

MAKE AUTO LOANS (base = 37)

  Modified vehicle treated conventionally:          23         62
  Specialty vehicle/Program:                        10         27
  Do not know:                                       4         11
  Total                                             37        100

PROBLEMS VOLUNTARILY REPORTED BY RESPONDENTS

  Resale problem:                                    1          3
  Reluctance to repossess:                           1          3
  Total reporting problems:                          2          6


3. USE OF COSIGNER/COMAKER IN LENDING DECISION

An overwhelming majority (94%) of lenders will accept or require 
a cosigner/comaker under at least some set of 
circumstances.[*****]  Data presented in Table 3 (pages 16-17) 
and reported below include many reasons why lenders "accept" or 
do "not accept" a cosigner.  The total number of reasons often 
exceeds 100%.  Different lenders may name the same reason but 
apply it to different categories.  For example, "inadequate 
income" may be a reason to use a cosigner at one lender; but be 
the same reason at a different lender not to accept a cosigner.  
Note the duplicated reasons in Table 3 under "ACCEPT/REQUIRE" and 
"NOT ACCEPT."[******]

Thus, an important minority (27%) of lenders will accept or 
require a cosigner under one set of circumstances but reject it 
under another.  A smaller minority (18%) of lenders indicated 
their institutions would accept a cosigner.  However, they did 
not list specific criteria.

The most frequent reasons (45% each) for accepting cosigners were 
for "not meeting credit standards" and "not meeting income 
standards."  Of the latter, some respondents (14% and 27% 
respectively) offered more specific reasons:  "lack of employment 
history" and/or "inadequate income to repay the debt."  Other 
reasons for accepting cosigners (about 15% each) included 
"case-by-case evaluation of the situation," "poor credit 
history," "inadequate collateral" or "low net worth."  Three 
respondents would only accept family members as a cosigner, of 
which one required the individual to be a parent.

Thirty-one percent of the respondents indicated a reluctance to 
accept cosigners.  (See continuation of Table 3 on page 17.)  
Reasons for not accepting cosigners included "poor credit 
history" (15%) and "inadequate income" (15%).  The next most
frequent reason (8%) was "a cosigner that could not qualify."  
"Lack of collateral" and "lack of income" received only one 
mention each.

Only two lenders (4%) categorically reject the use of a cosigner.  
One lender would not respond to the cosigner question.

At least one respondent seemed to differentiate between the 
statement "they required a cosigner to make a loan" versus "they 
would accept a cosigner as part of the loan package."  Many 
respondents seemed to differentiate between "cosigner" and 
"comaker."


TABLE 3:    USE OF COSIGNER/COMAKER BY RESPONDENT

                                                Number        % 
of
                                               Reporting      
Base

USE OF COSIGNER/COMAKER BY RESPONDENT
(base = 51)

  ACCEPT/REQUIRE:                                   48         94

       REASONS TO (voluntary responses)

       Unqualified (no specified reasons):        9        18
       Case-by-case:                              6        12 
       Credit standards not met:                 23        45
       Lack of credit history:                   14        27
       Poor credit history:                       7        14

            Late payments:                      1        2
            Delinquencies/Charge-offs:          0        0
            Adverse public record:              1        0

                 Liens:                       0        0 
                 Judgements:                  0        0 
                 Bankruptcies:                1        2 

       Income standards not met:                 23        45

            Employment history:                 7       14
            Inadequate income (to repay):      14       27

       Inadequate collateral/Too much debt:       8        18
       If family member/Parent:                   3         6
       Miscellaneous reasons for:[*******]             6        
12
       Total reasons to accept/Require:          99       197


TABLE 3:    USE OF COSIGNER/COMAKER BY RESPONDENT, CONTINUED

                                                Number        % 
of
                                               Reporting      
Base

USE OF COSIGNER/COMAKER BY RESPONDENT, CONTINUED
(base = 51)

  NOT ACCEPT:                                       16         31

       REASONS NOT TO (voluntary responses)

       Categorically (no specified reasons):      2         4
       Poor credit history:                       6        12

            Delinquencies/Charge-offs:            1         2

       Inadequate income:                         8        16
       Inadequate collateral:                     1         2
       Unqualified applicant:                     1         2
       Unqualified cosigner:                      4         8
       Total reasons not to accept:              22        46

  NO RESPONSE:                                       1          2
  TOTALS (include items from page 16):[********]         65   127
4. ACCEPTANCE OF MITIGATING CIRCUMSTANCES

   a. Loan Applicant

   Acceptance of mitigating circumstances in qualifying 
   individuals with disabilities for loans was high (84%).  Note 
   that, on average, about two reasons were given per respondent 
   (85 responses from 43 respondents).  (See Table 4 on page 20.)

   The most frequent reasons (45% each) for accepting mitigating 
   circumstances were:

     the backup of well-documented explanations for any credit 
      or income problems, directly keyed to circumstances 
      surrounding the disability; and
     a conviction on the part of the lending officer that the 
      applicant would be able to repay the loan.

   The next most frequent reason (29%) for accepting mitigating 
   circumstances was:

     a case-by-case evaluation or as an exception to the 
      standard policy.

   The least frequently occurring reasons (about 15% each) were:

     good collateral;
     the presence of a cosigner; or
     a desire to help ("lending with one's heart instead of 
      going strictly by the numbers").

   Outright rejection of mitigating circumstances was low (12%).  
   A few respondents that accept mitigating circumstances (6%) 
   cited two which they would not accept:  "lack of employment" 
   and/or "bad credit" in such forms as write-offs or 
   bankruptcies.  Two respondents did not know if their firm 
   would accept mitigating circumstances.

   b. Cosigner/comaker

   Acceptance of mitigating circumstances for cosigners was high 
   (75%) though not as high as the level noted for primary 
   applicants.  Again, note that, on average, almost two reasons 
   were given (63 responses from 33 respondents).  (See Table 4 
   on page 21.)

   The most frequent reason (48%) for acceptance of cosigner 
   mitigating circumstances was:

     a good outlook for repayment.

   Next in popularity (39% each) were:

     well-documented explanations;
     a case-by-case evaluation; or
     an exception to the standard policies.

   As with the direct applicant, only a minority (18%) of 
   respondents indicated a reason:

     desire to help ("lending with one's heart instead of going 
      strictly by the numbers").

   Outright rejection of cosigner mitigating circumstances was 
   similarly low (11%).  The number of executives not knowing 
   their firms' position on the issue was higher (14%).


TABLE 4:  MITIGATING CIRCUMSTANCES


                                                Number        % 
of
                                               Reporting      
Base

MITIGATING CIRCUMSTANCES (base = 51)

APPLICANT (base = 51)

  ACCEPT:                                           43         84

       REASONS TO (voluntary responses)

       With well-documented explanations:        23        45
       With good outlook for repayment:          23        45
       With good collateral:                      7        14
       Only with cosigner/Comaker                 8        16
       Heart vs head/Want to help:                9        18
       Case-by-case/Exception basis:             15        29
       Total reasons to accept:                  85       167


  NOT ACCEPT:                                        9         18

       REASONS NOT TO (voluntary responses)

       Categorically (no specified reason):       6        12
       Bad credit/Write-off/Bankruptcy:           2         4
       Lack of employment:                        1         2
       Reasons not to accept:                          9        
18

  DO NOT KNOW:                                       2     4
  TOTALS:[*********]                                     54   106


TABLE 4:  MITIGATING CIRCUMSTANCES, CONTINUED


                                                Number        % 
of
                                               Reporting      
Base

MITIGATING CIRCUMSTANCES, CONTINUED
(base = 51)

COSIGNER (base = 44)[*********]

  ACCEPT:                                           33         75

       REASONS TO (voluntary responses)
       With well-documented explanations:        17        39
       With good outlook for repayment:          21        48
       Want to help:                              8        18
       Case-by-case/Exception basis:             17        39
       Total reasons to                          63       144

  NOT ACCEPT (categorically):                        5         11
  DO NOT KNOW                                        6         14
  TOTALS:                                           44        100


5. VOLUNTARY COMMENTS

   a. Governmental Regulations/Programs

   Both positive and negative comments were offered regarding 
   government programs or regulations and their effects on 
   lending to individuals with disabilities.  (See Table 5a on 
   page 25.)  

   The Federal National Mortgage Association (Fannie Mae) and the 
   Federal Home Loan Mortgage Corporation (Freddie Mac), 
   quasi-government agencies that bundle mortgages for sale in 
   the secondary market, garnered within themselves both positive 
   and negative references (4% versus 20%).  The negative 
   responses were for lack of flexibility in adjusting lending 
   standards to meet the needs of borrowers with disabilities.  
   The positive comments, one each, were for: the effects the 
   Fannie Mae/Freddie Mac operations have had on keeping interest 
   rates on home mortgages lower than they would otherwise be; 
   and, their opening the secondary market to affordable housing.

   By far, the governmental program receiving the most favorable 
   comments (37%) was the Equal Credit Opportunity Act and its 
   requirements for nondiscrimination.  The only other 
   governmental regulations receiving favorable mentions (6%) was 
   the Community Reinvestment Act for its provisions to reinvest 
   funds in the community local to the lender.  Only one mention 
   of a state program to help individuals with disabilities with 
   the purchase of assistive technology devices was made by a 
   respondent.  This is a program called ABLE in North Dakota 
   which has special qualification provisions and a reduced 
   interest rate on the loan.[*********]


   Other government agencies or regulators that received negative 
   comments for their lack of flexibility were:

     bank examiners (8%)
     one mention each (2%) for:
      -   the Federal Deposit Insurance Corporation (FDIC); 
      -   auditors; and 
      -   the Office of Thrift Supervision (OTS).

   Lastly, a state law in Texas with two mentions deserves 
   special comment.  In that state, home equity loans are illegal 
   except for home improvements or the payment of taxes.  
   Similarly, first mortgages can be made only for the purchase 
   of the residence, and refinancings are allowed only for the 
   unpaid balance remaining on the mortgage.

   b. Miscellaneous Comments

   Positive miscellaneous comments out weighed negative comment 
   by three to one (32% versus 10%).  (See Table 5b on page 26.)

   The most frequently mentioned positive comment was by a small 
   number of financial institutions (14%) that mentioned their 
   flexibility in applying lending standards.  Some (7%) of these 
   attributed this flexibility to the fact that they hold their 
   own mortgages rather than sell them in the secondary market.  
   A few lenders (6%) noted that they are in the business to make 
   loans (not reject applications).

   Two lenders (4%) have special programs for rejected 
   applicants.  One has an appeals process that is totally 
   separate from the financial institution to preclude any form 
   of internal bias.  The other offers credit counselling 
   including a copy of the individuals credit report and help in 
   understanding it.

   Four lenders (8%) provide special programs for individuals 
   with disabilities.  In general, these programs provide relaxed
   loan qualification criteria.  In addition, one offers a 
   discounted loan rate and waives late fees.  Another (by an 
   auto maker) offers a credit of up to $1,000 on vehicle 
   modifications to meet the needs of the individual with a 
   disability and will make the loan against the full cost of the 
   vehicle, including the cost of the modifications.

   As indicated above, miscellaneous negative comments were low.  
   Two respondents (4%) mentioned that even though lending 
   officers in their institutions have flexibility in applying 
   standards to make loans where mitigating circumstances exist, 
   they could not be certain that this authority was, in fact, 
   exercised.  

   Only two other negative miscellaneous comments occurred, one 
   each (2%).  The first was an house appraisal problem where the 
   appraiser lower the appraisal because of the accessibility 
   modifications made to the home.  However, the lender was able 
   to make the loan anyway.  The other involved credit scoring 
   and how impersonal it is; if the score isn't high enough, the 
   loan is not made.


TABLE 5a:   OTHER VOLUNTARY COMMENTS, GOVERNMENT 
            REGULATIONS/PROGRAMS


                                                Number        % 
of
                                               Reporting      
Base

OTHER VOLUNTARY COMMENTS (base = 51)

  GOVERNMENT REGULATIONS/PROGRAMS

       Positive comments:                           25         49

            Fannie Mae/Freddie Mac:[*********]    2         4
            Community Reinvestment Act:           3         6
            ECOA/Nondiscrimination:              19        37
            Special state program:[*********]          1         
2

       Negative - Lack of flexibility:              19         37

            Fannie Mae/Freddie Mac:              10        20
            State bank examiners:                 4         8
            Other regulators:[*********]               3         
6
            State law:[*********]                      2         
4

       Suggestions:[*]                               2          4
       Total:                                       46         90


TABLE 5b:   OTHER VOLUNTARY COMMENTS, MISCELLANEOUS


                                                Number        % 
of
                                               Reporting      
Base

OTHER VOLUNTARY COMMENTS, CONTINUED
(base = 51)

  MISCELLANEOUS COMMENTS

  Positive:                                    16         32

  Flexible lending standards:                  7           14

  Holds own mortgages:                         3         6

  Special lender programs:[*]                  4            8
  In business to make loans:                   3            6
Appeals for rejected applicants:[**]            2           4

TABLE 5b:  LENDING INSTITUTION SURVEY TABULATIONS, CONTINUED


                                                Number        % 
of
                                               Reporting      
Base

OTHER VOLUNTARY COMMENTS, CONTINUED
(base = 51)

  MISCELLANEOUS COMMENTS, CONTINUED

       Negative:                                     5         10

            House appraisal lowered:[***]         1         2
            Credit scoring:                       1         2
            Not known if exception
              authority used:                     2         4
            Repossession no alternate 
              to repayment:[****]                 1         2
       Total:                                       21         42


6. TONE OF INTERVIEWS

De Witt & Associates attempted to assess the tone of each 
interview.  This was an entirely subjective assessment and can be 
influenced by the:

     biases of the interviewer; 
     acting ability of the respondent; 
     respondents assessment of the "proper" response; 
     interaction between the interviewer and the respondent;
     pressures of the work environment proximate to the conduct 
      of the interview; and
     operational knowledge of the respondent.

Having said this, De Witt & Associates found a high level (57%) 
of concern and sensitivity to the issues and needs of individuals 
with disabilities.  An important minority (33%) seemed 
matter-of-fact or insensitive.  In two cases, the respondent 
merely seemed to be providing the politically correct answers to 
the questions.  In three interviews (6%), De Witt & Associates 
could make no assessment.

TABLE 6:    TONE OF INTERVIEWS


                                                Number        % 
of
                                               Reporting      
Base

TONE OF INTERVIEW (base = 51)

       Concerned/Sensitive:                         29         57
       Matter-of-fact:                              17         33
       Politically correct:                          2          4
       Undecided:                                    3          6
       Total                                        51        100


C. SURVEY OF SUPPLIERS OF CREDIT SCORING SYSTEMS

Every consumer has a legal right to insert a "consumer statement" 
into his/her credit report to provide credit grantors with 
information relevant to specific components of the report.  Often 
such consumer statements address:

     disputes between the consumer and a credit grantor; 
     the consumer's belief that an adverse rating is in error; 
      or
     a consumer's inability to obtain a satisfactory revision to 
      the rating.

The consumer statement provides the consumer with the opportunity 
to tell his/her side of the story and have it appear every time 
his/her credit report is drawn.  For individuals with 
disabilities, this consumer statement is a means by which they 
can make sure that lenders know of any mitigating circumstances 
related to their disabilities surrounding derogatory information 
in their credit reports.

However, when a financial institution uses credit scoring, the 
loan officer need not necessarily ever draw a credit report or 
look at it; the decision could be made based upon the credit 
score.  To develop some insight on how credit scoring systems 
handle consumer statements, De Witt & Associates contacted three 
major suppliers of these systems.

     In two of the three systems, the software ignores the 
      consumer statement and reports a score as if no statement 
      were present.  A credit officer would be unaware of an 
      existing statement unless the full report were to be drawn.

     In the third system, the software recognizes the presence 
      of a consumer statement and reports no score, forcing the 
      lending officer to draw the credit report and review it to 
      make a decision.



 IV.Conclusions

A. TRADE ASSOCIATIONS

1. The trade associations that serve lenders are not aware of the 
   Technology-related Assistance Act of 1988.  Rather, they are 
   focusing attention on the Americans with Disabilities Act of 
   1990.  They seem to be interpreting the provisions of this law 
   and/or the Equal Credit Opportunity Act as requiring 
   nondiscrimination and/or equal access/opportunity for 
   individuals with disabilities to obtain credit on the same 
   basis as any other potential credit applicant.

2. Although the trade associations are aware of no obligations of 
   their members to make any special accommodations beyond the 
   provisions of these acts, many seemed concerned and sensitive 
   to the issues involved.  De Witt & Associates believes that at 
   least some of these associations may be willing to support or 
   sponsor programs with their members to foster increased 
   lending opportunities for individuals with disabilities for 
   purchase of assistive technology.

B. LENDERS SURVEY

1. A majority of the interviews elicited responses that suggested 
   that lenders were concerned or sensitive to the issues 
   involved.  In fact, a very small minority of financial 
   institutions indicated that they actually had specific written 
   policies in place to address lending to individuals with 
   disabilities.  However, because lenders do not collect data 
   that would define the extent of such lending, the research 
   could not gage the extent to which such sensitivity actually 
   permeates the lending process.


2. All four forms of lending studied in this research are broadly 
   available to individuals with disabilities, including:

     secured loans with an assistive technology device as 
      collateral;
     unsecured loans;
     mortgage loans, home equity or cash-out refinancings; and 
     auto loans to purchase a modified vehicle.

3. The lending standards, that seem so daunting when one seeks a 
   loan, really come down to two basic criteria:

     Will the loan be repaid?
     Will the loan and/or the financial institution's portfolio 
      of loans meet the applicable laws and regulations that 
      govern that lender's operations?

4. The essential message is:

     Lenders want to make any loan that will be repaid, but 
      regulations often limit what they can do.  
     Conversely: regardless of whether a loan meets the 
      regulations; or whether the loan is secured by an asset, a 
      good lender does not wish to make the loan unless one is 
      confident of repayment.

5. Lending standards are merely the imperfect tools which have 
   been developed as an attempt to establish, on a somewhat 
   routine, reliable basis, that the above criteria are met.  
   They are certainly not consistent from one institution to 
   another, attested to by the situation regarding cosigners.  
   For example, 14 institutions gave "inadequate income" to repay 
   as a reason to accept/require a cosigner while eight other 
   institutions gave the very same reason not to accept a 
   cosigner.


6. Security or collateral, except possibly in the form of a 
   near-cash asset, does not really alter the criteria above.  It 
   just limits the lender's down-side risk.  Repossession 
   constitutes a last resort that can often represent a loss of 
   principal, because the pay-down on the loan may be slower than 
   the loss of market value due to: more rapid obsolescence, 
   depreciation; or some other component of market value.  
   Repossession also can be costly in terms of direct lender 
   efforts and expenses to recover the asset.

7. Financial institutions have considerable latitude in their 
   application and interpretation of their lending standards so 
   long as the two prime criteria listed above are met.  However, 
   the desire to exercise such latitude for the benefit of 
   individuals with disabilities varies greatly between 
   institutions.  Even within an institution that provides broad 
   flexibility in applying lending standards or accepting 
   mitigating circumstances, the utilization of such flexibility 
   may vary between lending officers or require the approval of a 
   senior officer or even a management committee.

8. In addition, especially among large financial institutions, 
   the lending officer may not be aware of the applicant's (or 
   family member's) disability.  The officer may have no way to 
   judge the impact that disability may have on the applicant's 
   ability to meet normal loan qualification standards.

9. Several laws/regulations were mentioned as hindering or 
   helping the efforts of financial institutions as they seek to 
   meet the borrowing needs of individuals with disabilities in 
   obtaining assistive technology.  This research could not 
   determine the extent to which these laws/regulations actually 
   apply to individuals with disabilities:

     as written;
     as implemented by the regulators;
     as interpreted by the courts; or 
     as perceived by lenders.

   For example:

     the Community Reinvestment act was specifically mentioned 
      as helping legislation by three respondents, but another 
      did not believe it applied;

     the stringent underwriting guidelines of Freddie Mac were 
      highlighted in a recent study by the Federal Reserve 
      Board.[*****]  This has reportedly resulted in a relaxation 
      of some of Freddie Mac's rules.

C. SURVEY OF CREDIT SCORERS

1. Credit scoring can be a quick, reliable, and objective means 
   to gage large numbers of applications readily against a fixed 
   set of lending standards.

2. However, it is highly impersonal.  From the consumer's point 
   of view, credit scoring suffers from two problems:

     The GIGO (Garbage In, Garbage Out) principal is alive and 
      well with respect to credit reporting.  The horrendous 
      errors that sometimes occur in the reporting of consumer 
      credit has been widely documented in the business, trade 
      and lay press.  With credit scoring, these errors are 
      automatically and efficiently bundled into the loan 
      applicant's credit score.

     Two of the three systems surveyed in this study provide 
      scores regardless of consumer comments entered into the 
      credit report to explain circumstances surrounding 
      derogatory information contained in it.  Thus, a poor score 
      would be reported and the loan potentially denied based 
      upon incomplete information.

3. The third system provides no score where a report contains a 
   consumer comment, requiring that the credit report actually be 
   drawn and reviewed to arrive at a credit decision.

4. Individuals must review their credit reports before beginning 
   the credit application process.  This is essential to assure 
   that, on the initial credit review, all of the data that the 
   institution may consult provides a fair introduction to the 
   applicants' true situation.  Errors should be corrected and 
   consumer statements added, as appropriate, to explain any 
   derogatory information related to a disability.

   All three national credit repositories need to be checked - 
   TRW, CBI and TransUnion.  This is because each develops its 
   data independently.  Correcting an error on one will have no 
   effect on the same error reported by another repository.  
   Similarly, adding a consumer statement to one will have no 
   effect on the other two.


  V.Suggestions/Solutions

1. Work with trade associations on joint efforts to:

     make their members aware of the needs of individuals with 
      disabilities;

     develop a dialog among members on avenues to meet these 
      needs; and 

     suggest and institute model programs that members could 
      test within their own organizations.

2.    Investigate creative approaches such as:

     establish special lending standards for needy individuals 
      with disabilities;

     work with banks and manufacturers of assistive technology 
      devices to develop financing programs so that the 
      manufacturers can offer such an option directly to their 
      customers.

     establish among the various disability-related 
      organizations, a fund of unused cash or near-cash assets 
      that could be loaned to those with disabilities as 
      collateral for a loan - essentially a loan guarantee fund.

     seek Federal or state programs to:

      -   supply collateral; 
      -   guarantee loans; or 
      -   purchase loans on behalf of individuals with 
          disabilities.


3. Have legal counsel thoroughly investigate all laws and 
   regulations that have been identified as potentially 
   facilitating or inhibiting the making of loans to individuals 
   with disabilities.

     For those that facilitate the process, make sure that the 
      inclusion of those with disabilities is explicit.

     For those that inhibit the process, seek modifications in 
      the laws, regulations or practices to ease the granting of 
      such loans.

4. Establish programs for individuals with disabilities to help 
   them understand the lending process and what they must do to 
   make sure that their application is considered properly, such 
   as:

     Review your credit report, correct errors and insert a 
      consumer statement as appropriate.

     If rejected, find out why and make sure that the lender 
      knows of the disability and any mitigating circumstances 
      surrounding it.

     Request a review at higher levels within the lender 
      organization.

     Apply to different lenders since internal standards vary.


APPENDIX A-1:  Map of U.S. Census Regions and Divisions




APPENDIX A-2:   Chart of Institutions Contacted by Census Region 
                and Division

     UNITED STATES CENSUS
      REGIONS & DIVISIONS                  Banks
                                  Large       Small                 Savings & Loan
                                                               La
                                                            rge      
                                                            Small                         
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                              Credit
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                              Unions     
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                            Mortgage
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                            Companies   
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                            Finance
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                           Companies

NORTHEAST

     New England

                        Maine
                New Hampshire
                      Vermont
                Massachusetts
                 Rhode Island
                  Connecticut 
                              
                              
                              
                              
                              
                              
                              Boston         
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             Norwalk        
                                                            
                                                            
                                                            
                                                            Portl
                                                            and           
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          n               
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          n
                                                                                                                        

     Middle Atlantic

                     New York
                   New Jersey

                 Pennsylvania 
                              
                              New York       
                                             
                                             
                                             Ocean City     
                                                            
                                                            
                                                            
                                                            
                                                            Phila
                                                            delph
                                                            ia            
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          d               
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          e              
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         k 
                                                                                                         
                                                                                                         &
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         y 
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         l
                                                                                                                        
SOUTH

     South Atlantic

                     Delaware
                     Maryland
         District of Columbia
                     Virginia
                West Virginia
               North Carolina
               South Carolina
                      Georgia
                      Florida 
                              
                              
                              
                              
                              Baltimore      
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                             Chattahoochee  
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            McLea
                                                            n             
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
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                                                                                                                        n

     East South Central

                      Alabama
                  Mississippi
                    Tennessee
                     Kentucky 
                              
                              Birmingham     
                                             
                                             
                                             
                                             
                                             Lexington      
                                                            
                                                            Birmi
                                                            ngham         
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          e                                             

     West South Central

                    Louisiana
                     Arkansas
                        Texas
                     Oklahoma 
                              
                              
                              
                              Fort Worth     
                                             
                                             
                                             Little Rock    
                                                            
                                                            
                                                            
                                                            Irvin
                                                            g             
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
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                                                                                                         a              
MIDWEST

     East North Central

                         Ohio
                     Michigan

                      Indiana
                     Illinois
                    Wisconsin                
                                             
                                             
                                             
                                             
                                             
                                             
                                             Muncie         
                                                            
                                                            
                                                            
                                                            
                                                            Troy          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
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                                                                                          n 
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          s                             
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        /
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        n

     West North Central

                 North Dakota
                 South Dakota
                    Minnesota
                     Nebraska
                         Iowa
                     Missouri
                       Kansas 
                              
                              
                              
                              Minneapolis    
                                             
                                             
                                             
                                             
                                             North Platte   
                                                            
                                                            Fargo         
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
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                                                                                          n              
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         s              
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        s
WEST

     Mountain

                      Arizona
                         Utah

                       Nevada
                        Idaho
                      Montana
                      Wyoming
                     Colorado
                   New Mexico                
                                             
                                             
                                             
                                             Tempe          
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            Las 
                                                            Vegas         
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          e               
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          t 
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          e
                                                                                            
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          y                             

     Pacific

                   California
                       Oregon
                   Washington
                       Alaska
                       Hawaii 
                              
                              San Francisco  
                                             
                                             
                                             
                                             Tacoma         
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            Honol
                                                            ulu           
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          
                                                                          e               
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          
                                                                                          e              
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         n 
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         
                                                                                                         l
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        
                                                                                                                        e

APPENDIX A-3:  List of Lenders Surveyed


BANKS

North Pacific Bank
Tacoma, WA 

Rio Salado Bank
Tempe, AZ 

North Platte National Bank
North Platte, NE 

Star Financial Bank, Muncie
Muncie, IN 

Eagle Bank & Trust
Little Rock, AR 

The Coastal Bank
Ocean City, NJ 

The Norwalk Bank
Norwalk, CT 

Gadsden State Bank
Chattahoochee, FL 

Bank of the Bluegrass & Trust Company
Lexington, KY 

Bank of America, National Trust & Savings Association
San Francisco, CA 

Norwest Bank Minnesota, National Association
Minneapolis, MN 

(BANKS, continued)

Citibank, N.A.
New York, NY 

The First National Bank of Boston
Boston, MA 

Maryland National Bank
Baltimore, MD 

AmSouth Bank, N.A.
Birmingham, AL 

TeamBank
Fort Worth, TX 

First Chicago - The First National Bank of Chicago
Chicago, IL 

United Bank of Denver, National Association
Denver, CO 

SAVINGS & LOAN ASSOCIATIONS

Mid-Iowa Savings & Loan Association
Newton, IA 

Beckley Federal Savings & Loan Association
Beckley, WV 

Bennington Co-Operative Savings & Loan Association
Bennington, VT 

(SAVINGS & LOAN ASSOCIATIONS, continued)

Ridgewood Savings & Loan Association
Ridgewood, NJ 

Liberty Savings & Loan Association
Eugene, OR 

Security First Savings & Loan Association
Cheyenne, WY 

Rock Savings Bank, S.A.
Beloit, WI 

Home Federal Savings & Loan Association
Jonesboro, AR 

First Federal Savings Bank
Pineville, KY 

Honfed Bank
Honolulu, HI 

Primerit Bank, A Federal Savings Bank
Las Vegas, NV 

Perpetual Savings Bank, F.S.B.
McLean, VA 

Meritor Savings Bank
Philadelphia, PA 

Peoples Heritage Savings Bank
Portland, ME 

(SAVINGS & LOAN ASSOCIATIONS,
continued)

Metropolitan Federal Bank, FSB
Fargo, ND 

Standard Federal Bank
Troy, MI 

First Gibralter Bank
Irving, TX 

City Federal Savings & Loan Association
Birmingham, AL 

CREDIT UNIONS

Acorn Credit Union
Salt Lake City, UT 

McPherson Co-Op Credit Union
McPherson, KS 

Emerald Industrial Credit Union
Greenwood, SC 

A. T. Cross Employees FCU
Lincoln, RI 

Boeing Employees Credit Union
Seattle, WA 

United Air Lines Employee Credit Union
Arlington Heights, IL 



(CREDIT UNIONS, continued)

Navy FCU
Vienna, VA 

IBM Poughkeepsie Employee FCU
Poughkeepsie, NY 

MORTGAGE COMPANIES

First California Mortgage Company
San Rafael, CA 

Homestead Mortgage Corporation
Minneapolis, MN 

Inland Mortgage Corporation
Tulsa, OK 

Prudential Mortgage Capital Company
Newark, NJ 

GE Capital (formerly Travelers Mortgage Services)
Cherry Hill, NJ 

FINANCE COMPANIES

General Motors Acceptance Corporation
Detroit, MI 

Ford Motor Credit Company
Dearborn, MI 

ITT Consumer Financial Corporation
Minneapolis, MN 

AVCO Financial Services Inc.
Irvine, CA 

FINANCE COMPANIES, continued)

Beneficial Corporation
Wilmington, DE 

CREDIT CARD ISSUERS

The Chase Manhattan Bank, N.A.
Credit Card Operations
New York, NY 

American Express Credit Corporation
Wilmington, DE 

AT&T Universal Card Services
Jacksonville, FL 
APPENDIX B:    LENDER QUESTIONNAIRE


INSTRUCTIONS

All introductory material and questions are printed in boldface 
type.  These should be read verbatim.

Instructions for filling in answers or "skip" and "go to" are 
printed in normal type and are in the right-hand column.  Answers 
requiring verbatim entry may be abbreviated to save time during 
the interview.

Each interview must be edited immediately following the call.  
Verbatim responses written in abbreviated form should be expanded 
to represent the interviewee's exact words as closely as 
possible.

Be certain that the data called for at the end of the 
questionnaire are filled in (institution, date and your name).


SECTION 1

Hello, my name is [      ] of De Witt & Associates.  We're 
conducting a survey on behalf of the National Council on 
Disability, an independent federal agency. We're surveying 
lending institutions nationwide to develop an understanding of 
current lending practices toward individuals with disabilities.  
[Technology-Related Assistance Act of 1988, Title II, Part A, 
Sec. 201A(3) & Sec. D]

All responses are anonymous, they will only be compiled 
statistically.  This will only take about five minutes.


Q1   Is this a good time to talk?

A1                                          If yes, skip to Q2.
                                            If not convenient, go 
                                            to Q1a.
                                            If not right person, 
                                            go to Q1b.
                                            If not willing, go to 
                                            Q1c.:



Q1a  When in the next few days would be more convenient?


A1a                                         Record response.  END 
                                            INTERVIEW HERE, BUT 
                                            FILE AWAY FOR 
                                            CALLBACK.


Q1b  Please tell me the name of the individual in your 
     organization whom you believe may be in the best position to 
     discuss this subject or better able to refer me to such an 
     individual.


A1b                                         Record name, title, 
                                            department, and phone 
                                            number. 
                                            END CALL.  CALL 
                                            INDICATED PERSON, 
                                            ALTERING "Hello" 
                                            PARAGRAPH TO REFLECT 
                                            REFERRAL FROM PERSON 
                                            JUST CALLED.



Q1c  All responses are anonymous and the results will be compiled 
     statistically.  Since the study has been mandated by 
     Congress, would you like to reconsider?

A1c                                         Record response 
                                            verbatim and go to 
                                            Q2.

SECTION 2

In conducting this study, we are particularly interested in 
situations where individuals with disabilities are seeking funds 
to purchase assistive technology devices so that they can 
function as productive members of society.  Such devices, for 
example:  may be as basic as a powered wheel chair to provide 
mobility or as sophisticated as a computerized optical character 
scanner/reader that converts printed material into spoken words 
for blind readers.


Q2   Does your institution code loan applications for statistical 
     purposes so that you can analyze your portfolio to determine 
     the percentage of loans made to individuals with 
     disabilities?

A2                                          If yes, go to Q2a.
                                            If no, skip to Q3.


Q2a  Would you supply us with a summary of such data for the past 
     two years or the period when data was collected?

A2a                                         If yes, record period 
                                            covered.
                                            If no, skip to Q3.


Q3   Does your institution have written policies dealing with 
     loans to individuals with disabilities?

A3                                          If yes, go to Q3a.
                                            If no, go to Q3b.


Q3a  Would you also send us a copy of these policies?  We will 
     call back if we need clarification.

A3a                                         Record response and 
                                            go to Q4.


Q3b  In the absence of written policies, would you describe your 
     experience in making loans to individuals with disabilities?


A3b                                         Record response and 
                                            go to Q4.
                                            If none can be given, 
go to
                                            Q3c.



Q3c  Who in your organization might be in a better position to 
     discuss this subject?

A3c                                         Record response.

SECTION 3

Q4   Does your institution make secured loans to individuals with 
     disabilities using technology assisted devices as 
     collateral?


A4                                          Record response.


Q5   Does your institution make unsecured loans?


A5                                          Record response.


Q6   What is the upper and lower limit on your unsecured loans?


A6                                          Record response.


Q7   Does your institution make home equity loans to finance 
     assistive technology?


A7                                          Record response.


Q8   Does your institution make auto loans on vehicles modified 
     to accommodate hand controls or wheelchairs?


A8                                          Record response.



Q9   Under what circumstances does your institution use a 
     cosigner?


A9                                          Record response.


SECTION 4

Many individuals with disabilities may have poor or nonexistent 
credit records because they are:

         students or just entering the work force;
         not employed or under-employed because of their 
          disability;
         lacking the assistive technology devices that enable 
          them to work;
         having inordinately heavy medical expenses associated 
          with their disability.

          Disability affecting one family member may have an 
          effect upon the entire family's credit record as well.


Q10  Can your lending officers take such mitigating factors into 
     account in qualifying the individual with a disability for a 
     loan?


A10                                         Record response and 
                                            go to Q12a.


Q11a Is this covered in your written policies?


A11a                                        If yes, skip to Q12.
                                            If no, record 
response and go
                                            to Q11b.


Q11b Then, how are such mitigating factors treated in your 
     lending decisions?


A11b                                        Record response and 
                                            go to Q12.






SECTION 4, continued

Q12  Similarly, those on whom individuals with disabilities might 
     depend as cosigners (parents,etc.) may also have developed 
     poor credit records due to the costs of helping the affected 
     individual accommodate to their disability.  Do your lending 
     officers take such mitigating factors into account in 
     qualifying the applicant with a disability for a loan?


A12                                         Record response and 
                                            go to Q12a.



Q12a Is this covered in your written policies?


A12a                                        If yes, skip to Q13.
                                            If no, go to Q12b.


Q12b Then, how are such mitigating factors treated in your 
     lending decisions?


A12b                                        Record response and 
                                            go to Q13.

SECTION 5

Q13  This completes the formal questionnaire.  I have just one 
     general question to complete the interview.  Is there 
     anything else that might be useful for us to know?


A13                                         Record response 
                                            verbatim.
Thank you very much for your time and assistance in helping with 
this survey. Have a good day.


END CALL.

Institution:   

Date:          

Interviewer:   
APPENDIX C:    List of Trade Associations and Credit Scoring 
               Systems Surveyed


TRADE ASSOCIATIONS

American Bankers Association
Washington, DC 

Consumer Bankers Association
Arlington, VA 

Independent Bankers Association of America
Washington, DC 

Mortgage Bankers Association of America
Washington, DC 

National Association of Mortgage Brokers
Phoenix, AZ 

National Council of Savings Institutions
Washington, DC 

National Second Mortgage Association
Rancho Cucamonga, CA 

United States League of Savings Institutions
Washington, DC 

American Financial Services Association
Washington, DC 

National Foundation for Consumer Credit
Silver Spring, MD 

National Association of Federal Credit Unions
Washington, DC 

Community Service Credit Union Council
Washington, DC 

Credit Union National Association
Madison, WI 

CREDIT SCORING SYSTEMS

Trans Union Corporation
Chicago, IL 

TRW, Inc.
Credit Data Division
Orange, CA 

Equifax Services, Inc.
Atlanta, GA 20309

ATTACHMENTS:



1.   American Banker's Association (brochure excerpt)

2.   Credit Union National Association (newsletter excerpts)

3.   General Motors (loan program brochure)

4.   The Wall Street Journal (article)












Section Eight:






Consultant Directory on the Financing of Assistive Technology 
Devices and Services for Individuals with Disabilities


















NATIONAL COUNCIL ON DISABILITY



STUDY ON FINANCING OF ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES





Consultant Directory on the Financing of Assistive Technology 
Devices and Services for Individuals with Disabilities


March 18, 1992





Contractor:    United Cerebral Palsy Associations, Inc.
1522 K Street, N.W., Suite 1112
Washington, D.C.  20005

Welcome to The National Council on Disability's  

Consultant Directory on the 
Financing of Assistive Technology Devices and Services for 
Individuals with Disabilities 

I.   Introduction
The application of technologies to diminish the limitations and 
extend the capabilities of persons with disabilities is one of 
the prime social and economic goals of public policy.  (Gibbons, 
1982, Office of Technology Assessment).  In the past 25 years, 
Congress has established over 30 programs that affect Americans 
with disabilities.  There are over a dozen agencies on the 
federal level charged with the responsibility of managing these 
programs, interpreting Congressional mandates, and monitoring 
state implementation.  Although sometimes described as a 
patchwork quilt or "federal maze" (President Ronald Reagan, 
1983), which continues to grow more complex each year, there is 
agreement that federal laws and programs must be directed toward 
the national goal of "assuring equal opportunities and promoting 
independence for persons with disabilities," (National Council on 
Disability, 1986). 
Technology is a proven means to assure equal opportunities and 
promote independence.  The public record of House and Senate 
hearings that led to the passage of the Technology Related 
Assistance Act in 1988, (P.L. 100-407), documents professionals, 
parents, and consumers' viewpoints that for many individuals with 
disabilities, assistive technology devices and services enable 
them to:

     a.   have greater control of their lives;
     b.   participate in and contribute more fully to activities 
          in their home, school and work environments;
     c.   interact to a greater extent with non-disabled              
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      ; 
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      d
     d.   otherwise benefit from opportunities that are taken for 
          granted by individuals who do not have disabilities.  
          (Section 2:  Findings 29 USC 2201)

If persons with disabilities had a sufficient income base, 
identified appropriate technology would be purchased without 
third party involvement.  However, the limited economic status 
and purchasing power of persons with disabilities requires a 
search for alternative solutions.  The development and use of 
technologies by persons with disabilities is critically impacted 
by the availability and allocation of public resources in support 
of public policy to promote equal opportunity and independence.  
An effective funding system(s) that is incentive driven, outcome 
oriented and consumer responsive must be designed to respond to 
the concerns frequently expressed by potential technology users 
with disabilities.   "Technology could
dramatically change my life...  Unfortunately, I can't afford 
it!"  The purpose of this study is to examine the effectiveness 
of current third party payor options in the public and private 
sectors on state and federal levels and propose the development 
of alternative strategies for acquiring or paying for assistive 
technology devices and services.


II.  Recent Public Policy Experience
During the past six years, Congress and federal agencies have 
moved dramatically forward with public policy that improves 
access to assistive technology (see Table 1).  An effective 
funding and financing strategy must be designed in light of 
seventeen significant public policy developments that have 
occurred since 1986:

1.   Amendments to the Rehabilitation Act,  P.L. 99-506

     A.   In 1986, for the first time, a definition of 
          rehabilitation engineering was added to the Act to 
          "include a range of services and devices which can 
          supplement and enhance individual functions..."  The 
          Amendments require each state vocational rehabilitation 
          agency to describe in their three-year state plan how 
          rehabilitation technology services will be provided to 
          assist an increasing number of individuals with 
          disabilities.  The Amendments also require the 
          application of rehabilitation technology services when 
          making determinations of eligibility.  This is 
          particularly important for individuals who might 
          otherwise be found ineligible for vocational 
          rehabilitation services.  The Amendments further 
          include rehabilitation engineering technology as one of 
          only four services which must be provided by the state 
          rehabilitation system without consideration of 
          comparable services and benefits -- a clear indication 
          of Congressional recognition both of its importance and 
          of the need for public systems to provide funding 
          support to enable people who can benefit to be able to 
          access these important supports.   

     B.   An important new direction in public policy was 
          accomplished with the addition of Section 508 to the 
          Act, without imposing any significant new financial 
          burdens on government, business, or employees.  Federal 
          agencies must provide workers with and without 
          disabilities equivalent access to electronic office 
          equipment.  As a result of Section 508, the federal 
          government, with the General Services Administration 
          (GSA) taking the lead, has changed its rules for 
          purchasing/leasing information technology.  New 
          guidelines for functional performance can be 
          accomplished by manufacturers of computers "building in 
          alternative capabilities such as single keystroke 
          commands or providing hooks for the addition of 
          adaptive peripheral equipment such as a one-handed 
          keyboard or a braille printer."  (RESNA TA Project, 
          1990)  As implementation of Section 508 proceeds, it is 
          expected that accessibility-related equipment and 
          support services will become an integral aspect of 
          federal agency
          acquisition.  It is anticipated that these new 
          accessibility procurement guidelines by the federal 
          government, who is the single largest purchaser of 
          computers, will stimulate the accelerated development, 
          manufacturing and marketing of accessible or adaptable 
          office automation systems.

2.   Early Intervention for Infants, Toddlers and Families,
     P.L. 99-457

     In 1986, Congress enacted P.L. 99-457, within which was 
     included a new Part H amendment to the Individuals with 
     Disabilities Education Act (formerly Education for the 
     Handicapped Act).  This public policy declaration 
     dramatically advanced national efforts to provide 
     appropriate services to infants and toddlers with 
     disabilities and their families.  The statutory definition 
     of early intervention services states, in part, "...designed 
     to meet a handicapped infant's or toddler's developmental 
     needs in any one or more of the following areas:", which 
     include physical development, cognitive development language 
     and speech development, psychosocial development, or 
     self-help skills.  Amplification of Congressional intent 
     occurred in the Department of Education's final regulations 
     issued on June 22, 1989 at 34 CFR Part 303, which includes 
     the following:  

          'Occupational therapy' includes services to address the 
          functional needs of a child related to the performance 
          of self-help skills, adaptive behavior and play, and 
          sensory, motor, and postural development.  These 
          services are designed to improve the child's functional 
          ability to perform tasks in home, school, and community 
          settings, and include:  (i) identification, assessment, 
          and intervention; and (ii) adaptation of the 
          environment, and selection, design, and fabrication of 
          assistive and orthotic devices to facilitate 
          development and promote the acquisition of functional 
          skills.


     With this new legislation and regulations, a major leap in 
     assistive technology public policy occurred by creating an 
     entitlement to such services for infants, toddlers and their 
     families.  A five year planning process will in 1992 be 
     replaced by a new entitlement to services.


3.   Employment Opportunity for Disabled Americans Act,  
     P.L. 99-463

     The greatest public expenditures on behalf of persons with 
     disabilities remain income maintenance programs.  The two 
     largest are Supplemental Security Income (SSI), and Social 
     Security Disability Insurance (SSDI).  In 1986, Congress 
     approved new legislation to make it easier for people with 
     disabilities to work and not lose their SSI benefits.  As 
     part of this public policy goal, Congress permanently 
     authorized the PASS program.  PASS is an acronym for Plan 
     for
     Achieving Self-Support.  An individual who is receiving SSI, 
     or who would qualify for SSI by setting aside income from 
     their paycheck, is eligible to develop a PASS.  Each plan 
     must be approved by the Social Security Administration, and 
     can be used to purchase work-related assistive technology 
     equipment or devices.  The plan must state a clear and 
     realistic vocational goal, and explain how the sheltered 
     income will be spent within a specific timetable.  This 
     policy approach recognizes the importance of assistive 
     technology to achieve the goals of independence and 
     self-sufficiency, and gives special consideration from a  
     tax or income perspective of the extra costs associated with 
     acquisition.


4.   Developmental Disabilities Assistance and Bill of Rights Act 
     Amendments of 1987,  P.L. 100-146

     The Developmental Disabilities Assistance and Bill of Rights 
     Act reflects emerging "best-practice" supports and services 
     within a value-based context for individuals with 
     developmental disabilities and their families.  During the 
     1987 reauthorization process, Congress added assistive 
     technology as a priority for state planning and funding for 
     system development and system change.  Within the 1990 
     amendments to the Act (P.L. 101-576), Congress modified the 
     definition of assistive technology to conform to the 
     definition in the Tech Act (P.L. 100-407).  With this 
     legislation, public focus on the financing of assistive 
     technology was further advanced within a state system for 
     planning and systems advocacy.

5.   Older Americans Act of 1965, as amended, (P.L. 100-175)

     In 1987, the Act was amended (P.L. 100-175) to include 
     several provision related to older persons with 
     developmental disabilities and/or mental health needs. Among 
     the provision are requirements that:
     o    planning linkages be established between HHS 
          Commissioners of Aging, Developmental Disabilities and 
          Alcohol, Drug Abuse and Mental Health;
     o    the Commissioner of Aging consult and cooperate with 
          the Commissioner of the Rehabilitation Services 
          Administration in planning Older Americans Act 
          programs; and,
     o    in evaluating OAA programs the Commissioner on Aging 
          consult with developmental disability organizations 
          whenever possible.
     
     Title III, Part B,  Grants for Supportive Services, 
     Nutrition and Other Activities, assists older individuals in 
     avoiding institutionalization and individuals in long-term 
     care institution who are able to return to their 
     communities, including client assessment through case 
     management, and integration and coordination of community 
     services.
               
          The term "client assessment through case management"        
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
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                                                                      .
          
          The term "assistive technology" is defined as          
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
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                                                                 s 
                                                                 
                                                                 
                                                                 
                                                                 
                                                                 
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                                                                 .

     Grants are awarded to States to develop and strengthen 
     services systems on aging.  State plans include several 
     assurances including assurances associated with access to 
     services (i.e. transportation, outreach, and information and 
     referral).
          
          The phrase, "information and referral" includes 
          information regarding to assistive technology.
     

6.   Medicaid Amendments of 1988 for Special Education Related 
     Services,  P.L. 100-360

     The Medicare Catastrophic Coverage Act (P.L. 100-360), 
     contains a significant technical amendment to Medicaid law, 
     which was not repealed with the Catastrophic Act.  This 
     legislation was intended to resolve a historical dispute in 
     which the Health Care Financing Administration had declared 
     that any service within a child's individualized education 
     program (IEP), was the financial responsibility of the 
     education agency and could not be billed to Medicaid.  The 
     1988 amendment and accompanying report language explicitly 
     offered states the option of including special education and 
     related services under Part B of IDEA, and those services 
     included under Part H of IDEA as Medicaid reimbursable 
     services under the state's Medicaid plan.  With this policy, 
     Congress provided a major opportunity for states to access 
     federal Medicaid funds for a full range of individual 
     assistive technology services without adding additional 
     burdens to the local and state special education budgets.


7.   Technology-Related Assistance Act,  P.L. 100-407

     This federal mandate provides financial assistance to states 
     on a competitive grant basis, to plan and implement a 
     consumer responsive system of technology services for 
     individuals of all ages with disabilities.  Technology 
     services and devices are defined in a broad context to 
     stimulate creative problem solving, interagency coordination 
     and professional consumer collaboration.  In the first two 
     years of implementation of the Act, 23 states have competed
     successfully for funding.  States have broad discretion to 
     target their funds to training, public awareness, service 
     demonstration, policy analysis, and systems change.  Unlike 
     already existing public programs, this federal initiative 
     represents the first time Congress targeted new public 
     resources exclusively to expand access to assistive 
     technology.  

8.   Telecommunications Accessibility Enhancement Act of 1988,        
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      . 
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      2

     In 1988, Congress authorized P.L. 100-542,  The 
     Telecommunications Accessibility Enhancement Act of 1988.  
     The purposes of the Act are to implement an interim 
     telecommunications relay system to serve the needs of 
     individuals who are hearing-impaired and speech-impaired for 
     access to Federal departments and agencies; to equip all 
     Federal departments and agencies with TDDs or facilities to 
     accommodate portable TDDs; to provide for the assembly, 
     publication and maintenance of a TDD directory for Federal 
     departments and agencies; and for the publication of 
     governmental TDD access numbers in other existing 
     directories.

          The Act also required the FCC, in consultation with the     
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
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                                                                      . 

9.   Medicaid Early and Periodic Screening, Diagnosis and 
     Treatment Amendments of 1989,  P.L. 101-238

     Included within the massive Omnibus Budget Reconciliation 
     Act of 1989 (OBRA '89, P.L. 101-238), Congress enacted major 
     changes within the Medicaid program required in all states, 
     called Early and Periodic Screening, Diagnosis, and 
     Treatment (EPSDT).  Although EPSDT has been one of nine 
     state Medicaid mandated services since its enactment in 
     1967, the states have had great discretion in interpretation 
     and implementation of this benefit.  As of April 1, 1990, 
     the EPSDT Medicaid benefit was "federalized" and mandates 
     that all children from birth to twenty-one years of age 
     receiving, or eligible to receive Medicaid are entitled to 
     the "medically necessary" diagnostic and treatment services 
     for any physical or mental problem identified during such 
     screening or assessment.  Such services would be 
     reimbursable under Medicaid if such "treatment" is coverable 
     under federal Medicaid law, even if these "treatments" are 
     not in the state's Medicaid plan; e.g. augmentative 
     communication devices, wheelchairs, hearing aids, optical 
     aids including glasses, etc. As a result of this Amendment, 
     a significant number of children with physical, sensory or 
     mental disabilities now have a right to assistive 
     technology.  Due to established practices within Medicaid, 
     many challenges remain in assuring this right in concert 
     with the second, and often overlooked, statutory purpose of 
     Medicaid:  "to furnish rehabilitation and other services to 
     help such families and individuals attain or retain 
     capability for independence or self-care," (P.L. 90-248, 42 
     USC 1396, Sec. 1901).

10.  Americans with Disabilities Act (ADA),  P.L. 101-336

     Signed into law by President Bush on July 26, 1990, the Act 
     will protect over 40 million Americans with disabilities 
     from discrimination in employment, public services, 
     transportation, public
     accommodations and telecommunications.  Each Title of the 
     Act specifically references assistive technology equipment 
     or devices as a means to achieve access and equal 
     opportunity.  In Titles I and III, the purchase or 
     modification of equipment and devices is included within the 
     definition of "reasonable accommodation."  However, the 
     removal of architectural, physical, or communication 
     barriers, through "reasonable accommodation," is not an 
     absolute civil right.  On a case by case basis, access to 
     employment opportunity or public accommodations must be 
     weighed against a defense of "undue hardship," a still 
     evolving standard to evaluate the degree of difficulty and 
     expense to a particular business.
          Title IV of the ADA expands access rights to the 
     important area of telecommunications.  Telephone services 
     offered to the public in every state must include interstate 
     and intrastate telecommunications relay services so that 
     these services provide individuals with speech and hearing 
     impairments access to communications equivalent to those 
     provided to individuals able to use voice telephone systems.
          In multiple approaches, ADA will begin to redefine the 
     inclusion of assistive technology within the core and 
     penumbra of civil rights to be enjoyed by citizens with 
     disabilities.  The current year, 1991, represents a critical 
     year of regulatory development that will begin to more 
     solidly define the limits of access to assistive technology 
     as part of "reasonable accommodation" in the workplace, 
     commercial buildings, and public arenas.

11.  ADA Tax Credit,  P.L. 101-508

     Under the Omnibus Budget Reconciliation Act of 1990, a new 
     tax credit was created for small businesses, to provide 
     additional incentives and assistance to meet the access 
     requirements under ADA.  The credit amount allowed a tax 
     year is 50 percent of expenditures, up to a maximum of 
     $10,250.  Acceptable expenses include removal of 
     architectural, communication, or transportation barriers.  
     Coverage does include the purchase or modification of 
     adaptive equipment or assistive devices as part of an effort 
     to improve access to persons with disabilities.  To qualify, 
     a business must have gross receipts of less than one million 
     dollars, or fewer than 30 full-time employees.

12.  Decoder Circuitry Act of 1990,  P.L. 101-431

     In yet another approach to expand public policy, new 
     requirements are mandated for the manufacturers of 
     television sets with screens 13 inches or larger, sold in 
     the United States after July 1, 1993.  Televisions will be 
     required to have built-in decoder circuitry to be compatible 
     with current closed captioning signals.  This new mandate 
     will assure that people with hearing impairments will be 
     able to see captions on programs that provide them by merely 
     flipping a switch on their television.  Mass production of 
     the built-in decoders will cost an estimated three to five 
     dollars per television.  The potential audience for 
     closed-captioned programming for individuals with 
     communication disabilities is estimated to be more than 24 
     million.

13.  Policy Letter:  Office of Special Education Programs

     On August 10, 1990, Office of Special Education Programs 
     Director, Dr. Judy Schrag issued a policy letter that 
     clarifies the rights of children with disabilities to access 
     assistive technology.  This policy letter states clearly and 
     unequivocally that assistive technology services and devices 
     may be considered special education, related services, or 
     supplementary aids and services to enable a student with a 
     disability to remain in the regular education classroom.  In 
     other words, as part of the requirements of a "free, 
     appropriate public education," (FAPE), assistive technology 
     needs must be considered when developing a child's 
     individualized education program (IEP).  Needed assistive 
     technology devices and services must be appropriately 
     included as part of the IEP.  In response to the 
     requirements of the least restrictive environment principle 
     and as special education or related services, children with 
     disabilities have a right to assistive technology.  These 
     requirements were further reinforced in the recent 
     reauthorization of the Education of the Handicapped Act.  On 
     October 30th, 1990, President Bush signed into law the 
     Individuals with Disabilities Education Act (IDEA), P.L. 
     101-476, which, for the first time, includes definitions of 
     assistive technology devices and services identical to those 
     included in the TECH Act, P.L. 100-407.  In report language, 
     there is further emphasis on the right to assistive 
     technology as part of special education and related 
     services.

     The reauthorization language and the policy letter should 
     result in more consistent access to assistive technology by 
     school-age children with disabilities nationwide.

14.  Policy Memo:  Rehabilitation Services Administration

     On November 16th, 1990, Commissioner Nell Carney issued a 
     policy directive to all state vocational rehabilitation 
     agencies that sets important new guidelines concerning 
     implementation of the 1986 rehabilitation technology 
     amendments.  Each state must develop written policies to 
     address the need for assistive technology during the entire 
     rehabilitation process:  as part of determination of 
     eligibility, evaluation of rehabilitation potential, 
     extended evaluation, services provided under the individual 
     written rehabilitation plan (IWRP), annual reviews of 
     ineligibility, and post-employment services.  An assessment 
     of an individual with disabilities should consider how 
     assistive technology devices and services can:

          a.   increase or supplement function; and
          b.   modify environments to accommodate individual 
               abilities in the home and workplace.

     This added policy direction to implement the intent of 
     Congress should place new demands on a major public resource 
     program to allocate funds to increase access to technology.


Analysis of these public policy developments reflects numerous 
approaches which have been used to increase availability of and 
access to assistive technology.  These approaches include a range 
of activities designed to influence all aspects of policy 
development and implementation, (see Table 2).  While these 
policy approaches do not reflect all of the avenues available to 
direct the public policy arena toward increased access to 
assistive technology, they certainly provide excellent examples 
of approaches which have been successfully utilized to date to 
begin movement in that direction.  In addition, they provide 
important information on approaches which should be considered 
when developing additional strategies for the acquisition and 
financing of assistive technology services and devices in the 
future.

                                  Table 1

                     RECENT PUBLIC POLICY DEVELOPMENTS



1.





2.







3.




4.



5.





6.






7.



8.



9.



10.







11.




12.



13.



14.



15. 




16.





17. 




Year

1986





1986







1986




1986



1987





1987






1988



1988



1988



1990







1990




1990



1990



1990



1990




1991





1991
   Action

Amendments to Rehabilitation Act: add definition, expand program 
requirements

Amendment to Rehabilitation Act, Section 508:  new guidelines for 
federal procurement of computers


Early Intervention:  new entitlement, expand program benefits

Social Security Amendments 


Amendments to Developmental Disabilities Act:  expand program 
requirements

Older Americans Act
Amendments: adds provision of assistive technology to Act; 
defines
assistive technology

Medicaid Amendments: clarify funding options and mandates

Tech Act: Create statewide systems of technology assistance

New Telecommunications
Access Law

New Civil Rights Law
ADA:  employment, transportation,
public accommodations, telecommunications

ADA Tax Credit for Small Businesses



Decoder Circuitry Act:  design standard for televisions

Policy Memo
Special Education


Policy Memo
Rehabilitation


Amendment to IDEA adding definitions of assistive technology 
devices and services 

Amendment to Part H of IDEA adding definitions of assistive 
technology services and devices

Policy Letter





    Approach

Clarify and expand program benefit of major public program



Change procurement practices, impact manufacturers expectation of 
accessible design standards at lower cost

Establish new major public program



Tax sheltering of income to purchase technology

New priority within existing public program



Expands program benefit





Clarify and expand existing program benefit

New funding, new public program


New TDD access requirement within Federal agencies

New access requirements of private sector,
access technology by expanding concept of civil rights

Tax incentives to expand access to assistive technology, 

Require new manufacturer standard for access

Clarify rights under existing major public program

Clarify rights under existing major public program

Clarify rights under existing public program


Clarify rights under existing public program



Clarify right to take technology home from school










                                  Table 2

                             POLICY APPROACHES


1.   Redirect or increase resource allocation under existing 
     public programs.


2.   Modify entitlements under existing public programs.


3.   Clarify existing policy to mandate and monitor more 
     consistent practices.

4.   Modify discretionary priorities under existingpublic 
programs.


5.   Establish new public programs.


6.   Establish new laws to expand definition of civil rights.


7.   Alter procurement practices of government.


8.   Alter existing or create new tax incentives.


9.   Allow tax sheltering of income.


10.  Require new design standards for manufacturers of equipment 
     to displace need for specialized equipment purchases.


 


III.  Approach to the Consultant Directory

     The Directory identifies individuals from across the 
country, indexed alphabetically and by state, who have expertise 
in the acquisition, finance and payment of assistive technology 
services and devices.  The majority of individuals listed have 
expressed their willingness to provide assistance both within 
their individual states and nationwide.  
     
     To complete this Directory, NCD designed a questionnaire and 
mailed it to a large pool of published individuals; contacts in 
key national consumer and professional organization; individuals 
in each of the Title I (P.L. 100-407) state lead agencies; 
Rehabilitation Engineering Centers; the Veterans Administration 
and consumers.  The questionnaire addressed the following areas: 
(a) contact information; (b) area(s) of expertise; (c) types of 
assistive technology services/devices with which s/he has had 
experience securing financing; (d) funding streams with which 
s/he has had experience securing financing; (e) age and 
disability groups with which s/he has had experience securing 
financing of assistive technology devices and services; and, (f) 
the types of consultation s/he is willing to provide.  In 
addition, each individual was asked about their willingness to be 
included in the Directory.  All individuals listed in the 
Directory are self-nominated.  

     Given the growing interest in the issues of funding 
assistive technology and the activities now being implemented 
under the Technology-Related Assistance Act for Individuals With 
Disabilities (P.L. 100-407), this listing should not be seen as 
complete.  It is a list that will grow weekly as more people 
grapple with the financing of assistive technology.  We hope that 
this document is a resource that can be updated annually.  If we 
can be of further assistance, please contact Dr. Katherine 
Seelman (202) 267-3846 (Voice)/(202) 267-3232 (TDD).

     Thanks to all the people who have volunteered their time and 
commitment to improving access to the financing of assistive 
technology devices and services by becoming a part of this 
Directory.  


Sandra Swift Parrino                         Ethel Briggs
Chairperson                                  Executive Director
National Council on Disability               National Council on 
                                             Disability


George Oberle, P.E.D                         Katherine Seelman, 
                                             Ph.D.
Chairman                                     Research Specialist
Committee on Technology                      National Council on 
                                             Disability
National Council on Disability

                       IV. TABLE OF CONTENTS

I.    Introduction..............................................3

II.   Recent Public Policy Experience...........................4

III.  Approach to the Consultant Directory.....................16
IV.   Table of Contents........................................17

V.    Consultants..............................................19
Thomas C. Backiel..............................................19
Diane Baranik..................................................20
Jesse Barth....................................................21
Allan I. Bergman...............................................22
Gayl Bowser....................................................24
David Braddock, Ph.D...........................................25
Todd Brickhouse................................................26
J.A. Browder, M.D..............................................27
Carl Brown.....................................................28
Jan Brown......................................................29
Kenneth Brown..................................................30
Lynn Bryant....................................................31
Christopher Button, Ph.D.......................................33
Caron Cohen....................................................34
John C. DeWitt.................................................35
Alexandra Enders OTR/L.........................................37
Karen Sandra Franklin..........................................39
Jan Galvin.....................................................40
Lewis Golinker.................................................42
Bob Griss......................................................44
Colleen Haney..................................................45
Richard Hemp...................................................46
Anna C. Hofmann................................................47
Terry Holden...................................................48
Deborah Kaplan.................................................49
Joy Kniskern...................................................50
Elaine K. Koch.................................................51
Diana Kubovcik.................................................52
Justine Maloney................................................53
Sharon Meek....................................................54
Steve Mendelsohn...............................................55
Reese Michaels.................................................56
Judith K. Montgomery...........................................57
Michael Morris.................................................58
Joyce Munson-Davis. Ph.D.......................................59
Bill Newroe....................................................60
Marcia R. Nunnally, MEd, OTR/L.................................61
Peg O'Brien....................................................62
Alicia Hahne Oestmann..........................................63
Pat Ourand.....................................................64
Joyce Palmer...................................................65
Deborah Parker-Wolfenden, M.Ed. CCC-SLP........................66
Sandra Peterson................................................67
Sheron R. Rice.................................................68
Janina Sajka...................................................69
William M. Salyers, Ed.D.......................................70
Lawrence Scadden, Ph.D.........................................71
Katherine D. Seelman, Ph.D. ...................................73
William L. Self................................................74
Jolene Y. Shimada..............................................75
Patrick Terick.................................................76
Michael Towey..................................................77
Lawrence H. Trachtman..........................................78
Steve Tremblay.................................................80
Debra J. Waln..................................................81
Andy J. Winnegar, Jr...........................................82
Steven C. White, Ph.D..........................................83
Rachel Wobschall...............................................84
Bonnie Wooten-Webb.............................................85
Debra Wynkoop-Green............................................86

Consultants Listed By State....................................87
V.  Consultants

Thomas C. Backiel
Speech/Language Pathologies
P.O. Box 1245
Bangor, Maine  04402-1245
Telephone:     (207) 947-6056 

Scope of Expertise: Maine; All ages; All disabilities; 
Augmentative communication devices and computers.
     Expertise in individual problem solving to secure access to 
     assistive technology; knowledgeable in barriers 
     identification and systems change problem solving in 
     securing access to assistive technology, and reimbursement 
     of assistive technology, specifically:
     Medicaid 
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Health insurance coverage
     Disability insurance.

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs;
     Privately operated loan programs;
     Clearinghouse model, lending library, equipment banks, etc.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                     Voluntary
     Private/Contractual Consultation        Fee
     Presenter at Meetings and Conferences           Fee
     Personnel/Staff Training                Fee
     Written Correspondence                  Voluntary
     Travel                                  Fee
Diane Baranik
Funding Specialist
STAR Program
300 Centennial Building
658 Cedar Street
St. Paul, Minnesota  55155
Telephone:     (612) 297-7517
Fax:           (612) 297-7200


Scope of Expertise:  Nationwide; All ages; All disabilities; Full 
range of assistive technology devices and related services.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology 
     primarily in the area of private health insurance 
     reimbursement; and, individual problem solving to secure 
     access to assistive technology, and reimbursement of 
     assistive technology, specifically:
     Medicaid
     Medicare
     Rehabilitation Act
     Education programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Private health insurance

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Fee/Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary
     Willing to Travel                            Fee/Voluntary

Jesse Barth
Vermont Assistive Technology Project Director
103 South Main Street, Room 387
Waterbury, Vermont  05671-2305
Telephone:     (802) 241-2620
Fax:           (802) 244-8103

Scope of Expertise:  Nationwide; Working age; All disabilities
Full range of assistive technology devices and related services.

     Expertise in reimbursement of assistive technology, 
     specifically, Social Security Administration Work Incentive 
     Programs: 
     Plans for Achieving Self Support (PASS); and, 
     Impairment Related Work Expenses.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Fee/Voluntary
     Willing to Travel                            Fee


Allan I. Bergman
Deputy Director
Governmental Activities Division
United Cerebral Palsy Associations, Inc.
1522 K Street N.W.  Suite 1112
Washington, D.C.  20005
Telephone:     (202) 842-1266
               (800) 872-5827
Fax:           (202) 852-3519

Scope of Expertise:  Nationwide; All ages; All disabilities; Full 
range of assistive technology devices and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology, and reimbursement of assistive technology, 
     specifically:
     Medicaid  
     ICF/MRs 
     Community Supported Living Arrangements (CSLA)
     Education programs (IDEA, Vocational Education, P.L. 89-313) 
     Rehabilitation Act.

     Knowledgeable in the reimbursement of assistive technology, 
     specifically: 
     Medicare  
     Maternal and Child Health (Title V)
     Tax Code
     Health insurance coverage
     Supplemental Security Income: PASS.

Reimbursement: Provides the following types of consultation to 
all audiences:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Publications/Presentations:
Allan Bergman is a leading national expert on Medicaid, Medicaid 
reform and family support.  He has written and presented 
extensively on these topics and provides technical assistance in 
many states in a variety of areas related to supporting families 
with infants, children and adults with disabilities.  His work
has led to new insight and direction for state service delivery 
systems, professionals, parents and individuals with disabilities 
nationwide.  He is the Editor of Word from Washington, a 
bi-monthly publication of UCPA's Governmental Activities Division 
and Family Support Bulletin both of which are available through 
United Cerebral Palsy Associations, Inc.
Gayl Bowser
Coordinator
Oregon Technology Access Program
1871 N.E. Stephens
Roseburg, Oregon  97470
Telephone:     (503) 440-4791
Fax:           (503) 440-4771

Scope of Expertise:  Oregon; Birth-21 year(s); All              
disabilities; All assistive technology with particular expertise 
in augmentative communication and computers.

     Knowledgeable in barriers identification and systems change 
     problem solving; and, individual problem solving to secure 
     access to assistive technology.  Expertise in reimbursement 
     of assistive technology, specifically:
     Medicaid 
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Insurance Coverage

     Expertise in alternative strategies for the financing of  
     assistive technology, specifically: 
     Clearinghouse model; lending libraries, equipment bank, etc.  
     Formation of private non-profits.
     Private funding in Oregon

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Voluntary
     Travel                                       Fee

Resources/Publications:
Funding Assistive Technology Devices: A Resource Manual for 
Oregon Available through the Oregon Technology Access Project
 
Bowser, G., Computers in the Mainstream: A Guide for Special 
Educators, Oregon Technology Access Project: Douglass ESD, 
Roseburg, Oregon, 1990.

Bowser, G., Computers in Special Education Curriculum, Oregon 
Technology Access Project: Douglas ESD, Roseburg, Oregon, 1989.
David Braddock, Ph.D.
Director
University Affiliated Program in Developmental Disabilities
The University of Illinois at Chicago
1640 West Roosevelt Road
Chicago, Illinois  60608
Telephone:     (312) 413-1647
Fax:           (312) 413-1326

Scope of Expertise:  Nationwide; All ages; All disabilities with 
emphasis on developmental disabilities; Full range of assistive 
technology devices and services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     knowledgeable in individual problem solving to secure access 
     to assistive technology; and, reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code 
     Medicare.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     State programs.
 

Reimbursement: Provides the following types of consultation to a 
wide range of audiences:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Willing to Travel                            Fee
     

Todd Brickhouse
President
Brickhouse Design Group, LTD
8 Joan Lane
Massapequa Park, New York  11762
Telephone:     (516) 795-6962
Fax:           (516) 541-1509

Scope of Expertise:  Nationwide; All Ages; All Disabilities; 
Primarily architectural and design with consideration for the 
type of durable medical equipment the individual(s) may use 
including a variety of custom furniture.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     and, individual problem solving to secure access to 
     assistive technology.  Knowledgeable in reimbursement of 
     assistive technology, specifically:
     Medicaid/Medicare
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code.

     Expertise in reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Health insurance
     Workers' Compensation
     Casualty insurance
     Disability insurance
     No fault/Medical malpractice
     Crime victims.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouses, lending libraries, equipment banks, etc.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training (In New York)       Voluntary  
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee
J.A. Browder, M.D.
Developmental Pediatrics
Child Development Rehabilitation Center
Neuromotor Program
Child Development and Rehabilitation Center
Oregon Services for Children with Special Healthcare Needs
P.O. Box 574
Portland, Oregon  97207-0574
Telephone:     (503)494-4632
Fax:           (503) 494-4447

Scope of Expertise:  Oregon/Washington; Birth-18 year(s); 
Neuromotor/developmental disabilities; Assistive technology for 
mobility, communication and self-help needs technology.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology.  Expertise in reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Health insurance coverage

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically: 
     Clearinghouse model, lending libraries, equipment bank, etc.
 
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Fee
     Willing to Travel                            Fee


Carl Brown
President
Abilities Development Associates
P.O. Box 190
Purdys, New York  10578
Telephone:     (914) 276-3354
Fax:           (914) 276-3354

Scope of Expertise:  Nationwide; All ages with experience in teen 
age and adult population; All Disabilities; Full range of 
assistive technology devices and services with experience in 
voice recognition, speech synthesis and telecommunications.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology 
     and in individual problem solving to secure access to 
     assistive technology.  Knowledgeable in reimbursement of 
     assistive technology, specifically:
     Medicaid 
     Medicare
     Health Insurance 
     Workers Compensation
     Disability insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Clearinghouse model, lending libraries; equipment bank; etc. 
     Private industry
     Foundations.

Reimbursement: Provides the following types of consultation to a 
wide range of audiences:

     Telephone Inquiries                          Fee
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Fee
     Willing to Travel                            Fee

Jan Brown
Independent Living Counselor
Bureau of Rehabilitation 
Capital Shopping Center
Western Avenue
Augusta, Maine 04330
Telephone:     (207) 624-8090

Scope of Expertise:  State of Maine; All ages;  All disabilities; 
Full range of assistive technology devices and services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and, knowledgeable in reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Presenter at Meetings and Conferences        Voluntary*
     Personnel/Staff Training                     Voluntary*

     *In Central Maine

Kenneth Brown
Senior Project Engineer
Rehab Technology Program
ECRI
5200 Butler Pike
Plymouth Meeting, Pennsylvania  19462
Telephone:     (215) 825-6000
Fax:           (215) 834-1275

Scope of Expertise:  Nationwide and international; Adults and 
seniors with disabilities; All disabilities with strength in 
mobility-related disabilities; Full range of assistive technology 
devices and related services with primary expertise in the proper 
use of assistive technologies including the safety, performance 
efficiency, compatibility of devices, and transportation. 

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     and individual problem solving to secure access to assistive 
     technology.  Knowledgeable in reimbursement of assistive 
     technology, specifically:
     Medicare 
     Medicaid
     Rehabilitation Act
     Health insurance coverage
     Workers' compensation
     Disability insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology:
     Clearinghouse model, lending libraries, equipment bank, etc.

Reimbursement: Provides the following types of consultation 
primarily to healthcare professionals and facilities; government 
agencies, third-party payers, special-interest groups:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Voluntary
     Written Correspondence                       Voluntary
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee

Lynn Bryant
President
RehabTech Associates
3640 Dry Creek Court
Ellicott City, Maryland  21043
Telephone:     (301) 750-0353
Fax:           (301) 465-4072

Scope of Expertise:  Nationwide; Adults; All disabilities with 
expertise in orthopedic disorders, neurological dysfunction, 
spinal cord injury, multiple sclerosis;  Job accommodation 
technology, wheelchairs; seating and positioning, functional 
electronic stimulation; computer adaptation; "low tech" 
solutions. 
     
     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and, reimbursement of assistive technology, 
     specifically:
     Medicaid 
     Medicare
     Veterans programs.

     Knowledgeable in reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Health Insurance
     Workers' Compensation
     Disability Insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending library, equipment bank, etc.

Reimbursement: Provides the following types of consultation:
     
     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Fee/Voluntary
     Willing to Travel                            Fee

Publications/Resources
President/founder and CEO of a consulting firm on 
disability-related issues.  Authored and edited books and 
articles on technology for people with disabilities, financing of 
health care
and assistive technology, spinal cord injury care and treatment, 
and disability research.  

RehabTech Associates has developed the EIF Funding Locator System 
(EIF-FLS).  This System was developed to provide an easy-to-use 
method of obtaining technology funding information on a 
state-by-state basis.

Bryant, Lynn, "Questions and Answers on Wheelchairs Standards," 
TeamRehab Reports, 1991.

Phillips, Lynn and A. Nicosia, "An Overview...with Reflections 
Past and Present of a Consumer in Choosing a Wheelchair System," 
Clinical Supplement #2, Department of Veterans Affairs, March, 
1990.

Phillips, Lynn and P. Axelson, "Wheelchair Standards: Pushing for 
a New Era," Homecare, October, 1989.

Phillips, Lynn, "Technology, Body and Soul," Homecare, June, 
1984.

Phillips, Lynn, "Wheelchairs," Paraplegia News, May 1982.

Christopher Button, Ph.D. 
Deputy Director
Governmental Activities Department
United Cerebral Palsy Associations, Inc. 
1522 K Street N.W., Suite 1112
Washington, D.C. 20005
Telephone:     (202) 842-1266
               (800) 872-5827
Fax:           (202) 842-3519      

Scope of Expertise:  Nationwide; All ages; All disabilities;
All assistive technology and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology;  
     individual problem solving to secure access to assistive 
     technology, and reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Education Programs (IDEA, IDEA Part H, Vocational Education 
     P.L. 89-313).

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Resources/Presentations:
Christopher has lectured extensively and written on the topic of 
assistive technology and is a nationally recognized expert on the 
Individuals with Disabilities Education Act (IDEA) including Part 
H, Early Intervention for Infants and Toddlers with Disabilities 
and the Rehabilitation Act of 1973.  She was instrumental in the 
passage of key amendments related to assistive technology that 
were included in the 1986 reauthorization of the Rehabilitation 
Act, and the subsequent issuance by the Rehabilitation Services 
Administration of the Policy memorandum to state agencies that 
sets important new guidelines concerning implementation of the 
1986 rehabilitation technology amendments.    
Carol Cohen
Team Leader Knowledge Dissemination and Utilization
National Institute on Disability and Rehabilitation Research
U.S. Department of Education
400 Maryland Avenue, S.W.
Washington, D.C. 20202-2645
Telephone:     (202) 732-5066
Fax:           (202) 732-5015

Scope of Expertise:  Nationwide; All ages; Full range of 
assistive technology and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and, reimbursement of assistive technology, 
     specifically:
     Medicaid 
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, PL 89-313).

     Knowledgeable in reimbursement of assistive technology, 
     specifically:
     Maternal and Child Health Programs (Title V)
     Tax Code
     Health insurance
     Workers' Compensation
     Casualty insurance
     Disability insurance.

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending library, equipment banks, etc.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Fee/Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Fee/Voluntary
John C. De Witt
President
De Witt & Associates, Inc.
62 Oak Knoll Road
Glen Rock, New Jersey 07452-1632
Telephone:     (201) 447-5585
Fax:           (201) 447-6483

Scope of Expertise:  Nationwide; All ages; All disabilities with 
particular emphasis on sensory/perceptual limitations as they 
relate to barriers for communication in employment, places of 
public accommodation, transportation and education; Full range of 
assistive technology with particular strength in 
electronic/microprocessor - based technology. 

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology 
     and individual problem solving to secure access to assistive 
     technology.  Knowledgeable in reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code.

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
     Private Sector (corporate) initiatives.

Reimbursement: Provides the following types of consultation to 
all audiences with special interest in working with Federal/State 
agencies, service providers, professional organizations and 
corporations.

     Telephone Inquiries                          Fee/Voluntary
     Private/Contractual Consultation             Fee/Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Willing to Travel                            Fee/Voluntary

Resources/Publications:
John De Witt is a nationally recognized expert on public policy 
and assistive technology.  He has written and lectured 
extensively on the funding of assistive technology, 
telecommunications, transportation, financing assistive
technology and the lending practices of financial institutions, 
and tax law. 

DeWitt, J. 1991. The Role of Technology in Removing Barriers, in 
Americans With Disabilities: From Policy to Practice. New York.

Mendelsohn, S., and De Witt, J. 1991. Assistive Technology in 
Maryland   Funding: Existing Options and Alternative Strategies 
Under Federal/State Funded Programs, State-Based and Private 
Initiatives. Baltimore, MD.

De Witt, J., and Mendelsohn, S. 1990. Establishing a Foundation 
to Pay for Assistive Technology.  RESNA Technical Assistance 
Project, 1101 Connecticut Avenue, NM, Suite 700, Washington, D.C. 
20036.

Alexandra Enders, OTR/L
Associate Director
The University of Montana
The Rural Institute on Disabilities
52 Corbin Hall
Missoula, Montana  59812
Telephone:     (406) 243-5467
Fax:           (406) 243-2349

Scope of Expertise:  Nationwide; All ages; All disabilities; Full 
range of assistive technology devices and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology, and reimbursement of assistive technology, 
     specifically:
     Medicaid  
     Medicare
     Health insurance
     Workers' Compensation
     Casualty insurance
     Disability insurance.

     Knowledgeable in the reimbursement of assistive technology 
     through the Rehabilitation Act.

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
     Do-it-yourself/self approaches

Reimbursement: Provides the following types of consultation:
     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee*
     Presenter at Meetings and Conferences        Fee*
     Personnel/Staff Training                     Fee*
     Willing to Travel                            Fee*
     *negotiable

Publications/Presentations:

Enders, A., editor. Assistive Technology Sourcebook. RESNA Press. 
1990. 1101 Connecticut Avenue, N.W. Washington, D.C. 20036.

Alexandra Enders is a leading national expert on public policy 
and assistive technology.  She has written and presented 
extensively on the financing of assistive technology.  Her
numerous publications have provided new insight and direction for 
professionals, parents and individuals with disabilities 
nationwide.

Karen Sandra Franklin
Project Manager
RESNA Technical Assistance Project
1101 Connecticut Avenue, N.W.
Suite 700
Washington, D.C.  20036
Telephone:     (202) 857-1140

Scope of Expertise:  Nationwide; All ages; All disabilities; Full 
range of assistive technology devices and services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology.  
     Knowledgeable in individual problem solving to secure access 
     to assistive technology, and reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Technology-Related Assistance Act for Individuals with 
Disabilities.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Resources/Presentations: 

As the Manager of the RESNA Technical Assistance Project, Ms. 
Franklin provides technical assistance and information to states 
on the development and implementation of a consumer-responsive 
statewide system of technology-related assistance under the 
Technology-Related Assistance Act for Individuals with 
Disabilities (P.L. 100-407).  Ms. Franklin is a nationally 
recognized leader on promoting and improving access to assistive 
technology for individuals with disabilities.  She has worked 
closely with Congress and federal agencies on technology 
initiatives and she has lectured extensively and written on 
federal and state funding mechanisms for assistive technology 
services.
Jan Galvin
Director
Assistive Technology
Rehabilitation Engineering Program
National Rehabilitation Hospital 
102 Irving Street, N.W.
Washington, D.C. 20010
Telephone:     (202) 877-1498
TDD:           (202) 726-3996
Fax:           (202) 723-0628

Scope of Expertise:  Nationwide; Adult/working-age; mobility 
related disabilities; Full range of assistive technology devices 
and services. 

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, PL 89-313).

     Knowledgeable in alternative strategies for the financing  
     assistive technology, specifically:
     Clearinghouse model, lending libraries, equipment bank, etc.

Reimbursement: Provides the following types of consultation to 
providers, professionals, state agencies, individuals with 
disabilities and families. 

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Papers/Presentations:
Jan Galvin has written and presented extensively on the topic of 
assistive technology.  Listed below are some or the most recent 
papers and presentations:

Galvin, J., Ross, D., Implementing The Americans With 
Disabilities Act: Worksite Accommodations. NARRPS Annual 
Conference, Washington, D.C. March 1991.

Mueller, J., Galvin, J., Developing New Technologies for Worksite
Accommodations. Fourth Annual National Disability Management 
Conference, Florida. October, 1990.

Galvin, J., The Role of the Insurance Industry in the Future of 
Rehabilitation Technology.  Invited presentation to the Insurance 
Research Study Group on Medical Management in Rehabilitation, 
Washington, D.C. May, 1990.

Galvin, J., Phillips, E., What is Appropriate Technology?  Howard 
University Research and Training Center. National Conference on 
Employment of Minority Persons with Disabilities, Washington, 
D.C. March 1990.

Galvin, J., Editor, An Assistive Technology Resource Handbook. 
Rehabilitation Engineering Center, National Rehabilitation 
Hospital, Washington, D.C. September 1989.
Lewis Golinker
Funding Coordinator, Project Mentor
United Cerebral Palsy Associations, Inc.
Associate Counsel 
UCP of New York State
225 Ridgedale Road
Ithaca, New York  14850
Telephone:     (607) 277-7286

Scope of Expertise:  New York State; expertise extends to all 
states; All ages; All disabilities; Full range assistive 
technology devices and services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving; and, reimbursement of assistive 
     technology, specifically:
     Medicaid
     Rehabilitation Act
     Education Programs
     Social Security: PASS.
     
     Knowledgeable in reimbursement of assistive technology, 
     specifically:
     Medicare
     Maternal and Child Health Programs (Title V)
     Private health insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology through publicly operated loan 
     programs.

Reimbursement: Provides the following types of consultation:
     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Resources/Publications
Mr. Golinker is an attorney with 13 years experience representing 
persons with disabilities.  For 10 years, he worked as a staff 
attorney for the New York State Protection and Advocacy program 
where he developed expertise in assistive technology funding.  
Mr. Golinker is nationally recognized as an expert in assistive 
technology funding.  He has conducted training and provides 
technical assistance and litigation support for 26 affiliates of 
UCPA, RESNA Technical Assistance Project, National Association of
Protection and Advocacy Systems, and the American 
Speech-Language-Hearing Association with regard to the funding of 
assistive  technology.

Golinker, L., Monograph: Principal Assistive Technology Caselaw, 
Washington, D.C.: United Cerebral Palsy Associations Inc.; 
February 1991.

Morris, M. & Golinker, L. Assistive Technology: A Funding 
Workbook, Washington, D.C.: RESNA Press; January 1991.
Bob Griss
Senior Health Policy Researcher
United Cerebral Palsy Associations, Inc. 
1522 K Street, N.W. Suite 1112
Washington, D.C. 20005
Telephone:     (202) 842-1266
               (800) 872-5827
Fax:           (202) 842-3519

Scope of Expertise:  Nationwide; All ages; All disabilities;
All assistive technology and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology, 
     and individual problem solving to secure access to assistive 
     technology; and, reimbursement of assistive technology, 
     specifically: 
     Medicare 
     Health Insurance.

     Knowledgeable in reimbursement of assistive technology, 
     specifically:
     Medicaid 
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code
     Insurance Coverage
     Workers' Compensation
     Casualty Insurance
     Disability Insurance.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Fee/Voluntary
     Willing to Travel                            Fee/Voluntary

Resources/Presentations:  

Bob Griss is nationally recognized as an expert on private health 
insurance, health care financing, and Medicare.  He is the author 
of Access to Health Care, a four volume series of health policy 
bulletins analyzing the health care needs of persons with 
disabilities.   

Colleen Haney
Augmentative Communication Specialist/Coordinator
Pennsylvania Assistive Device Center
150 S. Progress Avenue
Harrisburg, Pennsylvania  17109
Telephone:     (800) 222-7372 (PA only) 
               (717) 657-5840
Fax:           (717) 657-5895

Scope of Expertise:  Pennsylvania (ideas may be generalized 
across the nation; Birth-23 year(s); All disabilities; 
Augmentative communication devices, computer access, writing and 
vision aids, amplification aids, environmental control units.
     Knowledgeable in reimbursement of assistive technology, 
     specifically education programs (IDEA, P.L. 99-457, 
     Vocational Education, P.L. 89-313).  Expertise in 
     alternative strategies for the financing of  assistive 
     technology, specifically:
     Innovative state planning
     Publicly operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.

Reimbursement: Provides the following types of consultation:
     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Fee
     Willing to Travel                            Fee

Publications
"Implementing the Technology: Successful Use of Minspeak and 
Words Strategy" Proceedings of the 4th Annual Minspeak 
Conference, St. Louis, MO, 1989.

"The Augmentative Communication Profile" Pennsylvania Assistive 
Device Center, Harrisburg, Pennsylvania, 1986, revised 1989.

"Across All Levels: Minspeak in Action" Proceedings of the 3rd 
Annual Minspeak Conference, Anneheim, California, 1988.

"Over 100 Minspeak Systems in Pennsylvania: What's Happening?" 
Proceedings of the Second Annual Minspeak Conference, New 
Orleans, 1987.

"The Assessment and Evaluation of Clients for Augmentative 
Communication Systems: The Pennsylvania Model,"  National 
Planners Conference on Assistive Device Service Delivery, 
Chicago, Illinois 1987.
Richard Hemp
Co-ordinator Technical Assistance
University Affiliated Program in Developmental Disabilities
University of Illinois at Chicago 
1640 West Roosevelt Road
Chicago, Illinois  60608
Telephone:     (312) 413-1976
Fax:           (312) 413-1326

Scope of Expertise:  Nationwide; All ages; All disabilities with 
emphasis on developmental disabilities; Full range of assistive 
technology devices and services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     knowledgeable in individual problem solving to secure access 
     to assistive technology; and, reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     State Agency programs.

Reimbursement: Provides the following types of consultation to a 
wide range of audiences:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Travel                                       Fee
Anna C. Hofmann
Marketing Coordinator
Phonic Ear, Inc. 
3880 Cypress Drive
Petaluma, California 94954-7600
Telephone:     (707) 769-1110 
Fax:           (707) 769-9624

Scope of Expertise:  Nationwide; Primarily children and young 
adults; all disabilities with primary interest in cerebral palsy 
and other causes of loss of speech, i.e. accident, stroke, etc. 
Augmentative communication devices.

     Expertise in individual problem solving to secure access to 
     assistive technology.  Knowledgeable in reimbursement of 
     assistive technology, specifically:
     Medicaid 
     Medicare
     Health insurance.


Reimbursement: Provides the following types of consultation:

     Presenter at Meetings and Conferences        Fee
     Willing to Travel                            Fee*

     *Fee is conditional

Publications:
"The Many Faces of Funding ...." 
     Monthly newsletter on funding and federal legislation 
     affecting individuals who are nonverbal.

Terry Holden
Physical Therapist/Therapy Coordinator
Children's Special Health Services
P.O. Box 16650
Salt Lake City, Utah  84116-0650
Telephone:     (801) 538-6165
Fax:           (801) 538-6510

Scope of Expertise:  Utah; Birth-18 year(s); Disabilities 
resulting from cerebral palsy, spina bifida, muscular dystrophy, 
and congenital. Assistive technology for mobility, seating and 
positioning, adaptive recreational equipment, augmentative 
communication.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology.  
     Expertise in individual problem solving to secure access to 
     assistive technology; and, reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Maternal and Child Health Programs (Title V)
     Health Insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology in the state of Utah.
 
Reimbursement: Provides the following types of consultation: 

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee

Deborah Kaplan
Director
Division of Technology Policy
World Institute on Disability
510 16th Street 
Oakland, California 94612-1522 
Telephone:          (510) 763-4100
Fax:                (510) 763-4109

Scope of Expertise:  Nationwide; All ages; All disabilities; Full 
range of assistive technology devices and related services with 
expertise in telecommunications systems, services and devices.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     and, individual problem solving to secure access to 
     assistive technology.  Expertise in financing assistive 
     technology for individuals with disabilities in 
     telecommunications systems.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee


Publications/Presentations:

Deborah Kaplan is nationally recognized for her work in the field 
of telecommunications systems and the financing of assistive 
technology for individuals with disabilities.  Ms. Kaplan has 
presented and written extensively on this topic.  Resources on 
the issue are available by contacting the World Institute on 
Disability.
Joy Kniskern
Rehabilitation Technology Manager
Georgia Division of Rehabilitation Services
878 Peachtree Street, N.E. Room 706
Atlanta, Georgia  30309
Telephone:     (404) 853-9151 
Fax:           (404) 853-9059

Scope of Expertise:  Nationwide with expertise in Georgia; Adults 
(16-65 years); All disabilities; General knowledge on the full 
range of assistive technology and related services with a 
commitment to identifying funding alternatives.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and, reimbursement of assistive technology, 
     specifically:
     Medicaid 
     Rehabilitation Act.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically, publicly operated loan 
     programs.

Reimbursement: Provides the following types of consultation to 
state rehabilitation agencies:

     Telephone Inquiries                Voluntary

Publications/Presentations:

"The Funding Dilemma, A Primer for Novices," News Update, Center 
for Rehabilitation Technology, Georgia Institute of Technology, 
April, 1990.

"New Uses of Technology for Transdisciplinary Service Delivery 
Teams," RESNA, 1990. 

"A Systems Integration Model for Assistive Technology Resource 
Development," Touch the Future Proceedings, 1989.

Low Cost Aids for Daily Living for the Geriatric Population, 
Panel Coordinator, Georgia Conference on Aging, May, 1989.

Technology and Employment, Panel Coordinator, Touch the Future, 
December, 1986.

Elaine K. Koch
Funding Coordinator
Prentke Romich Company
1022 Heyl Road
Wooster, Ohio  44691
Telephone:     (800) 262-1984
Fax:           (216) 263-4829


Scope of Expertise:  Nationwide; All ages; All disabilities; 
Augmentative communication devices.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology.  Expertise in reimbursement of assistive 
     technology specifically:
     Health insurance coverage
     Medicaid 
     Medicare.

     Knowledgeable in alternative strategies for the financing of 
assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee

Presentations:

Funding Options Panel, Add-Tech '90, A Conference n Assistive 
Technology, Boston, MA, September 1990.

AAC Devices Paid for by State Medicaid Programs, Poster, 6th 
Annual Minspeak Conference, Minneapolis, MN, October 1991.

Let's Talk About Finding, Panel, Turning on to Technology, Ohio 
Special Education regional Resource Centers, Kent State 
University, March 1991.

Selecting, Funding and Supporting Augmentative Communication 
Systems, Panel, Ohio Speech and Hearing Convention, Toledo, March 
1990 .
Diana Kubovcik
Clinical Manager
Options For Elders
Central Ohio Area Agency on Aging 
275 S. Gift Street
Columbus,  Ohio  43214
Telephone:     (614) 645-7250
Fax:           (614) 645-3884


Scope of Expertise:  Nationwide; Seniors; All disabilities; Full 
range of assistive technology devices and related services.  
Expertise includes mental health needs, independent living needs, 
elder abuse issues and related management and administration 
components of a community-based system for seniors.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology.  
     Knowledgeable in planning a complete community-based system 
     of care for seniors in a large urban area.  Expertise 
     includes planning a system of care for a large urban area 
     including central access and leveraging of funding from a 
     variety of several sources for community-based home care and 
     mental health services.


Reimbursement: Provides the following types of consultation with 
special expertise in agency (public and private) planning 
strategies; professionals in urban areas in particular:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee

Justine Maloney
Executive Committee
Learning Disabilities Association
3115 North 17th Street
Arlington, Virginia  22201
Telephone:     (703) 243-2614
Fax:           (703) 243-2614


Scope of Expertise:  Nationwide; All ages; Learning disabilities, 
attention deficit disorder (ADD); Special emphasis on computers.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and, reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, PL 89-313).


Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Voluntary
     Written Correspondence                       Voluntary





Sharon Meek
Technology Case Manager Coordinator
Access Group
1776 Peachtree Road, N.W.
Suite 310 N
Atlanta, Georgia  30309
Telephone:          (800) 821-8580 
Fax:                (404) 888-9091

Scope of Expertise:  Nationwide with expertise in southeast 
region of the United States; All ages; All disabilities; Full 
range of assistive technology devices and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology;  
     individual problem solving to secure access to assistive 
     technology, and reimbursement of assistive technology 
     specifically:
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, PL 89-313).

     Expertise in alternative strategies for the financing of  
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
     Corporate strategies.
     
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Steven Mendelsohn
Smiling Interface 
P.O. Box 2792
Church Street Station
New York, New York 10008-2792
Telephone:     (212) 222-0312
               (415) 864-2220

Scope of Expertise:  Nationwide; all ages; All disabilities; Full 
range of assistive technology and related services with special 
emphasis on sensory aids technology.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Tax Code/Tax Law
     Health insurance coverage
     Workers' Compensation
     Casualty insurance
     Disability insurance.

     Expertise in alternative strategies for the financing of  
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
     Manufactures/vendor-based financing
     Assistive technology company market development strategies.
 
Reimbursement:  Provides the following types of consultation:
     Telephone Inquiries                          Fee/Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee
     Publishing                                   Fee
Publications/Presentations:
Steve Mendelsohn is a consumer who is an attorney and 
rehabilitation practitioner.  His practical experience and 
expertise bring an insightful perspective to the area of funding.  
He has lectured extensively on technology and policy issues.  
He was the 1989 Switzer Scholar for the report, "Public Policy in 
Relation to Assistive Technology."

Mendelsohn, S., Financing Adaptive Technology: A Guide to Sources 
and Strategies for Blind and Visually Impaired Users, Smiling 
Interface, 1987, New York.
Reese Michaels
President
Hygeia Medical Supply Company, Inc.
555 Westbury Avenue
Carle Place, New York  11514
Telephone:     (516) 997-8150
Fax:           (516) 997-8093

Scope of Expertise:  New York (ideas can be generalized to other 
states); All ages; All disabilities
All technology devices and related services.

     Expertise in reimbursement of assistive technology through 
     Medicare.  Knowledgeable in reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Rehabilitation Act
     Education programs (IDEA, Vocational Education, P.L. 89-313)
     Health insurance
     Workers' Compensation
     Casualty insurance
     Disability insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically: 
     Publicly operated loan programs
     Privately operated loan programs.


Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Written Correspondence                       Voluntary

Judith K. Montgomery
Director Special Education
Fountain Valley School District
35 Lakeview
Irvine, California  92714
Telephone:     (714) 857-1478 
               (714) 843-3280
Fax:           (714) 843-3265

Scope of Expertise:  Nationwide; Birth-22 year(s). All 
disabilities with special expertise in cerebral palsy; ALS, 
traumatic brian injury; cytomegalic virus (CMV); and other 
developmental disabilities.  Assistive technology used for 
teaching and learning academics, school and leisure. Expertise in 
augmentative and alternative communication devices.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically: 
     Education Programs (IDEA, Vocational Education, P.L. 89-313) 
     Private health insurance.

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically:
     Privately operated loan program
     Clearinghouse model, lending libraries, equipment bank, etc.
     Local support groups
     National philanthropic organizations. 


Reimbursement: Provides the following types of consultation and 
technical assistance to state agencies, school districts and 
interagency cooperatives:          

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee  
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee
Michael Morris
Deputy Executive Director
United Cerebral Palsy Associations, Inc
1522 K Street, N.W. Suite 1112
Washington, D.C. 20005
Telephone:     (202) 842-1266  
               (800) 872-5827
Fax:           (202) 842-3519

Scope of Expertise:  Nationwide; All ages; Across disabilities; 
Full range of assistive technology devices and related services.

     Knowledgeable in individual problem solving to secure access 
     to assistive technology.  Expertise in barriers 
     identification and systems change problem solving in 
     securing access to assistive technology and reimbursement of 
     assistive technology, specifically:
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, PL 89-313).

     Knowledgeable in reimbursement of assistive technology, 
     specifically: 
     Medicaid
     Tax Code.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee

Resources/Publications:

Michael Morris is nationally recognized as a leader in promoting 
improved access to assistive technology.  He has written and 
presented extensively on the topic of the financing of assistive 
technology.  Through Michael's direction, UCPA has developed a 
significant record of accomplishments in policy and program 
development with regard to assistive technology on a state and 
national level.  Michael is also the project manager for NCD's  
National Finance Study on Assistive Technology for Individuals 
with Disabilities.

Morris, M. & Golinker, L. Assistive Technology: A Funding 
Workbook, Washington, D.C.: RESNA Press, January 1991. 
Joyce Munson-Davis, Ph.D.
Speech Pathologist
Child and Development Rehabilitation Center
Oregon Services for Children with Special Healthcare Needs
P.O. Box 547
Portland Oregon  97207-0574
Telephone:     (503) 494-4632
Fax:           (503) 494-4447

Scope of Expertise:  Oregon/Washington; infants and children with 
neuromotor/metabolic/traumatic/developmental disabilities; birth 
to 21 year(s); Mobility and communication assistive technology 
and related services.

     Expertise includes barriers identification and systems 
     change problem solving in securing access to assistive 
     technology; individual problem solving to secure access to 
     assistive technology; Knowledgeable in reimbursement of 
     assistive technology, specifically:
     Medicaid  
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Health Insurance. 
 
     Knowledgeable in the financing of assistive technology, 
     specifically through alternative strategies (i.e. 
     clearinghouse model, lending libraries, equipment banks, 
     etc.).
 
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Fee
     Willing to Travel (limited)                  Fee

Bill N. Newroe
Funding Specialist
New Mexico Technology Assistance Program
State of New Mexico
Department of Education
Division of Vocational Rehabilitation
604 W. San Mateo 
Santa Fe, New Mexico  87505
Telephone:     (505) 827-3533  
               (800) 866-2253 (New Mexico)
Fax:           (505) 827-3746

Scope of Expertise:  New Mexico/Southwest; All ages; All 
disabilities; Full range of assistive technology and related 
services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology.  Knowledgeable in reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, PL 89-313).

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically: 
     Clearinghouse model, lending libraries, equipment bank, etc.
     Private volunteer organizations in New Mexico
     Information sharing with database management systems
     Client and referral coordination systems.

Reimbursement:  Provides the following types of consultation:

     Telephone Inquiries                          Fee/Voluntary
     Private/Contractual Consultation             Fee/Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Fee/Voluntary
     Willing to Travel                            Fee/Voluntary

Marcia R. Nunnally, MEd, OTR/L
Occupational Therapist-Private Practice
P.O. Box 17282
Spartanburg, S.C. 29301
Telephone:     (803) 574-3352

Scope of Expertise:  Nationwide with expertise in South Carolina; 
All ages with special interest in technology for seniors; All 
disabilities; Adaptive computer access, alternative input 
methods, augmentative communication, low-tech devices, 
environmental control, seating and positioning, and independent 
mobility.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology 
     and individual problem solving to secure access to assistive 
     technology.  Knowledgeable in reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Medicare
     Health insurance coverage
     Workers' compensation
     Disability insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Clearinghouse model, lending libraries, equipment banks 
     Local resources and private groups. 

Reimbursement: Provides training and assistance to a varied 
audience.  Currently preparing a unique training program for 
professionals and caregivers in long-term care.  Provides 
introductory training on assistive technology for all ages and 
disabilities including the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee  

Publications/Presentations:

Nunnally, M. "Funding; the Private Practice Perspective" Spectrum
Fall, 1989.

Developed/Instructed graduate course, "Technology and Exceptional 
Populations."

Peg O'Brien
Funding Policy Analyst
Technology-Related Assistance for Individuals with Disabilities 
(TRAID) Project
NYS Office of Advocate for the Disabled
One Empire State Plaza, 10th Floor
Albany, New York  12223-0001
Telephone:     (518) 474-2825 (voice) 
Fax:           (518) 473-6005 (TDD)

Scope of Expertise:   Nationwide regarding the State of New York 
and general information pertaining to a broad range of 
disabilities; All ages; Broad range of assistive technology 
devices and services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     Individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Medicaid
     Rehabilitation Act 
     Education Programs (IDEA, Vocational education, P.L. 89-313)
     Supplemental Security Income: PASS
     Medicare
     Maternal and Child Health Programs (Title V)
     Health insurance coverage.    

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
 
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary*
     Personnel/Staff Training                     Fee/Voluntary*
     Willing to Travel                            Fee/Voluntary*

*Pending State of New York Approval

Alicia Hahne Oestmann
Funding Coordinator
Nebraska Assistive Technology Project
301 Centennial Mall South 6th Floor
P.O. Box 94987
Lincoln, Nebraska  68509
Telephone:     (402) 471-0733
Fax:           (402) 471-2701

Scope of Expertise:  Nebraska; All ages; All disabilities; Full 
range of assistive technology devices and services

     Expertise barriers identification and systems change problem 
     solving in securing access to assistive technology; and 
     individual problem solving to secure access to assistive 
     technology.  Knowledgeable in reimbursement of assistive 
     technology, specifically: 
     Medicaid 
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Health insurance coverage.
     
Reimbursement: Provides the following types of consultation in 
Nebraska.
 
     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Voluntary

Pat Ourand MS, CCC-SP
Funding Coordinator
Maryland Technology Assistance Program
2301 Argonne Drive
Baltimore, Maryland 21218
Telephone:          (410) 554-3202
Fax:                (410) 554-3206

Scope of Expertise:  State of Alaska; Primarily adults and 
seniors; All disabilities; Augmentative/Alternative Communication 
Devices and related services.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Medicare
     Rehabilitation Act
     Education programs (IDEA, Vocational Education, P.L. 89-313)
     Workers' Compensation.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
 
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee/Voluntary

Resources:  

An assistive technology funding resource book for the State of 
Maryland will soon be available through the Maryland Technology 
Assistance Program. 
Joyce Palmer
Administrator
Assistive Technologies of Alaska
400 D Street, Suite 230
Anchorage, Alaska  99501
Telephone:     (907) 274-0138 
Fax:           (907) 274-0516

Scope of Expertise:  Nationwide with expertise in the State of 
Alaska; Primarily adults; Individuals who are blind or low vision 
is specialty with working knowledge of all disabilities; 
Assistive technology for individuals who are blind and low vision 
(i.e. scanners, CCTV(s), speech programs, electronic braillers.)  

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Tax Code
     Workers' Compensation.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
 
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Voluntary*

     *Reimbursement for costs associated with travel

Resource:

Fact sheet on Alaska assistive technology funding resources 
avaialble. 

Deborah Parker-Wolfenden, M.Ed. CCC-SLP
Funding Researcher/Policy Analyst
Division of Special Education
Maine Department of Education
RR4 Box 4325
Freeport, Maine  04032
Telephone:     (207) 688-4809

Scope of Expertise:  Maine (ideas can be generalized to other 
states; Birth-64 year(s); All disabilities with primary interest 
in communication disabilities; Full range of assistive technology 
with expertise in augmentative communication devices.

     Expertise in reimbursement of assistive technology, 
     specifically:
     Medicaid 
     Education Programs (IDEA, Vocational Education, PL 89-313).

     Knowledgeable in reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Maternal and Child Health Programs (Title V)
     Health insurance coverage.
 
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Fee
     Willing to Travel                            Fee


Publications/Presentations:
"How to Pay for Assistive Technology; Worst Care Scenario to the 
Best Case Reality." July 1991.

"Public and Private Insurance Access Issues for Children and 
Families." April 1991.

"Accessing Third Party Sources for Educational Services: Is It 
The Pot of Gold at the End of the Rainbow." May 1990.
Sandra Peterson
Third Party Billing Coordinator
Oregon Department of Education
Office of Medical Assistance Programs
700 Pringle Parkway Suite 600
Salem, Oregon 97310
Telephone:     (503) 378-3598
Fax:           (503) 373-7968


Scope of Expertise:  Oregon; Birth-21 year(s); All disabilities; 
All assistive technology devices and related services.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology 
     and reimbursement of assistive technology, specifically:
     Medicaid 
     Education Programs.


Reimbursement: Provides the following types of consultation, 
training and technical assistance for state agencies, providers 
and professionals.

     Telephone Inquiries                          Fee/Voluntary
     Private/Contractual Consultation             Fee/Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Fee/Voluntary
     Willing to Travel                            Fee/Voluntary


Sheron R. Rice
Special Projects Administrator
American Foundation for the Blind
New York, New York  10011
Telephone:     (212) 620-2117
Fax:           (212) 620-3127

Scope of Expertise:  Nationwide; All ages; All disabilities with 
primary interest in individuals who are visually impaired or 
blind; assistive technology for visually impaired or blind.

     Knowledgeable in individual problem solving to secure access 
     to assistive technology.  Expertise in reimbursement of 
     assistive technology through alternative strategies,  
     specifically:
     Publicly operated loan programs 
     Privately operated loan programs 
     Clearinghouse model, lending libraries, equipment bank, etc.
 
Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee*

*depending on agency involved, if reimbursed for travel and per 
diem, fee may be waived.

Presentations:

Rice, S. Schreier, E. "Funding Assistive Technology Charting the 
Waters of Loan Programs" Paper presented at the California State 
University Conference, March 1991.

Janina Sajka
President, Baytalk
General Manager, WIDNET
World Institute on Disability
510 16th Street
Oakland, California  94612-1502
Telephone:     (510) 763-4100
Fax:           (510) 763-4109

Scope of Expertise:  Nationwide; All ages; All disabilities with 
expertise in blind and vision disabilities; Computers and 
telecommunications systems.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     knowledgeable in individual problem solving to secure access 
     to assistive technology and alternative strategies for the  
     financing of assistive technology, specifically:
     Publicly operated loan programs 
     Private loan programs
     Clearinghouse model, lending libraries; equipment bank; etc. 
 
Reimbursement:  Provides the following types of consultation to a 
wide range of audiences:

     Telephone Inquiries                          Voluntary
     Presenter at Meetings and Conferences        Fee
     Willing to Travel                            Fee
     


William M. Salyers, Ed.D
Director
Computer Assistive Technology Services
National Easter Seal Society
70 east Lake Street, 9th Floor
Chicago, IL  60601-5907
Telephone:          (312) 726-6200
Fax:                (312) 726-1494

Scope of Expertise:  Nationwide; All ages; All disabilities; 
Computer assisted technology access and technology access in 
employment.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology, and reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education P.L. 89-313)
     Workers' Compensation
     Casualty insurance
     Disability insurance.

     Knowledgeable in reimbursement of assistive technology, 
     specifically:
     Medicaid/Medicare
     Maternal and Child Health Programs (Title V)
     Tax Code
     Private health insurance 
     
     Expertise in alternative strategies for the financing of 
     assistive technology including;
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
     Corporate strategies.

Reimbursement: Specializes in telephone assistance;  skilled in 
developing an awareness of technology, providing an orientation 
to technology, and in training at a technical level.

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee
Lawrence A. Scadden, Ph.D.
Director
Rehabilitation Engineering Center
Electronic Industries Foundation
919 18th Street N.W Suite 900
Washington, D.C. 20006
Telephone:     (202) 955-5823
Fax:           (202) 955-5837


Scope of Expertise:  Nationwide; All ages; All disabilities with 
expertise in sensory-related disabilities; Full range of 
assistive technology devices and related services with expertise 
in computers and sensory-related technology.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology, and reimbursement of assistive technology 
     through the Rehabilitation Act. 
     
     Knowledgeable in reimbursement of assistive technology, 
     specifically:
     Medicaid 
     Medicare
     Education programs (IDEA, Vocational Education, P.L. 89-313) 
     Maternal and Child Health (Title V)
     Tax Code
     Health insurance.


Expertise in alternative strategies for the financing of 
assistive technology, specifically: 
     Publicly operated loan programs
     Privately operated loan programs.


Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Presenter at Meetings and Conferences        Fee/Voluntary
     Personnel/Staff Training                     Fee
     Willing to Travel                            Fee

Resource Information/Presentations:
The Electronic Industries Foundation conducts research related to 
public and private sector policies and practices that affect the 
production and distribution of technology for people with 
disabilities.  Dr. Scadden has conducted extensive research on 
the development and evaluation of assistive technology for people
with visual and auditory impairments.  He has served in an 
advisory capacity for numerous private organizations both 
nationally and internationally.  He is a nationally recognized 
expert on assistive technology for individuals with sensory 
impairments.  Dr. Scadden has written and presented extensively 
on a range of the topics related to assistive technology.

Katherine D. Seelman, Ph.D.
Research Specialist
National Council on Disability
800 Independence Avenue, S.W.
Washington, D.C.  20540
Telephone:     (202) 267-3846 
Fax:                (202) 453-4240

Scope of Expertise:  Nationwide; All ages; All disabilities;  
Full range of assistive technology devices and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology. 
     Knowledgeable in individual problem solving to secure access 
     to assistive technology.  Knowledgeable in reimbursement of 
     assistive technology, specifically:

     Medicaid
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Voc. Ed, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code
     Health insurance coverage
     Workers' compensation
     Casualty insurance 
     Disability insurance

     Expertise in the financing of assistive technology through 
     alternative strategies including:
     Publically operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending library, equipment bank,etc. 
 
Reimbursement: Provides the following types of consultation with 
strengths in training government agencies, professionals and 
consumers.  Experience with problems of access to buildings, 
transportation and communications.  Conducted seminars and 
outreach to universities, associations, government and industry.

     Telephone Inquiries                          Voluntary
     Willing to Travel                            Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Willing to travel                            Fee

William L. Self
Vocational Rehabilitation Counselor
State of Oregon
1245 S.E. 122nd Avenue
Portland, Oregon  97233
Telephone:     (503) 257-4412 
Fax:           (503) 257-4333

Scope of Expertise:  Oregon; 18-65 years; Orthopedic and visual 
disabilities; Assistive technology for individuals with 
orthopedic and/or visual disabilities.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology 
     and individual problem solving to secure access to assistive 
     technology.  Expertise in reimbursement of assistive 
     technology, specifically:
     Rehabilitation Act
     Workers' compensation.

     Knowledgeable in the financing of assistive technology 
     through alternative strategies (i.e. clearinghouse model, 
     lending libraries, equipment bank, etc.).
 
Reimbursement: Provides the following types of consultation 
primarily with clients of vocational rehabilitation:

     Telephone Inquiries                          Voluntary
     Willing to Travel                            Voluntary

Jolene Y. Shimada
Speech-language Pathologies M.S.-CCC
1394 Amesbury Circle
Salt Lake City, Utah  84121
Telephone:     (801) 277-7162 (Home) 
               (801) 268-8585 (Work) 



Scope of Expertise:  Salt Lake City, Utah; 3-21 years; 
Individuals with physical and cognitive disabilities; 
Augmentative communication devices.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     and, individual problem solving to secure access to 
     assistive technology.  Expertise in alternative strategies 
     for the financing of assistive technology, specifically: 
     Publicly operated loan programs;  
     State agency funding
     Case development/case management for funding justification.
 


Reimbursement: Provides the following types of consultation to 
those who have been evaluated by the state 
Alternative/Augmentative Communication Teams:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary



Patrick A. Terick
Director of Governmental Affairs
Cerebral Palsy Research Foundation
2021 North Old Manor
P.O. Box 8217
Wichita, Kansas  67208-0217
Telephone:     (316) 688-1888
Fax:           (316) 688-5687

Scope of Expertise:  Midwest/State of Kansas; All Ages with 
primary interest in 18 years and older; All disabilities; 
Primarily employment-related technology.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Tax Code
     State General Funds.

     Knowledgeable in reimbursement of assistive technology, 
     specifically: 
     Medicare
     Medicaid
     Maternal and Child Health Programs (Title V)
     Health insurance coverage
     Workers' Compensation
     Casualty insurance
     Disability insurance.

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee
Michael Towey
Speech/Language Pathologist
P.O. Box 287 - Waldo Hospital 
Belfast, Maine  04915
Telephone:     (207) 338-2500 
Fax:           (207) 338-6029


Scope of Expertise:  Maine; Birth-21 year(s); Communication 
disabilities; Augmentative Communication Systems with expertise 
in pre-language training.
 
     Knowledgeable in individual problem solving to secure access 
     to assistive technology and reimbursement of assistive 
     technology, specifically:
     Medicaid 
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Health insurance.


Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Fee
     Willing to Travel                            Fee

Lawrence H. Trachtman
Assistant Project Director
North Carolina Assistive Technology Project
1110 Navaho Drive, Suite 101
Raleigh, North Carolina  27609
Telephone:          (919) 850-2787
Fax:                (919) 850-2792

Scope of Expertise:  Nationwide with expertise in South and North 
Carolina; All ages; All disabilities; Full range of assistive 
technology devices and related services.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     and, individual problem solving to secure access to 
     assistive technology. 

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically: 
     Publicly operated loan programs 
     Identification of funding resources in South/North Carolina.

Reimbursement: Provides the following types of consultation 
expertise in state planning especially in the area of alternative 
approaches to financing such as loan programs:
     Telephone Inquiries                          Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Voluntary

Publication/Resources/Presentations:

Editor-in-Chief Elect, Assistive Technology, the official journal 
of RESNA (November 1991 to present).

Wiles, D.L. and Trachtman, L.H. "Payment for Assistive 
Technology: Options for the 1990s," Proceedings of the Southeast 
Regional Symposium on Assistive Technology: Current Practices in 
Service Delivery, March 1990, Myrtle Beach, South Carolina.

Trachtman, L.H. "Developing an Assistive Technology Funding 
Resources Guide in South Carolina," Proceedings of Touch the 
Future, Second Southeast Regional Conference on Assistive 
Technology, November 1989, Atlanta, GA.

"State Funding Resources Identification." Presented for the 
Center for Special Education Technology State Forum Audio 
Teleconference on Technology Funding - Issues and Answers, Part 1 
May 1990, West Columbia, S.C.

"South Carolina Statewide Initiative." Presented for the 
S.M.A.R.T. Exchange audio teleconference on Reimbursement 
Strategies for Assistive Technology Devices, August 1989, West 
Columbia, SC.

"Innovative and Alternative Programs for Funding Assistive 
Technology," A special session hosted by SIG-01. Organizer and 
panel moderator at the 13th Annual RESNA Conference on 
Rehabilitation Technology, June 1990, Washington, DC.

"A Guide to Funding Resources for Assistive Technology in South 
Carolina, " Anderson, S.L., Stevens, J.H. and Trachtman, L.H. 
January 1990.

"Funding Resources for Assistive Technology in South Carolina," 
Report of a symposium held July 11-13, 1989. Trachtman, L.H. 
Langton, A.J. and Anderson, S.L. August 1989.
Steven C. Tremblay
Founder/Executive Director
Adaptive Living Programs for Handicapped Americans (ALPHA) One 
Independent Living Center
85 E. Street 
South Portland, Maine  04106 
Telephone:     (207) 767-2189

Scope of Expertise:  Maine (ideas can be generalized to other 
states); All ages; All disabilities; Full range of assistive 
technology devices and services.
     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Medicaid/ Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Tax Code
     Insurance Coverage.

     Knowledgeable in reimbursement of assistive technology, 
     specifically: 
     Private health insurance
     Workers' Compensation
     Casualty insurance
     Disability insurance.

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically: 
     Publicly operated loan programs; 
     Privately operated loans programs; 
     Clearinghouse model; lending libraries, equipment bank, etc.
 
Reimbursement: Provides the following types of consultation:
     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Fee
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary 
     Willing to Travel                            Fee

Resources:
Founder, Wheelchairs Unlimited
Founder and Executive Secretary, Adaptive Environments
Information HUB manager for Maine Consumer Information and 
Technology Training Exchange (CITE)
Debra J. Waln
Medical Policy Analyst
Office of Medical Assistance Programs
203 Public Service Building
Salem, Oregon  97310
Telephone:     (503) 378-5581
Fax:           (503) 373-7689

Scope of Expertise:  Oregon; All disabilities; Augmentative 
communication devices and related services.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology. 
     Expertise in reimbursement of assistive technology through 
     Medicaid.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
 

Reimbursement: Provides the following types of consultation 
training and technical assistance to state agencies, providers 
and professionals:
     
     Telephone Inquiries                          Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Reimbursement



Andy J. Winnegar, Jr.
Director
New Mexico Technology Assistance Program
State of New Mexico
Department of Education
Division of Vocational Rehabilitation
604 W. San Mateo 
Santa Fe, New Mexico  87505
Telephone:     (505) 827-3533
Fax:           (505) 827-3746


Scope of Expertise:  Nationwide; All ages; All disabilities; Full 
range of assistive technology and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and reimbursement of assistive technology, 
     specifically:
     Medicaid 
     Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Health insurance coverage
     Workers' compensation
     Casualty insurance
     Disability insurance.
     
Reimbursement: Provides the following types of consultation to 
consumers and state agencies:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Steven C. White, Ph.D.
Director
Healthcare Financing Division
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, Maryland  20852
Telephone:     (301) 897-5700
Fax:           (301) 571-0457

Scope of Expertise:  Nationwide; All ages; All disabilities; 
Augmentative communication devices. 

     Expertise in reimbursement of assistive technology 
     specifically:
     Medicaid 
     Medicare 
     Health insurance coverage.

Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Fee
     Written Correspondence                       Voluntary
     Willing to Travel                            Fee

Resources:

Steve White is nationally recognized as a leader in promoting and 
improving access to assistive technology.  He has worked closely 
with Congress and federal agencies on technology initiatives and 
has written and lectured extensively on the financing of 
assistive technology for individuals with disabilities with 
expertise on augmentative and alternative communication devices.

Rachel Wobschall
Executive Director
STAR Program
300 Centennial Building
658 Cedar Street
St. Paul, Minnesota  55155
Telephone:     (612) 297-1554
Fax:           (612) 297-7200

Scope of Expertise:  Nationwide with expertise in the State of 
Minnesota; All ages; All Disabilities; Full range of assistive 
technology devices and services.
     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     knowledgeable in individual problem solving to secure access 
     to assistive technology; and, reimbursement of assistive 
     technology, specifically:
     Medicaid/Medicare
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Private Health Insurance 
     Workers' Compensation
     Casualty insurance.

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs;
     Privately operated loan programs;
     Clearinghouse model, lending libraries, equipment bank, etc. 
Reimbursement: Provides the following types of consultation to a 
wide range of audiences:
     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Fee
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Fee/Voluntary
     Written Correspondence                       Fee/Voluntary
     Willing to Travel                            Fee/Voluntary

Presentations:
Rachel Wobschall has written and presented extensively of the 
subject of interagency collaboration and agency initiatives which 
promote the use of assistive technology as a model for other 
states.  Rachel is the Executive Director of the Governor's 
Advisory Council on Technology for People with Disabilities and 
is a recognized national leader in promoting improved access to 
assistive technology and the involvement of primary and secondary 
consumers in the process of systems change.
Bonnie Wooten-Webb
Project Director
Access Group
1776 Peachtree Road, N.W.
Suite 310 N
Atlanta, Georgia  30309
Telephone:     (800) 821-8580 
Fax:           (404) 888-9091

Scope of Expertise:  Nationwide with expertise in the southeast 
region of the United States; All ages; All disabilities; Full 
range of assistive technology devices and related services.

     Expertise in barriers identification and systems change 
     problem solving in securing access to assistive technology;  
     individual problem solving to secure access to assistive 
     technology, and reimbursement of assistive technology 
     specifically:
     Rehabilitation Act
     Education Programs (IDEA, Vocational Education, PL 89-313).

     Expertise in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Privately operated loan programs
     Clearinghouse model, lending libraries, equipment bank, etc.
     Corporate strategies.
     
Reimbursement: Provides the following types of consultation:

Telephone Inquiries                          Voluntary
Private/Contractual Consultation             Fee
Presenter at Meetings and Conferences        Fee
Personnel/Staff Training                     Fee
Written Correspondence                       Voluntary
Willing to Travel                            Fee

Debra Wynkoop-Green
Director Planning and Program Development
120 North 200 West #201
Salt Lake City, Utah  84103
Telephone:     (801) 538-4200
Fax:           (801) 538-4279

Scope of Expertise:  Utah; Children and adults with developmental 
disabilities; All assistive technology and related services.

     Knowledgeable in barriers identification and systems change 
     problem solving in securing access to assistive technology; 
     individual problem solving to secure access to assistive 
     technology; and, reimbursement of assistive technology 
     specifically:
     Medicaid 
     Education Programs (IDEA, Vocational Education, P.L. 89-313)
     Maternal and Child Health Programs (Title V)
     Health Insurance. 

     Knowledgeable in alternative strategies for the financing of 
     assistive technology, specifically:
     Publicly operated loan programs
     Clearinghouse model; lending library; equipment bank, etc.
     One time carry over requests
     Private donations. 


Reimbursement: Provides the following types of consultation:

     Telephone Inquiries                          Voluntary
     Private/Contractual Consultation             Voluntary
     Presenter at Meetings and Conferences        Voluntary
     Personnel/Staff Training                     Voluntary
     Written Correspondence                       Voluntary
     Willing to Travel                            Voluntary*

     *Reimbursement requested for out-of-state travel.




                    Consultants Listed By State

Alaska
Joyce Palmer

California
Anna Hofmann
Deborah Kaplan  
Judith K. Montgomery
Janina Sajka

District of Columbia
Allan I. Bergman
Christopher Button, Ph.D.
Carol Cohen
Karen Sandra Franklin
Jan Galvin
Bob Griss
Michael Morris
Lawrence Scadden, Ph.D.
Katherine D. Seelman, Ph.D.

Georgia 
Joy Kniskern
Sharon Meek
Bonnie Wooten-Webb

Illinois
David Braddock, Ph.D.
Richard Hemp
William M. Salyers, Ed.D.

Kansas
Patrick A. Terick

Maine
Jan Brown
Michael Towey
Steve Tremblay
Deborah Parker-Wolfenden
Thomas C. Backiel

Maryland
Lynn Bryant
Pat Ourand, MS, CCC-SP
Steve C. White, Ph.D.

Minnesota
Diane Baranik
Rachel Wobschall

Montana
Alexandra Enders, OTR/L

Nebraska
Alicia Hahne Oestmann

New Jersey
John C. DeWitt

New York
Todd Brickhouse
Carl Brown
Lewis Golinker
Steve Mendelsohn
Reese Michaels
Peg O'Brien
Sheron R. Rice

New Mexico
Bill N. Newroe
Andy J. Winnegar, Jr.

North Carolina
Lawrence H. Trachtman

Ohio
Elaine K. Koch
Diana Kubovcik

Oregon
Gayl Bowser
J.A. Browder, M.D.
Sandra Peterson
William L. Self
Debra J. Waln
Joyce Munson-Davis, Ph.D.

Pennsylvania
Kenneth A. Brown
Colleen Haney

South Carolina
Marcia R. Nunnally

Utah
Debra Wynkoop-Green
Terry Holden
Jolene Y. Shimada

Vermont
Jesse Barth

Virginia
Justine Maloney









Section Nine:







Equality In Access To Knowledge Through Telecommunications For 
All Individuals Including Those With Functional Limitations
















NATIONAL COUNCIL ON DISABILITY


STUDY ON FINANCING OF ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES



                  Equality In Access To Knowledge
          Through Telecommunications For All Individuals
            Including Those With Functional Limitations

                             May, 1992




                                by
                           John De Witt
                                of
                    De Witt & Associates, Inc.
                       Glen Rock, New Jersey


BACKGROUND

In the 1990's, telecommunications is construed to mean 
electronically-based technology, connections through the 
telephone and associated networks, radiowaves, and increasingly, 
with applications of light.[******]  All telecommunications 
systems require an originating device, one or more receivers, and 
a transmission channel, that is a means of communication:  radio 
waves, fiber optics, copper wire, coaxial cable, communications 
satellite, wired or infra-red local area network, or combination 
of these.

Little more than a decade ago, it was easy; telephones were used 
for voice conversations; computers for data manipulation, and 
radio, Tv or cable for entertainment and news.  The general 
public usually considered each technology as separate, the 
potential of interacting with another technology only 
indeterminately perceived.  Today, simple distinctions are a 
thing of the past.  

Telecommunications are global.  Telephones are virtually 
indistinguishable from computers and other microprocessor based 
technologies.  Radio and light waves are as common as wire as 
channels of communications.  The products, services, components 
and features that serve to convey, manipulate and store 
information, whether by sound, data or video, are virtually 
common to all electronically-based hardware, firmware and 
software.

For individuals with limitations in hearing, seeing, moving, 
speaking or cognition, the explosion of telecommunications offers 
opportunities as never before.  None the less, technical and 
economic barriers continue to impede access to this rapidly 
changing world.  Unless dramatic, comprehensive and coordinated 
action is taken at the Federal, state and local level, and within 
private industry, individuals with disabilities will be excluded 
from the full enjoyment and participation made possible through 
global telecommunications.

Concentration upon telecommunications access was not originally 
contemplated as
a separate, vitally distinct aspect to this study of financing of 
assistive technology for individuals with disabilities.  However, 
it has become apparent as the study has unfolded, that both 
technical and economic issues in this area must be addressed if 
assistive technology is to effectively become a tool for 
integration of individuals with disabilities into educational 
environments, the workplace and community life.

Several areas must be explored:

    a modern understanding of the term "universal service" in 
     the context of today's and tomorrow's technologies, 
     especially with respect to individuals with 
     disabilities;[*******]

    definitions applicable to telecommunications and disability;

    Federal and state laws affecting telecommunications; and

    funding mechanisms designed to offset the high cost of 
     telecommunications.

Barriers are not only technical; they are equally, economic.  
Without conscious, concentrated effort to stimulate accessible 
design elements into every type of electronic equipment, physical 
access limitations will continue to deny individuals with 
disabilities entre into the full range of telecommunications.  
Without conscious, concentrated effort to stimulate an affordable 
system of global telecommunications, individuals with 
disabilities will continue to have barriers posed to their full 
participation in society.  For example, a residential telephone 
for an individual without a disability can be purchased for under 
$50 including advanced communications features.  An individual 
who cannot speak or is deaf must spend $200 or more for a text 
telephone, without advanced features.  On the extreme end of the 
scale, a deaf-blind individual needs a unique device, TeleBraille
2, costing several thousand dollars - just for very basic 
communication.  An individual with upper mobility limitations 
requiring an alternative switch technique to operate devices, 
must pay about $400 for a telephone that can only reach a human 
operator, nothing more.

For an individual needing access to information, such as most 
daily newspapers provide, but who cannot read print or hold the 
paper, electronic databases typically charge up to $15 per hour 
or more for access to newspaper databases.  Of course, the 
individual first must have a PC, modem, access software for 
converting the screen display into speech or an alternative 
method of entering keystrokes.  In short, whether it's the 
equipment needed to communicate or the enhanced service required 
to access information in an alternative manner, 
telecommunications for individuals with disabilities is costly.

Nothing short of a comprehensive, coordinated effort at the 
Federal, state and local  level as well as within the private 
sector, will ameliorate current and expanding inequities.  Reform 
of Federal laws, regulations and practices relative to assistive 
technology should place special emphasis upon telecommunications 
access, and thereby access to the global information age.




In 1988, the U.S. Congress established a national policy 
regarding assistive technology, in its Preamble to the 
Technology-Related Assistance Act, when it found that for:

   some individuals with disabilities, assistive technology is a 
   necessity that enables them to engage in or perform many 
   tasks...[and] to have greater control over their own lives; 
   participate in and contribute more fully to activities in 
   their home, school, and work environments, and in their 
   communities; interact to a greater extent with non-disabled 
   individuals; and otherwise benefit from opportunities that are 
   taken for granted by individuals who do not have disabilities.


Edward J. Markey, Chairman Subcommittee on Telecommunications and 
Finance U.S. House of Representatives, recently wrote:

   The past several years have witnessed rapid, sweeping, and 
   comprehensive change in the  ways we utilize 
   telecommunications.  Never before in our history have 
   Americans had  access to such a wide array of 
   telecommunications products and services.  Americans are  no 
   longer limited by the reach of their traditional copper wire 
   telephones.  Today, new  and innovative technologies such as 
   cellular phones, fiber optics, facsimile transmission,  and 
   satellite systems have enabled us to communicate almost 
   instantaneously with any  person, at any time, and at any 
   place in our wide world.

   It is unconscionable, however, that for many persons with 
   disabilities, these new  technologies offer little of promise.  
   Often at a disadvantage in the use of basic telephone  
   service, people with disabilities have particular needs to 
   which new communications  services are insensitive.  The 
   telecommunications system of the future will represent a  mix 
   of voice, graphic, and videotext services that may not be 
   fully utilized by people who  are deaf or hearing-impaired, 
   blind or visually-impaired, or speech-impaired
   unless steps  are taken now to guarantee their full and equal 
   access.  Passage of the Americans with  Disabilities Act in 
   1990 was an important stride forward in this effort.  However, 
   with  regard to telecommunications access by persons with 
   disabilities, many fundamental  issues remain to be 
   addressed.[********]

Nowhere is the application of assistive technology more relevant 
and essential than in the area of telecommunications.  Regardless 
of the medium, telecommunications products and services serve as 
the conduit through which information is acquired, stored, 
manipulated, managed, moved, controlled, displayed, switched, 
exchanged, transmitted or received.  

The key component is information.  Without access to information 
in its myriad forms, individuals with disabilities will not, 
cannot become fully woven into the fabric of American social and 
economic life.

Telecommunications is more than the traditional residential 
telephone with which voice conversations occur.  IT goes beyond 
the copper wires, fiber optics or cellular transmission systems 
and networks that connect one telephone to another.  Modern 
telecommunications reaches into computers of every sort, travels 
through modems linking enormous databases of information and 
executes transactions of every type.

Telecommunications continues to evolve with applications such as:

    interactive cable systems for making entertainment choices 
     or participating in "electronic" town hall meetings;

    kiosks with interactive video terminals, placed in strategic 
     public locations to convey necessary information about and 
     access to local governmental services;

    remote classrooms using "real-time video" for the teaching 
     of science and math by competent, stimulating teachers; 

    TV receivers with built-in decoder circuitry to provide 
     closed captioning of aurally delivered program material; or

    VCRs with built-in secondary audio program circuitry, to 
     provide "descriptive video" - spoken interpretation of 
     visually presented TV program material.

The term "telecommunications" has become synonymous with any 
method used to deliver and communicate information 
electronically.  No longer can the term be confined to the 
telephone and its associated networks or to radio, TV and cable 
broadcasts and transmissions.

Substantial barriers to access continue for even the most basic 
telecommunications services:

    convenient telephone voice communication between deaf, hard 
     of hearing, speech impaired individuals and the 
     hearing/speaking public, despite the increasing development 
     of intra- and interstate telecommunications relay services;

    access by individuals with visual limitations to elementary 
     visual information displayed on terminals of every sort - 
     telephone status LEDs, TV, ATMs, flight information 
     displays, shopping mall directories or library on-line 
     catalogs;

    use of keypads, keyboards and controls/switches by 
     individuals with limitations in reach or articulation 
     prevent full access to voice and data communications;

    complicated choice menus, whether visual or aural, limit the 
     usefulness of audiotext, videotext or computer system 
     software for individuals with limitations in cognition.


The National Council on Disability, conducted three forums in 
conjunction with this study of the financing of assistive 
technology.  It heard from witnesses concerning 
telecommunications as follows:

   NCD Public Forum Minneapolis,  Minnesota, October, 1991

   Emerging telecommunications are designed in a way that 
   requires an ever greater number of functional abilities.  
   Since every human ability defines a human disability more and 
   more, people with disabilities can expect to be excluded from 
   telecommunications access, unless, through public policies, 
   and the industry, in its product designs, take action to build 
   electronic curb cuts into all products and services

   Recommendations that were made include:

     1. Equivalent access for all people with the full range of 
        current and emerging telecommunications technology is not 
        only possible, but imperative if individuals with 
        disabilities are to take command of their lives and live 
        them more fully.

     2. People with Text Telephones have little assurance that 
        they can communicate with government offices, even those 
        listed as having text telephones.  Government workers are 
        often untrained in TT use and hang up the phone because 
        they do not recognize the sound of a TT call.  911 
        operators do not recognize a TT call.  There are 
        non-technical barriers to access to telecommunications. 
        Equipment training for all individuals and attitudinal 
        barriers need to be addressed.

     3. The focus of our attention should not be on the 
        individual with disabilities or on improving the fit 
        between persons and telecommunications services.  The 
        nature of the problem is not the disability itself but 
        the lack of access to appropriate tools, information and 
        training.  The desired outcome for an individual is best 
        described in terms of freedom of choice.  


The Telecommunications for the Disabled Act of 1982, (P.L. 
97-410) for the first time established as national policy a right 
to persons with impaired hearing to have reasonable access to 
telephone services.  The Act established three specific 
requirements for the purpose of attaining hearing aid 
compatibility.  The Act required the Federal Communications 
Commission (FCC) to:

    1.establish regulations for uniform technical standards for 
     hearing aid compatibility

   2.require telephones in certain locations designated as 
     essential phones, to be equipped for use with hearing aids

   3.establish specific requirements for informational labeling 
     on telephone equipment by the FCC.

Toward this end, in 1983 the Commission issued a Rule requiring 
that every telephone offered to the public on or after June 1, 
1984, contain on the surface of its package a statement whether 
or not it is hearing aid compatible.

Congress defined "essential phones" to include coin-operated 
telephones, telephones provided for emergency use, and telephones 
frequently needed by individuals with impaired hearing.  In 1984, 
the FCC clarified each of these categories.  First the Commission 
defined coin-operated telephones to include those telephones 
found in public or semi-public locations, such as drugstores, gas 
stations, or private clubs.   Second, the FCC divided "telephones 
provide for emergency use into three categories: (1) telephones 
in isolated locations such as elevators, tunnels, and highways, 
(2) telephones with direct lines to emergency authorities such as 
the police and fire departments, and (3) telephones needed to 
signal life-threatening or emergency situations in confined 
settings such as hospitals or prisons.  The final category 
defined in the rules as "essential" are those which are 
frequently needed by individuals who are hearing impaired.

Essential phones are: (1) telephones for use with credit cards 
only (unless a hearing aid compatible coin operated telephone is 
located nearby), (2) telephones in the
workplace which are necessary for the performance of the 
employee's duties, (3) telephones found in buildings in which 
visits by the public are reasonably expected, e.g., lobbies of 
hotels and apartment buildings, stores, and public transportation 
terminals, (4) telephones available for a minimum of ten percent 
of the rooms in any given hotel, and (5) telephones in locations, 
such as hospitals and prisons, where and individual may be 
confined, but which are not needed to signal the presence of a 
life-threatening situation.  The FCC required that all essential 
telephones installed on or after January 1, 1985 be hearing aid 
compatible.   Moreover, the new rules mandated that essential 
phones that are either coin operated or used for emergency use be 
retrofitted or replaced for the purpose of making them hearing 
aid compatible by January 1, 1985.


As many as thirty-six states have de-tariffed specialized 
equipment; yet programs to provide such equipment at reduced 
rates have sprung up in only 25 states.[*********]  The majority 
of individuals with disabilities are not covered by many of these 
programs. Additionally, most of these programs provide no 
specific funding for the research and development of new 
technologies in specialized customer equipment.


RECOMMENDATIONS FOR REFORM

General

A national policy should be established that addresses in a 
comprehensive and complementary manner the two essential 
attributes of access to telecommunications, i.e., technical and 
economic.  Without laying the foundation for technical access, 
economic affordability will be meaningless.  Solving technical 
issues without laying the foundation for affordable access will 
be, likewise, meaningless.  In the following set of 
recommendations, it is hoped that a logical sequence of executive 
and legislative actions can be encouraged that will lead to the 
concept for a overarching national policy of access to 
telecommunications by and for individuals with disabilities.

Federal Level - Executive

1. Encourage the White House to form a Task Force on 
   Telecommunications and Disability with a specific mandate to 
   examine telecommunications-related policies and practices that 
   impact upon individuals with disabilities.  The Task Force 
   should include appropriately high-level personnel from every 
   Federal agency with a substantial interest in national 
   telecommunications policy and practice, procurement, 
   production, distribution, and use.  Individuals with 
   disabilities who have expertise in a variety of disability and 
   telecommunications issues should be consulted to assist the 
   Task Force in its deliberations.  The goal of the Task Force 
   will be to identify current policies and practices, future 
   trends and proposed legislation/regulations so as to ensure 
   that individuals with disabilities will be able to obtain 
   equally effective use of telecommunications along with the 
   general public, and at an affordable cost.

   Examples of such Federal agencies include, but may not be 
   limited to the:

   a.Architectural and Transportation Barriers Compliance Board
   b.Corporation for Public Broadcasting
   c.Federal Communications Commission
   d.General Services Administration
   e.Interagency Committee on Computer Support of Handicapped 
     Employees
   f.National Captioning Institute
   g.National Council on Disability
   h.National Institute on Disability and Rehabilitation Research
   i.National Telecommunications and Information Administration
   j.Office of Management and Budget

2. All Federal agencies and offices should be encouraged to 
   consider the needs of any individual with a limitation in the 
   use of telecommunications and not restrict their attention to 
   a narrowly focused group.  For example:

   a.access to the Federal Telephone System is imperative not 
     only for voice communications, affecting individuals with 
     limitations in hearing and speech, but equally for data and 
     video information, processing, and exchange.  Affected 
     individuals include those with limitations in vision, motion 
     and cognition as well as hearing and speech.  Strict 
     adherence to the Telecommunications Accessibility 
     Enhancement Act of 1988 will limit access to individuals 
     with limitations in vision, motion or cognition.  Under 
     existing laws, e.g., Section 508 of the Rehabilitation Act 
     or Titles I or II of the Americans With Disabilities Act, 
     agency policies and practices could require access to the 
     FTS, despite the currently limited language of the 1988 
     statute.

   b.access to other electronic office equipment, including 
     computers, but also including devices such as facsimile 
     machines, photocopiers, optical scanners or postal metering 
     equipment, is essential for complete integration into 
     effective telecommunications use by any individual with a 
     disability.  The cost of providing accessible equipment is 
     far less, over the work life of an individual with a 
     disability, than the cost of "job restructuring," or 
     on-going "reasonable accommodation" through third-party 
     assistance.  Again, under existing law such as the ADA or 
     Rehab Act's 504 provisions, policies and practices could be 
     explicit with regard to inclusiveness.

3. The National Telecommunications and Information Administration 
   should be encouraged to immediately assign an individual to 
   interface with the disability
   community to identify aspects of its work that does or may 
   have impact upon individuals with disabilities.  For example, 
   the NTIA should be encouraged to examine its role in spectrum 
   allocation so as to ensure that services of particular 
   interest to individuals with disabilities are protected, such 
   as the need for a standard set of frequencies for use in 
   remote signage of analog or digital information.  Such 
   information will enable individuals with disabilities to 
   increase their wayfinding capacity both in places of public 
   accommodation and within public spaces, such as street 
   intersections, university campuses, etc.

4. The Federal Communications Commission also should be 
   encouraged to assign an individual(s) to interface with 
   individuals with disabilities on issues of concern to them, as 
   well as disability-related organizations active in 
   telecommunications.  The FCC needs to be sensitive to the fact 
   that many of its technical rulemaking actions impact 
   individuals with disabilities and that these individuals are 
   in the best position to analyze, with the aid of Commission 
   staff, what impact a particular rulemaking will have.  For 
   example:

   a.The Commission did not investigate or address disability 
     issues in its "video dial tone" NPRM.

   b.There is little doubt that aspects of the development of 
     high definition TV will affect individuals with disabilities 
     in one or more ways.  The Commission should immediately 
     invite knowledgeable individuals with disabilities to 
     examine the technology and its impact upon technical access 
     and affordability.

   c.Similarly, the FCC must weigh the impact of the cost of new 
     technologies upon individuals with disabilities since both 
     product and service costs may be out of reach for many such 
     individuals who need such products or services.

5. The Telecommunications for the Disabled Act of 1982, (P.L. 
   97-410) concentrated upon the need for hearing aid 
   compatibility of essential telephones.  However, another 
   provision of the Act, Section 610(g) provides for access by 
   individuals with limitations in "vision, mobility,and speech."  
   This
   was not addressed in the 1983/84 rulemaking procedure in a 
   substantive manner.  The Commission should consult with the 
   disability community and others in anticipation of preparing a 
   Notice of Inquiry regarding how best to implement this and 
   other unaddressed provisions.

6. There are many issues remaining unaddressed with respect to 
   the Americans with Disabilities Act and communications, 
   especially in Titles II and III.  The Department of Justice, 
   Department of Transportation and the Architectural and 
   Transportation Barriers Compliance Board should actively 
   continue to pursue areas left "reserved" or in need of 
   clarification.  For example:

   a.The interpretation of "commercial facility" is ambiguous 
     where a good or service is offered through 
     telecommunications.  An increasing proportion of commerce in 
     this country is conducted by phone or through PCs and modems 
     connected to databases by agencies, organizations and firms 
     that quite literally maintain no facility or premises where 
     they meet with their customers.  For them, an electronic 
     catalog is their showroom, the telephone their sales office.  
     By its emphasis on places of public accommodation, Congress 
     did not mean to exclude these fastest growing sectors of our 
     economy, whose activities manifestly affect commerce, from 
     coverage under the ADA.  

     Congress did not intend to suggest that a variety of 
     practices, procedures and methods that bear upon access most 
     heavily could be exempted from coverage simply because of 
     where they happened to or happened not to take place.  If we 
     note that individuals with disabilities often place 
     particular reliance upon the telephone and PCs, it would be 
     particularly incomprehensible to believe that Congress 
     intended for public accommodations and commercial facilities 
     which operate through these modalities to be excluded from 
     coverage.  Yet, if the newly adopted regulations are not 
     redrawn more broadly and clearly, such commercial facilities 
     may be inadvertently excluded from coverage under Titles II 
     and III.

   b.Congress explicitly included automatic teller machines (ATM) 
     as an example of equipment that must be made accessible to 
     individuals with disabilities. 
     The transactional services conducted between the ATM and a 
     bank, using telecommunications technology, are not 
     significantly different than those represented by an 
     information kiosk based by a municipality for use by its 
     citizens.  The technology is parallel; both use 
     telecommunications, both involve access to data and 
     transactions important to any citizen.

     Nevertheless, the ATBCB and DOJ did not address this and 
     similar access areas when drawing up its accessibility 
     guidelines or regulations.

7. The General Services Administration is charged with the 
   responsibility of implementing and enforcing the provisions of 
   Section 508 of the Rehabilitation Act, which requires that all 
   Federal agencies purchasing or leasing electronic office 
   equipment ensure that such equipment can be made accessible to 
   employees with disabilities.  The GSA, to date, has placed 
   emphasis upon computers, especially PCs.  It has not uniformly 
   insisted upon incorporating accessibility into purchases of 
   other equipment, especially telephone systems where access by 
   individuals with limitations in vision, cognition or motion 
   are affected.  Existing law does not exclude any specific type 
   of electronic office equipment from coverage under Section 
   508.  It is recommended that the GSA be more aggressive in its 
   training and education of Federal agency personnel as to the 
   imperative need for access to all types of equipment, 
   especially any involved in information processing and 
   handling.

8. Under provisions of the Telecommunications Accessibility 
   Enhancement Act of 1988, the GSA is also required, in 
   conjunction with the FCC, to promote the use, reduce the costs 
   and improve the capabilities of equipment for providing 
   telecommunications accessibility for those with hearing and 
   speech impairments.  Little has been done to implement, 
   through regulation, these provisions.  

   Much of the text telephone equipment still in use in Federal 
   agencies is outdated.  It is based upon the exclusive use of 
   the Baudot format despite use of ASCII as a preferred format 
   for data communications generally.  The FCC and GSA, in 
   conjunction with the deaf and speech impaired communities 
   should address the need to encourage the use of ASCII.  
   However, to accommodate
   the large embedded base of Baudot TDDs, a standard protocol 
   must be developed to ensure automatic access to emergency 
   telephone services such as "911," whether the incoming call is 
   Baudot or ASCII based.  Standards for auto-answering of Baudot 
   and ASCII formats must be developed, including, for ASCII, 
   recognition of not only baud rate but also data bits, stop 
   bits, parity and handshaking.

9. The Corporation for Public Broadcasting should take an 
   increasingly active stance in advocating for and the use of 
   closed-captioning, descriptive video and accessible remote 
   educational technologies for television productions it helps 
   to support.  In particular, CPB together with the National 
   Captioning Institute, the Department of Education and the 
   National Institute on Disability and Rehabilitation Research, 
   should ask Congress for increased appropriations for this 
   vital telecommunications function.


Federal Level - Legislative

1. Establish in Federal law a comprehensive, coordinated national 
   policy on the right to access to knowledge, using information 
   processing resources through telecommunications technology, by 
   individuals with functional limitations in communication by 
   conventional methods.  Examples of laws to be included, 
   directly or by reference, are:

   a.Air Carrier Access Act
   b.Americans with Disabilities Act
   c.Communications Act
   d.Developmental Disabilities Assistance and Bill of Rights Act
   e.Individuals with Disabilities Education Act
   f.Older Americans Act
   g.Rehabilitation Act
   h.Technology-Related Assistance for Individuals with 
     Disabilities Act
   i.Telecommunications Accessibility Enhancement Act

2. Incorporate into the Communications Act of 1934, Section 151, 
   ("Purposes"),
   the following language with respect to "Universal Service":  
   "...so as to make available, so far as possible, to all the 
   people of the United States, [including individuals with 
   disabilities who require 'communications accessibility,'] a 
   rapid, efficient, Nation-wide and world-wide wire and radio 
   communications service with adequate facilities at reasonable 
   charges..."

3. Incorporate into the laws cited in "1." above, if not already 
   incorporated, the following definitions and/or rights:

   a."Disability" as defined in the Americans With Disabilities 
     Act, Section 3(2);

   b."Assistive Technology Devices" as defined in the 
     Technology-Related Assistance Act, Section 3(1);

   c."Assistive Technology Services" as defined in the 
     Technology-Related Assistance Act, Section 3(2).

   d.Communications Accessibility - means making all expressive 
     and receptive communications accessible to individuals with 
     disabilities, and recognizes that virtually every individual 
     is:

     (1)capable of communicating, 
     (2)    knows best how to convey his or her thoughts to 
            others and 
     (3)    extends the same basic common courtesies of 
            interacting with people with disabilities that are 
            extended to others in receiving the goods, services, 
            facilities, privileges, advantages, or accommodations 
            offered by an entity providing such services. 
            (proposed definition)

   e.Communications Accommodation - means taking the time to 
     communicate to an individual with limitations in speech, 
     cognition, hearing or vision using appropriate assistive 
     technology or by communicating directly to such an 
     individual, to the extent practical, using his/her preferred 
     method of communication rather than using a third party, 
     unless directed otherwise by the individual involved. 
     (proposed definition)

   f.Class of Telephone - means telephones or telephone systems 
     designed for residential, business, public phone or 
     emergency use; and includes, but is not limited to, corded, 
     cordless, wireless, answering systems, data terminals and 
     video devices/displays.

   g.Specialized Customer Premises Equipment (SCPE) - means any 
     equipment, including associated hardware, firmware or 
     software,  needed by individuals with disabilities to access 
     the telephone network without assistance, or needed by 
     individuals who are non-disabled for the purpose of 
     communication with persons with limitations in hearing, 
     seeing, moving speaking or cognition. (proposed 
     redefinition)

   h.Value Added Service (VAS) - means any offering over the 
     telephone network which is more than a basic transmission 
     service. (proposed redefinition)

   i.Enhanced Service - means any service, offered over common 
     carrier transmission facilities, cable systems or other 
     interactive technologies, which employs information 
     processing resources that act on the format, content, code, 
     protocol or similar aspects of a subscriber's transmitted 
     information; provides the subscriber additional, different 
     or restructured information; or involves subscriber 
     interaction with stored information. (proposed redefinition)

4. The Telecommunications Accessibility Enhancement Act of 1988 
   (Pub. L. 100-542), directs the Federal telecommunications 
   system be fully accessible to individuals who are hearing and 
   speech impaired, including Federal employees.  It is 
   recommended that language be included that expands access to 
   the FTS to all individuals using the system by whatever means, 
   voice, data, video or combination of technologies.

5. Require each class of telephone intended for sale in the 
   United States, whether produced within the United States or 
   imported from another country, to have at least one model, 
   comparable in quality, style, function and price that provides 
   accessible design components/features to an individual with 
   limitations in
   hearing, seeing, moving, speaking or cognition.[*********]

6. Make explicit inclusion of accessible telecommunications 
   products/services into existing funding streams:

   a.Medicare
   b.Medicaid
   c.SSI and SSDI work incentive programs

7. Expand Title IV of the ADA to establish a national program for 
   the distribution of specialized customer premises equipment 
   for use with telephones and associated networks.


state Level

1. Encourage public utility commissions, in conjunction with the 
   National Association of Regulatory Utility Commissioners 
   (NARUC) and the disability community, to develop consistent 
   definitions of individuals with disabilities with respect to 
   use of telecommunications, eligibility for services and 
   specialized customer premises equipment under mandated or 
   permissive state legislation, and to develop a model program 
   based upon the best features of existing state programs for 
   the distribution, training and maintenance  of SCPE.

2. Eliminate the present inconsistencies among states in the 
   provision, cost, availability and repair of specialized 
   customer premises equipment;

3. Encourage enactment of legislation that protects the access 
   interests of individuals with disabilities regarding the 
   provision of state and local programs and services through 
   telecommunications technologies such as information
   kiosks, electronic town halls/meetings, voting or other such 
   interactive services.

4. Encourage state utility commissions to require local common 
   carriers to provide Specialized Customer Premises Equipment 
   (SCPE) and Value-Added Services (VAS) or "enhanced services" 
   at affordable rates with a variety of finance options such as:

   a.tax credits
   b.tax deductions
   c.loan guaranty programs
   d.general tariff provisions

5. Develop comprehensive, coordinated public utility policies 
   within states on communications accessibility.

6. Require that state Vocational Rehabilitation agencies use a 
   portion of Independent Living program funds to finance 
   assistive technology, specifically telecommunications devices 
   under Part A.  Federal regulations have included 
   telecommunications, sensory and other technological aids and 
   devices to the list of approved devices under this part.

















Section Ten:






     Federal Income Tax Law and Assistive Technology Finance 













                  NATIONAL COUNCIL ON DISABILITY


STUDY ON FINANCING ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES



     Federal Income Tax Law and Assistive Technology Finance 

                           May 1, 1992




by 

Steven Mendelsohn



Federal Income Tax Law and Assistive Technology Finance




     Introduction 

   No study of financing options for assistive  technology 
devices and services would be complete without an  examination of 
the subsidies offered by the tax system to individual purchasers 
of technology and their families.  The notion that tax benefits, 
such as deductibility, represent a governmental subsidy may seem 
novel at  first.  Yet for those who can reduce their 
out-of-pocket costs  through effective use of the tax law, the 
end result is little  different from what would be achieved with 
a government check for  the same amount as the savings.

     As a source of subsidization for the self-funding of 
technology, the tax system offers opportunities  of great 
magnitude to individuals with disabilities.  Unfortunately, this 
potential for reducing technology's costs to  the consumer remain 
surprisingly little-known to assistive technology providers, 
advocates and users.

     This chapter offers an overview of the chief tax law 
provisions bearing upon assistive technology.  It discusses the  
legal and factual issues surrounding successful utilization of  
these provisions.  Finally, it recommends reforms that, without 
loss of revenue to the US Treasury, could materially  enhance the 
ability of many people with all disabilities to  secure the 
technology they need for education, employment and the  highest 
possible quality of life.

     An Obscure Funding Source

   The assistive technology  community consists of people with 
many specialties, drawn from innumerable  backgrounds and 
disciplines.  From engineers to social workers,  administrators 
to advocates, and consumers of all ages and backgrounds, it is a 
community of immense diversity and scope.   Anecdotal evidence 
from technology users around the country  indicates that a 
significant number of people have incorporated  sophisticated tax 
planning into their personal equipment funding  strategies.  But 
their experience and often hard-won knowledge in  this area have 
too often remained private.  Dissemination of such knowledge to 
the community of consumers and providers has  never been 
systematically undertaken or raised to a priority  level by any 
major information dissemination organizations or  publications in 
the disability field.  The Council for Exceptional Children has 
offered tax information through its  publications, and occasional 
articles have been published or  presentations made in other 
forums, but few advocates or counselors are well-versed in either 
the issues or the opportunities.

     Nor is this lack of information difficult to understand.   
People with interest or
involvement in assistive technology have  been required to absorb 
an enormous amount of information, in  areas including the 
technology itself, the service system and the  rapidly evolving 
pattern of laws (such as the Technology-related  Assistance for 
Individuals with Disabilities Act of 1988 and the  Americans with 
Disabilities Act of 1990) that bear upon access to assistive 
devices.  Moreover, even many of those advocates who  have made 
technology funding a central concern have understandably tended 
to concentrate on publicizing and  improving major governmental 
and nonprofit funding sources that promised to benefit the 
largest  number of would-be technology consumers.

     A further factor influencing the allocation of resources is  
the fact that most people who need or want it can find advice and  
assistance in preparing their tax returns.  Regrettably, most  
accountants and other tax professionals and preparers lack the 
training or experience necessary to effectively advise 
individuals and families with respect to  technology acquisition.  
Knowledge of the tax law is not alone  sufficient for effective 
guidance in this area.  If a tax professional does not know of 
the existence of a disability  in the family, is unaware of which 
purchases constitute assistive  technology and why, is not privy 
to the hopes and aspirations of the client, or is uncomfortable 
with frank discussion of the day-to-day realities of living with 
a disability, then even the most comprehensive body of tax law 
knowledge may never be brought to  bear on behalf of needed 
technology.  Among people with disabilities, only the very 
wealthy few or the  fortunate are able to find a tax adviser with 
the time, inclination and capacity to translate their aspirations 
for  technology into the terminology, the assumptions and the 
technicalities and forms that comprise our tax system.

     For people with disabilities who want basic information on  
features of the tax law that may affect them, a useful starting  
point would be IRS Publication No. 907 "Tax Information for  
People with Handicaps or Disabilities."  IRS Publication No. 17  
"Your Federal Income Tax" is made available in braille through  
the co-operating network libraries of the Library of Congress's  
National Library Service for the Blind and Physically 
Handicapped.  The Internal Revenue Service has also undertaken a  
number of outreach efforts aimed at reaching people with 
disabilities.  To the degree that the tax law has implications  
for people with disabilities that go well beyond technology,  
these resources represent a useful jumping off point for those  
who want to acquaint themselves with the basics.



     What The Tax Law Can Do for Technology

   The Internal  Revenue Code offers the potential for 
subsidizing, through tax deductibility, of virtually every 
assistive device we purchase.  We pay tax, not on  our entire or 
"gross income," but on the proportion of that which  is our 
"taxable income."  Deductions serve to reduce this taxable  
income figure.  Except for people whose
incomes are below the  threshold for owing any tax, people in 
this country pay on the  basis of a three-tier rate.  Depending 
on income, an individual's  rate will be 15%, 28% or 31%.  If one 
is in the 31% top bracket,  an income tax deduction for the $100 
cost of a hypothetical  assistive technology device results in a 
$31 tax saving, meaning  that the net cost of the equipment is 
reduced from $100 to $69.   For someone in the 28% bracket, it is 
$28 and for a taxpayer  taxed at the 15% marginal rate it is $15.

     Among itemized deductions that individuals may claim on 
their annual tax returns, the medical care deduction  offers 
major opportunities for the deduction of assistive technology, 
particularly technology that is used in a personal  living or a 
special education context.  For assistive technology  expenses 
directed toward employment, the impairment-related work  expenses 
(IRWE) deduction offers the greatest opportunities.   Finally, 
provisions such as the disabled access credit provide  important 
tax incentives for small businesses which are prepared,  
consistent with the mandate of the ADA, to provide equipment that  
is needed to facilitate either employment of or access by 
individuals with disabilities.  Since these three major 
provisions represent the most significant provisions for 
assistive technology, we shall focus on them in the succeeding 
sections.

     The Medical Care Expenses Deduction

   Medical care expenses are tax deductible if two conditions are 
met.  (1) A  taxpayer must have sufficient itemized deductions, 
under this and  all other deduction categories, to warrant 
itemization rather  than use of the standard deduction.  (2) The 
portion of medical  expenses that are deductible are those that 
exceed 7.5 percent of  the taxpayer's adjusted gross income (AGI) 
for the year.

     Although the tax deductibility of medical care expenses  
appears to be widely known, the scope of this deduction seems to  
be far less well-appreciated.  The tax code's definition of  
medical care expenses is far broader than many people's common 
notion of the term.  We commonly think of medical care in terms 
of what doctors or  dentists prescribe, treat or do; in terms of 
what health insurers  will reimburse us for; or in terms of what 
television health  reporters or public health officials discuss.  
Each of these is a valid  measure in its own sphere, but the tax 
law uses its own definition and standards.  These predicate 
definition and deductibility upon the nature and purpose of an 
expenditure.  Section 213 (d) of the Internal Revenue Code  
defines medical care expenses as: "amounts paid for the 
diagnosis, cure, mitigation, treatment or prevention of disease  
or for the purpose of affecting any structure or function of the  
body..."

     Most of us would assume that this includes medical equipment  
such as oxygen tents, hospital beds or dialysis machines, but it  
includes a great deal more equipment than that.  From the 
standpoint of assistive technology devices, the key words here 
are "mitigation" and "affecting any structure or  function of the 
body."  We do not use
assistive devices to  "diagnose," "treat" or "cure" disease; we 
do use them to "mitigate" functional impairments which limit 
various "functions" or "structures" of the body.

     Consistent with the wording of the statute, a number of  
rulings, by the Internal Revenue Service itself and from the US 
Tax Court, uphold (though without ever using the term) the  
inclusion of assistive technology within this definition.  For  
example, rulings and cases establish the deductibility of: TDD'S  
for use by person with hearing impairments in using the 
telephone; hand controls and wheelchair lifts to facilitate the  
operation and use of a motor vehicle by people with physical and 
mobility disabilities;  closed-caption decoders to make the audio 
portion of television broadcasts accessible; braille writing 
equipment; and  comparable devices applicable to the range of 
physical, mobility  and sensory impairments.

     It is obvious that the law cannot hope to keep up with the  
technology revolution.  If we waited for revenue rulings or court 
cases dealing with each specific item, we would  find ourselves 
falling further and further behind.  Accordingly, as in  any area 
of law, we must use the principles articulated in the  
precedent-setting decisions to extrapolate to other devices.

     For example, when the Internal Revenue Service ruled that  
closed-caption TV decoders are deductible, the rationale for its 
decision indicates  that the same result would be reached on the 
deductibility of  equipment used to receive "audio description."  
These services, by  providing a narration of visual action for 
television viewers who cannot see  the screen, play the same role 
for blind persons as the closed-caption presentation does for 
people who are deaf.  It  compensates for the inability to see 
the screen, just as the  captioning does for the functional 
impairment of not being able  to hear the audio.

     Regardless of the impairment in question, the key to the  
deductibility of assistive technology is the ability to 
understand, and if called upon to document, its role in 
mitigating a functional impairment of one or another function,  
system or organ of the body.  Any disability reflects itself in  
some or other functional impairment.

   To be sure, there are nuances and pitfalls.  It is not a 
simple matter of saying that one purchased this or  that item, 
say a good chair, because it reduced back pain.  With  a device 
that is designed or modified specifically for use  by a person 
with a disability, the claim of impairment mitigation will be 
relatively easy to sustain.  After all, who would spend  $3,000 
for a braille-output device for a computer except someone  who 
actually needed it, given that standard monitors run at only  a 
fraction of this cost?  It will help to have a physician's  
recommendation, and the purchaser may be required to prove the  
existence of the disability, as well as to explain exactly what  
the device does, but once the requisite facts and documentation  
are assembled, no valid basis for denying deductibility should  
exist.

     When we turn to off-the-shelf, standard devices that take on 
their assistive character by virtue of how  and by whom they are 
used, our problem of proof becomes a bit  more complex.  With the 
nature of the device no longer sufficient to make its use 
obvious, we must be prepared to prove  not only the truthfulness 
of our claim of functional impairment,  but we also have to prove 
how the device in question mitigates  the functional impairment 
or affects the structure or function in  question.  And we have 
to prove one thing more.  Since the device  could equally well be 
used by other people or by us for other  purposes, we need to be 
able to show that mitigation of the  impairment was our motive in 
purchasing it.

     Ordinary "personal use" items have been held medically 
deductible on numerous  occasions, however.  These include a 
reclining chair for a cardiac patient, a clarinet and lessons for  
an orthodontic patient, air-conditioners for people with 
respiratory  disabilities and many others have been held 
deductible where the  Internal Revenue Service believed the 
claims underlying their acquisition  and use.

     The character of the equipment is never the issue.  Its  
purpose and role is.  Telephones have been held medically 
deductible where the evidence supported the taxpayer's contention  
that they were obtained or used solely to call a physician.  In  
other cases where this claim was not supported by the evidence,  
they have been denied.

     In cases involving standard items such as the chair, the  
clarinet or the air-conditioner, medical evidence, in the form of  
a physician recommendation in connection with a particular  
diagnosis or treatment regimen, has played a key probative role.

     People with disabilities frequently meet their assistive  
technology needs with what we shall call "mixed systems."  These  
are configurations that consist of a standard and a 
specially-designed or modified component, for example, computer  
systems which include a standard computer to drive a speech 
synthesizer, an augmentative communications  device, an 
environmental control unit, or some other specialized peripheral 
or software.  Although there should be no problem  deducting the 
specialized peripheral or software, the ordinary  computer 
presents a problem.

     From the definitional standpoint, the home computer is not 
assistive technology.  In tax law  parlance it is a "personal 
use" item.  Proving that a personal  use item is in fact a 
medical expense is often problematical.   For one thing, it is 
not the computer that mitigates the functional disability, but 
the assistive  component (the speech synthesizer for reading the 
screen, the  augmentative communications device for effective 
communicative  output) that allows the computer to be used.

     A good illustration of this reasoning is provided by the  
rules on automobiles.  In the area of vehicle modifications, the  
add-on components attributable to mitigating the functional  
consequences of the disability are routinely deductible, but the  
cost
of the basic car is not.  Obviously, the individual with  the 
disability could not use either component in the absence of  the 
other, since the van would be inaccessible without the lift,  
while the lift or hand controls would have no practical use  
without the vehicle.  The individual may be able to prove that  
the car would not have been bought but for the availability of  
these add-ons, but that does not make the car medically 
deductible.

     Nevertheless, some taxpayers have succeeded in deducting  
their entire mixed type computer systems.  The taxpayer who would  
undertake to try this should be prepared to respond in the event  
of a tax audit.  Prospects of success would be strongest in cases  
where the complete system represents an integrated and the only  
means for achieving a basic life function, such as communicating  
with others.

     The taxpayer who would deduct standard items, whether  
independently or as part of mixed systems, faces another problem  
of proof.  Even if it can be shown that the standard device does  
play the requisite functional role, its nature leaves room for  
the question whether it has actually been procured for the stated  
purpose.  You must be able to prove not only its potential but  
that it was actually and solely used for the specified purpose.   
Put another way, how can I demonstrate that I or my family  
wouldn't have bought a home computer anyway?  After all, many 
families do!

     Like every other question of this kind, the answer depends  
upon the facts of the case.  There are any number of ways the  
motive of the purchase might be proved.  Perhaps the standard  
computer component of your assistive technology configuration was  
recommended by a rehabilitation engineer or by a physician?   
Perhaps the model of computer you chose was dictated by the  
interface requirements of your peripherals?  Maybe you did not  
buy parts of the computer that a person without your disability 
would use  (such as a blind person who does not purchase a 
standard monitor)?  Hopefully, you can simply assert, because it 
is true,  that no one else makes any material use of it but you?

     In such a case, the recommendation of a physician could  
conceivably have some evidentiary value, but physicians do not  
"prescribe" assistive technology.  Nor would it necessarily be  
desirable to place assistive technology under the ambit of the  
medical profession, for this would significantly raise its costs  
and probably set back to the development of consumer-responsive  
models in the field.  More to the point in these ambiguous  
situations is what people with disabilities can do directly.

     Taxpayers themselves play a major role in determining the  
scope of the law.  By what they claim, and most important by what  
adverse decisions they appeal to the Tax Court they create the  
arguments and the opportunities for tax law provisions to be  
applied to new situations.  Tax law provisions are not static.   
They are constantly being interpreted and applied, being 
broadened or narrowed in their scope.  The issues are as much or  
more attitudinal and informational as they are legal.

     Hard as it may be to imagine in the aftermath of the ADA,  
there are still many people who cannot readily understand how 
obscure devices, not provided by physicians or other credentialed  
health care providers, could possibly be characterized as medical 
devices.  For the potential of the tax law to be fully realized,  
people with disabilities need to do a great deal of what can best  
be called educational work.  Much therefore depends upon the  
organization and cogency of one's analysis and presentation. So 
long as there are people,  within the tax advisement and 
enforcement community no less than  in society as a whole, who 
equate mitigation with medical improvement rather than with 
restoration of function by alternative means, our task will be 
harder than the law requires  it to be.

     If a device is deductible under the health care rationale,  
the costs of its upkeep and maintenance are deductible as well.   
If the need for the technology ceases, so does the deductibility 
of its upkeep.  An individual  whose disability ceases is not 
required to repay tax benefits  derived from the purchase of 
assistive devices while disabled,  however.  Likewise, if an 
assistive device is sold, the seller  may be liable for tax on 
any profit (gain") that may accrue, but  the "basis" or purchase 
price against which profit or loss is measured ordinarily need 
not be reduced by the amount of any tax  subsidy involved in the 
original purchase.


     Technology Services

   For deductibility of assistive  technology services as medical 
care, success is often possible if  some recurrent difficulties 
are foreseen.  Among assistive  technology services, training 
would typically represent the most important example.  Generally  
speaking, the medical deductibility of costs incurred for 
services is determined by the nature of those services and by the  
identity of the service provider.  Thus, services provided by  
doctors, dentists, nurses, physical and occupational therapists,  
psychologists and other recognized health care professionals are  
routinely deductible, provided they are for the treatment of some  
problem, illness or the like.  Fees paid for a half-hour's  
discussion of the state of medical research in this country would  
not be deductible, simply because paid to a physician.  But the  
services of others, even including in some cases 
nonprofessionals, can be deductible, if their nature  and purpose 
meets the medical care standard.

     With assistive technology training, we therefore face two  
hurdles.  First, there is as yet no standardization of the 
professional credentials of those who provide it.  This is one of  
the reasons why people who have obtained their training from  
noncredentialed disabled peers at independent living centers have  
had difficulty in deducting the fees or voluntary contributions 
they paid for this  assistance.

     Closely related, the second hurdle is that of demonstrating 
the specialized (that is, the functional improvement objective) 
nature of the training.  Particularly  where the credentials of 
the trainer or the training facility are  limited, emphasis must 
be placed
on the nature of the training  provided; but in all cases, 
whoever offers the training, its  nature is what should qualify 
it for deductibility.

     Special Education

   To the degree that assistive technology devices and services 
are deductible in an educational  context, this opportunity 
likewise derives from the medical  expense provision of the law.  
With few exceptions not pertinent  here, educational expenses are 
not tax deductible.  But when  goods or services used or provided 
within an educational setting  can be characterized as 
"therapeutic" rather than "educational"  in nature, deduction is 
permitted.  For example, tuition for  attendance at "special 
schools" has been held deductible where  the purpose of 
attendance was primarily therapeutic.

     In today's special education settings, many families feel  
called upon to supplement the resources available under a child's  
Individualized Education Plan (IEP) with additional goods and  
services for which they pay.  Where these involve assistive  
technology, they should usually be medically deductible if their  
purpose can be characterized as treating or overcoming the  
disability.  Braille writing equipment or lessons in braille,  
braille books (to the extent their price exceeds that of 
equivalent print editions), assistive listening systems for use 
in  the classroom, modified keyboards or other peripherals and  
software for accessing and using school computers or other  
equipment: these would be illustrative of the range of devices  
that would qualify.

     The line between these and educational expenses can be a  
difficult one to find, particularly when it comes to services.   
Training in the assistive devices would qualify, but remedial  
education services, even if arguably necessitated by the school's  
failure to provide accommodations that would facilitate learning,  
would raise a red flag.

     There is no requirement in the law that the family have  
exhausted all avenues for school system payment in order to claim  
the deduction.  Nor does the sharing of financial responsibility  
between the school and the family in any way deprive the family  
of its deduction for the amount of its deductible expenditures.

     Earlier, we mentioned that the medical care deduction was  
important because it applied to assistive technology purchased  
for use in a number of spheres  One major exception is 
employment.  Fortunately, the law does provide important subsidy  
opportunities for the assistive technology needs to which we must  
respond in order to work.

     Impairment-related Work Expenses

   Added to the Internal  Revenue Code in 1986, Section 67 (d) 
defines these as:
"expenses of a  handicapped individual...for attendant care 
services at the  individual's place of employment and other 
expenses in connection  with such place of employment which are 
necessary for such  individual to be able to work..."

     For the definition of "handicapped individual" we are in 
turn referred to Section 190  (which deals with the architectural 
and transportation barrier removal  deduction).  Section 190 
(b)(3) contents itself with telling us that the term includes but 
is not limited to people  who are deaf and people who are blind.

     Because the impairment-related work expenses (IRWE) 
provision is a relatively new statute, not much interpretive 
guidance has yet been amassed.  This limitation in  our knowledge 
is compounded by some problems in the wording of  the statute, 
such as the use of the words "attendant care services" to include 
readers and interpreters.  Likewise, the  references to "at" or 
"in connection with" the place of employment do not mean, as some  
have feared, that the goods or services in question must be used 
or provided only at  the work site.  Impairment-related goods or 
services utilized at  the worker's home for work-related purposes 
would still qualify  for the deduction.  Finally, the words 
"necessary...!be able to  work" do not mean that the goods or 
services be a condition for getting or keeping the job.  It is 
enough that they  contribute to satisfactorily performing one's 
work, and there is  no requirement either that the employer have 
instructed you to  get them or that the employer have first 
refused to pay.

     The IRWE statute makes no specific reference to expenses for  
goods, but the words "other expenses" should be read to include  
whatever may be appropriate, including assistive technology 
devices.  To be  deductible, goods or services must meet two 
conditions.  (1) The  item must be necessary for and actually 
used in one's work.  (2) The goods or services must be 
impairment-related, that is, must be of a nature that would not  
be needed or used but for the functional impairment.

     IRWE's are an itemized deduction.  This means, as with 
medical care, that in order to  claim the deduction the taxpayer 
must be in a position to itemize.  Of course, if an individual is 
self-employed, IRWE's would be included among business expenses 
that go into determining profit or loss.  In that case,  the 
IRWE's are reflected on Schedule C, so the taxpayer gets  their 
benefit irrespective of the decision whether to itemize,  and 
irrespective of the capacity to do so.

     Provided an employed person has enough itemized deductions,  
IRWE'S are not subject to any floor the way medical expenses are.  
If there is any question concerning a given device's 
impairment-relatedness, an important fall-back position should be 
noted.  So long as the expense is  work-related, it should also 
be deductible, like other unreimbursed employee business 
expenses, under the Miscellaneous  Itemized Deductions (MID) 
provision of Section 67 (b).  However, with MID's a 2% of AGI 
threshold does  apply, meaning that the itemized deductions will 
be available  only to the extent your MID's exceed that figure.

     The Disabled Access Credit

   Enacted several months after  passage of the ADA in 1990, this 
provision (full name, Expenditures to Provide Access to Disabled 
Individuals) was  designed to help small businesses offset 
economic hardship that might result from  compliance with the new 
civil rights provisions.  It also serves  to encourage businesses 
to make accommodations that will afford individuals  with 
disabilities greater access and opportunity, whether as  
employees (Title I of the ADA) or as customers (Title III).

     Set forth as Section 44 of the Code, the credit is available 
for 50% of "eligible access expenditures"  incurred by a small 
business.  The maximum amount of the credit is $5,000,  computed 
as 50% of eligible expenses that exceed the firm's first  $250 of 
such expenses, and up to a maximum of $10250 in any tax  year.  
As a tax credit, rather than a deduction, its amount is  
subtracted, not from one's income as a deduction would be, but  
directly from the tax the firm would otherwise owe.  This makes  
it considerably more valuable than a comparable deduction would  
be.

     A small business is defined as one with gross receipts for  
the year of under one million dollars, or, alternatively, as one  
that had thirty or fewer "full-time" employees during the year.

     The definition of "eligible access expenditures" clearly  
includes assistive technology.  Subsection (c) defines eligible 
access expenses generally as amounts paid "for the  purpose of 
enabling the eligible small business to comply with applicable  
requirements under the Americans with Disabilities Act..."  It  
then goes on to enumerate specifically covered expenditures,  
among which are included: expenses: "to acquire or modify 
equipment or devices for individuals with disabilities" or  "to 
provide...modifications, materials or equipment."

     Only costs that are "reasonable" and necessary for achieving  
the access goal are covered, but applicability of the credit does  
not depend upon any administrative or judicial order to comply  
with the ADA, or upon any finding or allegation of its violation.   
The credit seeks to encourage voluntary measures.

     With a statute as new as this, many questions remain to be  
answered, but one potential restriction upon the ability of  
businesses to provide whatever technology may be appropriate is  
suggested by the requirement of Subsection (c)(5) that, to be 
eligible for the credit, expenditures must meet standards 
prescribed by the Secretary of  the Treasury in cooperation with 
the Architectural and Transportation Barriers Compliance Board.  
It is unlikely that  the Treasury Department (of which the 
Internal Revenue Service is  a part) will or can develop 
standards covering the myriad devices  and configurations that 
technology, the ingenuity of business and  consumers, or the 
flexibility of the ADA will yield.  Nor is it  entirely clear 
what such standards would require in application  to various 
types of equipment.  Regulations have not yet been issued, but 
the concern is that with assistive devices for which standards 
are not
established, taxpayers may find it difficult to assess whether  
their proposed expenditures will qualify for the credit.

     There is a precedent for this standards-setting approach in  
Section 190 of the Code, which, in providing an up to $15,000 
annual tax deduction  for the removal by businesses of 
architectural and transportation  barriers to the elderly and the 
handicapped, likewise predicates  deductibility for each barrier 
removal expenditure upon its  compliance with regulations to be 
issued by the Treasury.  The  regulations issued under Section 
190 set standards in terms of: the required width of walkways, 
slope of ramps, height of drinking fountains,  nature of warning 
signals or safety information, and so on.  But  recognizing the 
possibility that businesses would identify and  seek to remove 
architectural barriers of a kind for which no  standards had been 
set, the Section 190 regulations also contain  a residual or 
"other" clause, allowing the deduction for the  removal of other 
barriers in many cases.

     Pending the promulgation of regulations to implement Section  
44, taxpayers have no real option but to assume that the scope of  
the ADA defines the scope of the credit.  If an item of equipment  
meets the definition of an "accommodation," of a "modification"  
or of "auxiliary goods and services" under ADA, it must be deemed  
to comply with the requirements of the disabled access credit  
provision as well.  While Section 44 should be amended, as  
discussed below, there is every reason to believe that 
expenditures for equipment that are intended to comply with the  
requirements of ADA and that have that effect will be granted the 
credit.

     Tax Strategy

   To say that technology is deductible under  one or another 
rubric is still not to say when and under which  provision its 
acquisition can garner the largest tax subsidy.   For example, 
with medical care expenses, the 7.5% of AGI deductibility 
threshold introduces some strategic decisions.  There is little 
point in buying assistive technology in a year when your  health 
care costs, including the assistive device, will not  exceed the 
7.5%, if you have the option to make the purchase in another year 
when they will.  Of course, we  may not always have that choice 
for a variety of economic and  personal reasons, but to the 
extent that we do, the bottom line  implications of all strategic 
options must always be carefully  weighed.

     An important element of strategy always consists in using  
the right forms and procedures.  Medical care expenses are  
deducted on Schedule A to Form 1040.  Impairment-related work  
expenses are also itemized deductions (except in the cases of  
self-employed people, as noted above), so also require the use of  
Schedule A.  But with employee business expenses, including  
IRWE's, Form 2106 may also need to be filed.  The disabled access  
credit is claimed on the business's return, but with it the Form  
8826 must also be completed.  Because this credit is one of a  
group of credits comprising the General Business Credit, some  
firms that elect to use it may also be obliged to file Form 3800.


     Recommendations

   To the degree that important opportunities for encouragement 
of assistive technology utilization through the tax system 
already exist, the first  imperative is to ensure that 
information about these benefits is  disseminated as widely as 
possible.  Methods must be developed  for making this information 
available to consumers and service  providers.  The mechanisms 
developed for doing this must be  on-going, so that the 
technology community may be apprised  promptly and accurately of 
relevant changes in or interpretations  of the law.


     Of equal importance, the accounting and tax preparation 
communities must be further sensitized to the tax  planning 
issues surrounding disability in general, assistive technology in 
particular.  The tax preparation community is itself a diverse  
one.  Successful outreach to this community will require 
collaborative efforts to develop professional training materials  
and programs that will sensitize practitioners to the nature of  
disability, to the role of technology in the lives of growing  
numbers of people with disabilities, and to the professional and  
personal appropriateness of confronting these questions with  
their clients.

     While the existence of salutary provisions is being made  
better known, simultaneous efforts to improve and clarify the law  
should be undertaken by the advocacy community.  This effort must  
be undertaken on three interconnected levels:

   (1) Review of Current Laws.  Our current body of tax law, 
accumulated as it has been over many years,  reflects many 
different views of people with disabilities.  Taken  as a whole, 
our tax law, in its terminology as well as in its  content, fails 
to embody a clear or consistent public policy.   Certainly, 
public policy in connection with disability remains a  complex, 
often elusive, frequently even contradictory matter.   But with 
the emergence over recent years of a body of law that  recognizes 
and aspires to enhance the independence and full  participation 
in society of citizens with disabilities, the  urgency and 
timeliness of a complete review of our tax laws and  regulations 
has become increasingly apparent.  There are many  provisions in 
the law that inhibit, without intention to do so and often  
without significant revenue-collection justification, the goals  
of other laws and the implementation of evolving awarenesses at  
many levels.  Even without any substantive changes in the law, 
such measures as clarification of inaccessible  provisions or 
merely review of terminology could go far both to  making the tax 
law more available to people with disabilities and  their 
advisers, and to removing negative stereotypes to which the  law 
inadvertently and unnecessarily subscribes.

     Among the provisions we have examined, several examples of  
what we mean can be found.  For example, inasmuch as assistive  
technology already comes within the ambit of the medical care  
deduction, significant benefits could result from clarifying
that  "mitigation" includes appropriate rehabilitation services, 
including technology that restores function.  Similarly, in the  
IRWE provision, the term "attendant care services" represents a 
less than ideal choice of nomenclature for  use as the one 
specific example of the kinds of expenses contemplated by the 
statute.  Such terminology hardly conveys the reality of what  
assistants do, and hardly projects the positive potential of  
individuals with disabilities in the work place that is, after  
all, the statute's reason for existence.  If "attendant care  
services" were literally the only thing that those who drafted  
the statute meant to be deductible, that would be one thing.  But  
since that is not what the statute has been interpreted to mean,  
would not a more accurate choice of terminology be useful to  
everyone?

     The shocking truth is that where the word "disability"  
occurs in the Internal Revenue Code, it more often occurs in the 
same  sentence or paragraph as the word "death" (as in "expected 
to  result in death or in disability") than in any other context.  
Apart from what is or is not deductible, this situation  must 
change.  Congress should, through one of its subcommittees  or a 
special committee, or through the appointment of a commission 
charged with the task, review the entire corpus of the  law to 
identify and remedy this and other comparably unfortunate 
provisions that have accrued over the years.  While doing this,  
the need for substantive change should not be overlooked.

   (2) Revision of Key Code Provisions.  The Code  contains many  
provisions that adversely affect people with disabilities and 
their families.  While some  of these may have revenue 
implications sufficient to prevent  their modification, and while 
others may need to be retained for  the sake of consistency in 
the Code or for other technical or  structural reasons, many 
others will be found to have no such  justification.

     Several major law changes that would significantly benefit  
people with disabilities will be mentioned here.  The first  
relates to the detrimental effects of using itemized deductions  
as the chief vehicle for individuals' deducting of assistive  
technology expenses.  The requirement that people be able to  
itemize in order to claim their assistive devices results in the  
forfeiture of tax benefits by those who cannot itemize.  If it is  
our intention to give a tax subsidy to assistive technology,  
might it not be advisable to do so in a way that does not 
condition the availability of the benefit upon so many variables  
unrelated to need?  Typically, it is higher income taxpayers who  
itemize.

     This problem could be addressed by allowing taxpayers who do  
not itemize the option of claiming their assistive technology as  
"above-the-line" adjustments to income?  Above-the-line 
deductions or adjustments are those that taxpayers can claim in  
the process of computing their adjusted gross incomes.  
Essentially, these adjustments represent the difference between  
gross and adjusted gross income.

     Although the majority of "deductions available through  
income adjustments are reserved for business, there are 
precedents in the law for  granting this treatment to
individuals.  Most notably, in connection with employee business 
expenses (which would ordinarily be deductible as itemized 
deductions under the MID's  category), certain employed 
performing artists are permitted to  deduct some of their 
expenses in this way.  If this same option  were extended to the 
assistive technology expenses of workers  with disabilities, they 
would be freed from the necessity to  itemize in order to obtain 
the tax advantage.  Every worker who  incurred assistive 
technology expenses in order to work would  thus be able to gain 
a tax benefit, provided only that their  income (including where 
applicable joint income with a spouse)  was sufficient to absorb 
the deduction.  This could be accomplished by a simple amendment 
to Sec. 162 of the Code.

     Reform such as this would make tax benefits available to  
low-income people with disabilities who work.  Bearing in mind  
that highly instrumental assistive technology purchases can often  
require fairly modest sums, this change would also ensure 
deductibility in these cases to a much greater extent than is now  
forthcoming, since taxpayers would no longer be required to have  
other deductions in order to benefit.

     People who attempt to deduct their assistive devices under  
the medical expense provision face another potential inequity.   
Frequently, people will need to buy technology after the onset of 
a disability, at a time when their income has been  sharply 
reduced.  Their objectives may be improvement of the  quality of 
life, eventual return to work or both.  But because  income may 
be low, resources for the purchase of needed assistive  
technology will often have to be drawn from savings.  It is such  
cases as this to which we refer in speaking of people with  
incomes inadequate to absorb these potential deductions.  There  
is no deduction, because there is little or no adjusted gross  
income to be reduced.  Even treating their assistive technology  
expenses as an income adjustment would not benefit these people.

     A solution may be found in the rules concerning when the  
expense can be deducted.  Medical care expenses are ordinarily  
deductible in the year incurred.  If an exception could be made  
for assistive technology, whereby the deduction could be either  
carried backward to higher earning previous years, and/or carried  
forward to prospective, higher-earning future years, people with  
disabilities who had the commitment and the courage to invest  
their savings in the technology they need would not be 
disadvantaged for their self-reliance.

     "Carryover," both forward and back, is a well-recognized  
principle of tax law, though again primarily in connection with  
the expenditures of businesses.  The disabled access credit, by  
reason of its inclusion among the group of credits comprising the  
"general business credit," is itself subject to carryover in  
certain instances.

     Congress has already recognized the hardship that 
interruption of a career due to onset of a disability can cause.   
For example, the law provides for waiver of the "Section 72"  
penalty tax that ordinarily applies to premature withdrawal of 
certain
retirement funds.  If  the withdrawal is necessitated by 
disability, the 10% "additional  tax" will not be charged (Form 
5329).  Even if introduced on a  limited basis, so as to apply 
only to people who have endured  substantial loss of income owing 
to disability, such a carryover  provision could significantly 
encourage the reintegration into  society of many people who 
might otherwise face lives of idleness  and unproductivity.

     A final recommendation harks back to the disabled access  
credit.  This provision is profoundly important.  Beyond the  
expanded use of assistive technology it will facilitate, the  
disabled access credit represents the first instance in which we  
are aware when a major piece of disability-legislation was 
perceived to have a tax law dimension.  So that this precedent  
may be a positive one, it is especially crucial that the credit  
prove effective in advancing the goals of the ADA and in 
minimizing business apprehensions about the legislation.

     To ensure that the ADA credit will not be inadvertently  
interpreted in a manner that makes its scope narrower than that  
of the ADA, Section 44 of the Code should be amended to clarify  
that "intention" and "efficacy" should govern the qualification  
of expenses for the credit.  These are not difficult standards to  
apply and enforce.  By and large, they are the standards used  
throughout our tax system.  While it is appropriate to vest the  
Treasury Department with the authority to determine the 
truthfulness of ADA-related claims, there seems little need or  
justification for imposing upon it the heavy burden of 
determining what "services, modifications, materials or 
equipment" satisfy the requirements of the ADA.  Provided they  
are made with the intention of earning a profit, the expenses  
incurred by business firms are not denied deductibility, simply  
because the Internal Revenue Service regards them as evincing  
poor business judgment.  So should it be with the ADA.

   (3) The final level of our recommendations concerns how the  
interests and aspirations of people with disabilities can be  
assured of attention as the tax code evolves in the years to  
come.  It is easy to understand how the concerns of this 
population can be lost in the great  debates over tax rates, 
capital gains and similarly momentous  issues.  One current tax 
policy debate exemplifies the crucial  concerns that need to be 
taken into account.

     Much attention is currently being directed to the goal of 
restoring major incentives for "research and  development" to the 
tax code.  To be sure, anything that spurs  the economy is good 
for everyone, but some far more specific  issues are involved.  
One of the great issues facing our engineering and product design  
communities is that of "universal" or "accessible" design.  To  
the degree that mainstream products can be designed in ways that 
make them usable  by people with disabilities, the need for 
add-ons--and therefore,  the costs of assistive technology--can 
be commensurately reduced.   Many manufacturing and 
information-services companies, while professing commitment to  
the goal of universal or accessible design, go on to contend that 
the competitive exigencies of their industries and product lines 
make  fulfillment of these commitments impractical.  Inclusion in 
any new R and D credit of provisions making
clear that accessible design research qualifies for the benefit 
could go a  long way toward helping companies to implement these 
goals.

     Since passage of the landmark revisions of the Internal  
Revenue Code in 1986, a reformulation that was supposed to  
provide stability to the tax code for years to come, no fewer  
than four significant tax bills have been adopted into law.   
While each of these contained provisions that bear upon the  
burgeoning assistive technology field, what is perhaps even more  
striking are the linkages and opportunities that were overlooked.  
Meeting these opportunities will prove difficult, however, unless  
methods and strategies are developed to better determine the  
revenue implications of proposed changes.

     Many of the tax law changes that would benefit people with  
disabilities have the additional virtue of being "revenue 
positive" to the Federal treasury.  In  no area is this more true 
than that of assistive technology.   Unfortunately, the exact 
amount of benefit, along with the time  period within which it 
will accrue, are sometimes difficult to  determine.  This 
uncertainty is exacerbated by budgeting practices that require 
all tax revenue losses to be made up with  increased funds from 
other sources.  Regrettably, claims for the  benefits to society 
from various measures proposed on behalf of people with 
disabilities  have often been difficult to prove.

     In the tax debates of the years to come, it will be 
indispensable that forecasts be based on the most complete and  
accurate information possible.  Congress should create a 
commission consisting of leading disability statisticians,  
advocates and tax policy officials, including appropriate 
representation from the Treasury Department, to review existing  
data collection and forecasting techniques in this area, to  
determine the kinds of reports that the Internal Revenue Service  
should develop and maintain on existing utilization of 
disability-related provisions of the law, and to ensure that when  
relevant tax policy issues come before Congress, adequate and  
comprehensive cost-benefit information will be available to the  
maximum extent possible.  Such research should also include the  
systematic marshalling of data, and the evaluation of data 
collection methodologies, concerning reductions in governmental  
transfer payment expenditure attributable to existing or proposed  
tax law provisions.

     Conclusion

   Part and parcel of the technology revolution  that has swept 
society over the past two decades, the dramatic  development of 
assistive technology is transforming the lives of  people with 
disabilities, as well as the attitudes of society.   As in any 
other area of our lives, the nation's body of tax laws  has had 
an impact on this progress.  That impact has been less  dramatic 
than it might have been, due mainly to the relative  
inaccessibility of key provisions of the law.  With expanded  
information dissemination, with attention to the ways our tax  
laws do or do not serve other public policy objectives, and with  
attention to technical and substantive law changes that are  
consistent with our values and goals, this positive potential of  
the law can
continue to grow and to contribute.  No matter how progressive 
and far-sighted, our tax system does not represent an answer to 
the assistive technology funding dilemma.  It does represent one 
source among many that must be understood and expanded. 








Section Eleven:






Universal Design as a Necessary Element
for Reducing the Cost of Assistive Technology























                  NATIONAL COUNCIL ON DISABILITY



STUDY ON FINANCING ASSISTIVE TECHNOLOGY DEVICES AND ASSISTIVE 
TECHNOLOGY SERVICES FOR INDIVIDUALS WITH DISABILITIES


              Universal Design as a Necessary Element
                for Reducing the Cost of Assistive Technology



by

John De Witt

                    De Witt & Associates, Inc.
                       Glen Rock, New Jersey
                            July, 1992
              UNIVERSAL DESIGN AS A NECESSARY ELEMENT
           FOR REDUCING THE COST OF ASSISTIVE TECHNOLOGY


BACKGROUND

This paper is concerned with how design principles based upon 
examining the needs of individuals with functional limitations 
can increase accessibility and decrease the cost of financing 
specialized assistive technology.  It concentrates upon those 
areas where public policy attention should be focused:

    Understanding the essence of "universal design";

    Examining how broadly its application can serve to reduce 
     reliance upon public-sector funding for specialized 
     assistive technology;

    Critical paths toward the goal of universal design to reduce 
     public expenditures.

Universal design has become a popular phrase to use, especially 
within the assistive technology community.  Everyone knows that 
it is a simplistic way of expressing an elementary concept with 
complex implications.  Its fundamental premise is that when 
products, services and environments are designed to accommodate 
as broad a range of users as possible, there will be less need to 
produce them for individuals who function differently, for 
example, because of age, physical size,, or physical, sensory and 
cognitive ability.  The goal is, in essence, design to include 
everyone.

Universal design might more properly be expressed as "accessible" 
or "inclusive" design.  The underlying goal of the principle is 
to always examine the broadest possible application of the design 
objective for the broadest range of individuals.  In doing so, 
design concepts must be developed with an understanding of how 
individuals function in using a product, service or physical 
environment.  By always
striving to increase ease of use and convenience for the broadest 
possible range of individuals, the potential pool of users 
expands, marketability multiplies and cost is contained.  
Profitability is enhanced, public expenditures are stabilized or 
diminished.

This is not to say that one size can fit all.  Clearly many 
individuals require specialized equipment that is designed for a 
narrow base of users.  No one would suggest that augmentative 
communications boards be built into every computer regardless of 
who might use them, or that every graphic image displayed on a TV 
set be encrypted, in some fashion, to automatically interpret 
every image for a potential blind viewer.  Some devices and 
environments through which one travels (wayfinding)techniques 
will probably always be needed as dedicated assistive technology 
or a specialized accommodation to particular individuals.

However, the extent to which accessibility to product, service 
and environmental use can be incorporated within basic designs, 
the less need there will be to dedicate funds for what can and 
should be generally accessible for most individuals.  An example 
is the volume amplification control for a telephone.  As a 
specialized product, costing about $40, it drains the resources 
of state-funded telecommunications equipment distribution 
programs.  Built into the original design of a telephone, the 
cost is inconsequential. The technology is useful not alone to 
individuals who are hard of hearing, but equally to anyone using 
a telephone in a noisy environment.  Telephones designed with the 
needs of hard of hearing individuals in mind, becomes an 
attractive feature for all hearing users as well.  Public funds 
are now available to be applied toward a truly specialized piece 
of assistive technology, for example, an artificial larynx.  

Several proposals will be outlined later in this paper.  First, 
some additional background should be helpful to frame them 
conceptually.


In 1989, the following appeared in a major reference work:

     Improved design standards, better information, new products, 
     and lower costs have made it possible for design 
     professionals to begin designing all buildings, interiors 
     and products to be usable by everyone. Instead of responding 
     only to the minimum demands of laws which require a few 
     special features for disabled people, it is possible to 
     design most manufactured items and building elements to be 
     usable by a broader range of human beings including 
     children, elderly people, people with disabilities, and 
     people of different sizes. This concept is called universal 
     design. It is a concept that is now entirely possible and 
     one that makes economic and social sense."  Encyclopedia of 
     Architecture, Design, Engineering and Construction, p.754. 
     1989.

There are at least three domains within which the concept must be 
applied:

    End-user products and services;

    Building exterior sand interiors; and

    Environments through which one travels (wayfinding).


End-User Products and Services

Product/service managers, designers and engineers are always 
concerned with their product's appearance and marketability, but 
all too often, without critical attention to function.  Those 
involved with ergonomics deal with the fundamental issue of 
physical design and the human interface.  In theory, if a 
product's design can be made easy, comfortable and convenient to 
use, it will attract a broad spectrum of buyers and satisfied 
users.

Only recently have ergonomic/human factor engineers begun to 
understand the value of considering individuals with functional 
limitations in developing effective designs.  Traditionally, 
product managers, designers and engineers have aimed to design 
for the "normal" human profile - not too tall or short, not too 
slim or stout, always with normal vision, hearing, speech and 
mental capacity, not to mention ability to move about, walk and 
manipulate the environment pretty much like every one else.  
Increasingly, designers and engineers are eager to incorporate 
universal design principles but are faced with a lack of useful 
performance specifications around which to design and fabricate.

One of the major books used by the human factors community is 
Human Factors Handbook, by W. E. Woodson  (McGraw-Hill, 1981).  
It is a vast accumulation of data on human size and performance 
variables.  However, the basic source for the data were young 
males in military service of the United States.  One can imagine 
the variables that never were captured: extremely short, problems 
with agility, extra large torso, vision and hearing outside 
standard military ranges, etc.  The "handbook," too large to lift 
with one hand, is still commonly used.  A similar volume is Human 
Scales (Henry Dreyfus & Company, 1990).  It contains a compendium 
of tables that can be matched to female and male percentiles.  

In theory, many designers look to meet the needs of the 
5th-percentile female to the 95th-percentile male.  For example, 
a designer might look at the height of a 95th-percentile male and 
5th-percentile female when seated in order to know how much 
tilt-angle is require on a PC monitor so both can see the screen 
from a specified distance without moving their head.  In 
practice, the "mean" is frequently used.  A "typical" 5'10" male 
and 5'4" female produce a "mean" person who is 5'7".  It is 
possible that a design for the mean will serve very few 
individuals effectively.  In fact, it should not be too difficult 
to design monitor tilt to accommodate the broadest possible range 
of individual preferences - standing up and looking down, seated 
and looking straight ahead, or lying on one's back and looking 
up!

The boundaries of size and performance variables must be 
expanded.  To the credit
of Henry Dreyfus & Company, their tables now include individuals 
in wheelchairs.  Yet the data on how a broad range of people 
really function are far from comprehensive.  For example, what 
are the reach ranges of 95th percentile male 5th percentile and 
female sitting  in a variety of wheelchairs with specified 
limitations of reach?

Studies are needed to show the range of human performance.  One 
such study is illustrative of the needed direction.   In Boston, 
a group of males were measured for their ability to hear.  A 
curve was developed showing "hearing thresholds" across a range 
of thresholds, by age for both frequency and amplitude.  
Designers of telephone products or public address systems can use 
such data to include a broad range of potential users.  (Brant, 
L.J & Fosard, J.L.  Age Changes in Pure-Tone Hearing Thresholds 
in a Longitudinal Study of Normal Human Aging in Journal of 
Acoustical Society of America. 1990.)

In Japan, the data sources from the United States are so 
inadequate to meet the variables found in that country, that the 
Japanese government is sponsoring a major study.  It will examine 
180 different variables across a sample of 50,000 individuals.


Building Exteriors and Interiors

On May 5, 1992, the Architectural and Transportation Barriers 
Compliance Board (Access Board) issued its proposed Technical 
Assistance and Research Plan for Fiscal Years 1993-1997; Focus 
Issues and Americans With Disabilities Act Research Agenda.  For 
the first year, 1993, the Access Board proposes to examine 
Universal Design.  Projects will address the design of buildings 
and  facilities throughout the lives of the people using them.  
Several points in the Request for Comments document are of 
interest.

     Buildings which accommodate all people through their life 
     span can be achieved through the application of universal 
     design principles in all phases of the environmental design 
     process including programming,
     conceptual design, plan development, product specification, 
     and design documentation. Building programs should 
     incorporate information about the variety of building users 
     and their abilities. People with disabilities and older 
     people can be expected to be among employees, customers, and 
     visitors to a facility.  This knowledge, along with 
     information about the functional limitations of these 
     populations, can guide designers in making important 
     decisions about building access in conceptual design and 
     plan development stages, and in integrating universal design 
     features in a sensitive manner. 

     For example, accessible entrances are needed by the 10% of 
     the adult population that has difficulty with stairs, but 
     they also benefit virtually everyone. While an entrance to a 
     building can be made accessible in many ways, some are more 
     consistent with the building form than others. Access 
     standards permit ramps, lifts, or walks which meet the 
     specifications set out in the standards. Ramps, which are 
     perhaps most commonly used, are not ideal for many people, 
     and lifts may malfunction, leaving many people with 
     disabilities unable to enter or exit. In most situations, 
     proper sitting and adjustment of footings can produce level 
     entrances. When site or design constraints conflict, level 
     entrances can be provided through the creative use of 
     bridges to high ground, overhead walks, or exterior elevator 
     towers which can be shared by more than one building.  From 
     the perspective of cost and efficiency, universal design has 
     many advantages:  

       The elimination of the need to make future structural 
        modifications to accommodate the changing needs of people 
        as they age.  

       The elimination of special, duplicative, and more costly 
        elements to accommodate the needs of people with 
        disabilities. For example, if a building is sited and 
        designed properly to allow for an entry at grade level, 
        it is not necessary to construct a ramp; and the use of 
        appropriate available
        lavatories and hardware eliminates the use of more costly 
        "handicapped" lavatory and hospital hardware commonly 
        used.  

       The building will more efficiently serve the needs of all 
        users. For example, when eliminating separate 
        "handicapped" entrances through the design of one serving 
        the needs of all users, the need to duplicate supporting 
        elements and services such as providing two sets of 
        informational and directional signage and security 
        service is eliminated.  

   While the concept is relatively simple, integration of the 
   concept of universal design into the practice of architecture 
   and design, and into the construction of buildings and 
   facilities and vehicles, is much more complex and difficult. 
   It involves changing the way people think about design. It 
   involves changing model building codes and accessibility 
   standards and it involves mainstreaming the concept of 
   designing for everyone.

As the above quotation from the Access Board indicates, increased 
attention must be given to changing the way we conceive of 
design.  Integration of building interior and exterior elements 
into a cohesive framework is essential if accessibility costs are 
to be minimized.  AT the same time, the inevitable connection 
between structural elements within a building and the products 
and services applied to the building's use cannot, must not be 
overlooked.

Environments Through Which One Travels (Wayfinding)

Wayfinding in complex indoor and outdoor environments poses 
challenges to master planners, program planners, architects, 
designers and engineers.  The proliferation of roads, 
transportation facilities, single-use and multi-faceted buildings 
and structures increasingly extends within large cities, suburban 
and rural communities.  Yet, there are imperatives to protect and 
nurture our natural and built environments.  Our outdoor and 
indoor landscape needs to remain as uncluttered as possible while 
allowing people to easily find their way through it.  

An analogous human imperative also exists to acknowledge that 
national, cultural and physical diversity is one of our nation's 
greatest strengths.  If diversity is to be celebrated and equal 
opportunity offered to everyone, innovative wayfinding solutions 
are critical to this promise.  No longer can we permit 
individuals with disabilities to feel loss of independence due to 
artificial barriers in moving through environments.

The explosion of technology, undreamed of even ten years ago, can 
provide exciting new ways to solve wayfinding challenges.  Still, 
the exercise of plain old common sense and imagination is equally 
crucial.

Wayfinding should envision:

    Extending the known boundaries of this primarily visual art 
     beyond environmental graphics to embrace a coordinated 
     matrix of wayfinding components;

    Incorporating creative strategies that take advantage of 
     visual, auditory, spoken and tactile clues that may be used 
     by everyone in one or more combinations;

    Acknowledging and building upon each individual's physical, 
     sensory, cognitive and language needs or abilities.

Traditional wayfinding has generally concentrated upon moving 
people through spaces by the creative application of visual 
signage, symbols and color.  For many individuals, because of 
visual, auditory, cognitive or language differences, alternative 
forms are increasingly important.  Designers, architects and 
engineers can no longer model for a standard young male adult, 
5'10", 170 pounds, 20/20 vision, normal hearing, and full mental 
capacity, who happens to speak English.  

Inclusive design embraces a much broader range of individual 
differences.  Limited design results in accentuating differences 
in a way that excludes many individuals
from full and independent participation in the programs, services 
and facilities of our modern society.  The cost of assisting 
individuals with disabilities through outdoor and indoor 
environments can be reduced through the creative application of 
universal design principles.


Proposals

The proposals made here are fundamental to the ultimate goal of 
integration of individuals with disabilities into all aspects of 
our society.  To achieve this goal, a reformation in our concepts 
of inclusiveness and a corresponding renaissance in design will 
be required.  It will take many years, probably generations.  
This author, for one, is optimistic about the results.  The 
benefits to everyone will be:

    easier and more comfortable access to our environment, 
     facilities, goods and services; and

    a reduction in public financing of the cost for special 
     assistance and technologies currently required to meet the 
     needs of individuals with disabilities.

There are three basic elements to the proposals regarding 
universal design.  Each is key; the positive impact of any one is 
tied to implementation of all three.

   1)Fund, through both public and industrial participation, an 
     ergonomic-demographic study of human performance 
     characteristics specifically targeted to individuals with 
     functional limitations in areas such as audition, vision, 
     speech, motion, sensation, cognition, environmental 
     sensitivity, etc.

     The study should be conducted by a consortium of public and 
     private entities and funded jointly by each.  Since the 
     study will benefit all industries which produce or develop a 
     wide variety of products and services, no single industry
     or firm should maintain proprietary control over the 
     project. Individuals and organizations knowledgeable in 
     ergonomics, functionally-related disability statistics and 
     product/service design should be directly involved in 
     formulation of the study team and development of its scope, 
     methodology, data collection, analysis and report 
     generation.  Individuals with each of the functional 
     limitations mentioned above, who also have knowledge of one 
     or more study elements, should be brought in as contributors 
     to the study team.

     Every attempt should be made to build upon the existing body 
     of knowledge, expanded and refined to incorporate the limits 
     of performance suitable to individuals with functional 
     limitations.  Team members should draw upon any existing 
     models (Woodson or Dreyfus, for example) and upon other 
     sources (Acoustical Society, Japanese study, World Institute 
     on Disability's Blue Ribbon Panel Report, Laying the 
     Foundation, etc.).


   2)Extend, in Federal legislation, the concept of accessibility 
     to goods and services provided by commercial facilities and 
     public entities, such coverage not to be limited to 
     building/facility interiors and exteriors, but to the 
     general environment within which every one must make their 
     way (wayfinding).

     Much of the current body of Federal law incorporates the 
     concept of accessibility to programs, services,facilities 
     and some products for individuals with disabilities.  
     However, virtually all of them envision the use of assistive 
     technology devices and services as a means to achieving the 
     goal of accessibility.  Almost nothing in the 
     Technology-Related Assistance Act or the Rehabilitation Act 
     addresses the need for applying universal design principles.  
     For example, Section 508 of the Rehabilitation Act requires 
     access to electronic office equipment by individuals with 
     disabilities, but its implementation focuses almost entirely 
     upon finding ways to help Federal agencies learn about and 
     purchase peripheral products that will enable an individual 
     with a disability to use what would otherwise be 
     inaccessible.  Emphasis should be placed upon encouraging, 
     or requiring, equipment design that demands as few assistive 
     technology peripherals as practicable.  

     Similar examples can be cited in state-mandated 
     telecommunications equipment distribution programs.  In 
     these, states should be encouraged to fund any telephone 
     product, specialized or not, that serves an individual's 
     need.  Note the discussion of a volume amplification 
     handset, above.

     An even stronger case could be made for certain durable 
     medical equipment.  If encouraged to do so, manufacturers of 
     grab bars could, and should, design them to be attractive, 
     durable and relatively inexpensive as a general household 
     product.  On the contrary, the more rugged (durable) they 
     appear, the more likely they are to be funded by public or 
     private insurance, even though the cost is higher than it 
     should otherwise be.

   3)Enable the Architectural and Transportation Barriers 
     Compliance Board to
     expand its mandate beyond the artificial barrier of physical 
     structures to include goods and services, and the wayfinding 
     environment.  The Board should assist American business and 
     industry to develop guidelines for accessibility that embody 
     the principles of universal design drawing upon the 
     ergonomic-demographic study, above.

     In conjunction with both public and private entities, the 
     Board should engage in a process to define appropriate 
     methods for measuring how human performance, as reported by 
     the ergonomic-demographic study team, can be effectively 
     translated into design guidelines.  However, the guidelines, 
     rather than being prescriptive, should foster creative 
     approaches to universal design principles.

     Simultaneously, publicly-funded R&D should be mandated to 
     foster projects that apply principles of universal design.  
     Private industry should be encouraged, and in some instances 
     mandated, to consider how new goods and services can be 
     easily used by as broad as range of individuals as possible.  
     For example, the fields of telecommunications and computing, 
     consumer electronics, educational technologies, information 
     services, to mention but a few, can no longer be permitted 
     to engage in research, design and manufacture of products 
     and services that exclude individuals with functional 
     limitations because no consideration was given to their 
     inclusion.  

Those who conceive, design, fabricate or market goods and 
services to the general public must be required to address as 
broad a range of users as possible.  These proposals do not 
envision that all individuals with all types of limitations must 
be served by every product or service without the use of any 
further peripheral component or human assistance.  Neither do 
these proposals envision that an unreasonable burden be applied, 
to either technical feasibility or economic viability.  However, 
implementation of these proposals does envision that individuals 
with functional limitations must be included within the design 
framework.  As a matter of public policy, inclusiveness in design 
is equally important as a civil right as it currently
is for access to employment, places of public accommodation and 
public entities for their programs and services.  The age of 
Universal Design is now.




Section Twelve:






Summary of Issues Raised at the Three Regional Public Forums



                  NATIONAL COUNCIL ON DISABILITY





A STUDY ON FINANCING OF ASSISTIVE TECHNOLOGY DEVICES FOR 
INDIVIDUALS WITH DISABILITIES








Summary of Suggestions From Three Regional 
Public Forums

                          March 18, 1992








Contractor:  United Cerebral Palsy Associations, Inc.
1522 K Street N.W., Suite 1112 
Washington, D.C.  20005






     The National Council on Disability conducted three regional 
     public forums on the financing of assistive technology for 
     individuals with disabilities.  Forums were held in Los 
     Angeles, California, March 21 - 22, 1991; Portland, Maine, 
     July 11 - 12, 1991; and Minneapolis, Minnesota, October 17 - 
     18, 1991.  Over 100 individuals, including parents of 
     children with disabilities, individuals with disabilities, 
     professionals, government representatives, and national and 
     regional experts testified from twenty-six states.  
     Witnesses presented over 200 suggestions, based on their 
     personal and professional experiences, on the financing and 
     acquisition of assistive technology for children, adults and 
     senior citizens with disabilities.  The following pages 
     provide a framework of the issues and suggestions presented 
     at the forums.  

                           TABLE OF CONTENTS

                                                           Page
I  Information Resources/Outreach/Education and Training.............1


II Service Delivery Issues...........................................3


IIIImproved Funding of Assistive Technology 
   and Related Services..............................................5


IV Justification Standards/Criteria..................................7

V  Special Populations I:  Minority/Rural Outreach...................8

VI Special Populations II:  Elderly Individuals and Technology.......8

VII  Universal Design/Integrated Accessibility Design................9

VIII Telecommunications.............................................10

IX Technology and Long-term Care Facilities.........................12

X  Alternative Solutions/Innovative Programs........................13


I. Information Resources/Outreach/Education and Training

   It is difficult for consumers and their families to learn what 
   technology is available.  There is no single professional or 
   agency which knows all of the assistive technology available.  
   Information is sometimes difficult to find, and often 
   inconsistent from source to source.  Further, many geographic 
   areas lack any qualified and informed professionals at all.   
   The lack of vendors, and that fact that many vendors favor 
   specific brands of technology adds to a consumer's ignorance 
   of available technology options.  (Witness, NCD Public Forum:  
   Portland, Maine; July, 1991)

   The lack of awareness of appropriate technology and effective 
   funding strategies includes individuals with disabilities and 
   their families, as well as professionals, educators and 
   funding/claims agents.  Physicians, often responsible for 
   prescribing various assistive technology devices, in general 
   have very little knowledge about the options.  There is a 
   reluctance to allow persons an opportunity to learn how to use 
   a device, particularly persons with mental retardation.  This 
   difficulty may lie not with the technology but in assessing 
   the need for it.  The dilemma in assessing technology is that 
   people aren't accustomed to looking at technology and 
   translating its usefulness into information about an 
   individual child.  (Witness, NCD Public Forum:  Minneapolis, 
   Minnesota; October, 1991)


Suggestions:
Information Resources and Outreach
1. Conduct extensive outreach and information dissemination to 
   the general public, including major national, regional and 
   local campaigns to educate the public about the existence of 
   assistive technology, its benefits to numerous individuals of 
   all ages, individuals rights by to technology and related 
   services law, as well as methods of acquisition.  Assure that 
   information is made accessible to individuals with sensory 
   impairments.  Include efforts to see the use of assistive 
   technology in mainstream commercial advertisements.  (See 
   also, V and VI:  Special Populations.)

2. Create national and regional clearinghouses with toll-free 
   phone numbers, and information networks to serve parents, 
   children, professionals, manufacturers, vendors and funding 
   sources' personnel alike.  Regional and national single points 
   of contact, including lending
   libraries, would greatly facilitate the entire maze of 
   information and reduce fears.  Included contact information 
   about these centers in the outreach efforts described above.

3. Create equipment demonstration and loan centers that can 
   facilitate the ability to assess equipment, relative to an 
   individual consumer's particular needs and desires.  These 
   loan centers could provide assessment services, while allowing 
   an individual to borrow and "test" a particular device in 
   real-life situations.  This serves to eliminate the common 
   problem of wasted funds and time on the purchase of 
   inappropriate equipment.

4. Create "funding managers" and/or "funding coordinators" at the 
   state and/or program level.  These individuals should be 
   formally trained, working to assist individuals and their 
   families in piecing together the puzzle of available funding 
   options, serving as a central resource and advisor on funding 
   issues.  (See also, II, 2).

5. Encourage and financially support the establishment of support 
   groups.  Support groups will facilitate people sharing 
   valuable information and informal technical assistance and 
   advice, which is not available through health care 
   professionals, in determining technology needs and securing 
   funding for assistive technology.

Education and Training of Professionals
6. Create expert assessment teams, each with a particular 
   specialty and expert perspective (i.e., one physical 
   therapist, one speech therapist, one occupational therapist, 
   etc.)  which can help consumers identify useful assistive 
   technology.  The use of teams would help to overcome the 
   current difficulty of assistive technology expanding and 
   changing so quickly that no single person who conducts 
   assessments can be fully informed of all that is currently 
   available to the consumers they advise.

7. Training must be targeted to parents and school staff about 
   how technology can work for a child, by identifying needs that 
   can be translated into IEP goals.  Capacity must be expanded 
   to properly assess the need for assistive technology.  Educate 
   professionals and consumers on how to translate the usefulness 
   of appropriate technology to individual learning goals and 
   objectives.

8. Training and education of professionals, including physicians, 
   special education teachers and therapists is critical, 
   particularly in areas where shortages of qualified 
   professionals
   exist.  Incentives should be offered to entice qualified 
   individuals to receive the additional training they may need 
   to work with people with disabilities in the assessment, 
   identification, and utilization of assistive technology.  
   Also, establish funding as an incentive for training for 
   interpreters for the deaf and hearing impaired to advance 
   their skills.  Provide incentives for teachers to enter deaf 
   education programs and stipends to provide training for 
   teachers in this, and related fields.

9. Professionals and physicians need continued information and 
   training on available assistive technology and appropriate 
   applications in different environments, and the ways to write 
   documentation necessary to fund technology.  Many requests for 
   funding of assistive technology are denied simply because the 
   documentation is insufficient or weak.  Professionals and 
   physicians need training to eliminate this unnecessary type of 
   denial.

10.  Mandate training initiatives regarding assistive technology 
     for certain professionals from a federal level as a 
     requirement for all relevant state agencies.  Establish 
     credentialing and licensing for assistive technology 
     specialists.  This will help to insure that consumers of 
     assistive technology are receiving the appropriate equipment 
     and the appropriate training.


Education and Training of Policy Makers and Advocates for Systems 
Change
11.  Develop a networking system and/or legal database for 
     Protection and Advocacy and Client Assistance Programs to 
     access what other attorneys and advocates are doing around 
     the country.  Especially helpful would be the strategies and 
     legal arguments that they have found to be successful.  
     Develop and maintain as a function of this network and/or 
     database a national list of experts on the appropriate use 
     and financing of assistive technology, to assist advocacy 
     agencies and legal service agencies at hearings and in 
     court.  Encourage these experts to work on a pro bono basis.

12.  Vocational Rehabilitation staff, special education and 
     school administration personnel, and public insurance 
     personnel need more education about assistive technology, 
     especially assistive technology that enables persons with 
     disabilities to lead more independent and productive lives, 
     and achieve full integration in the school, workplace, home 
     and community.

13.  Persons with disabilities should serve in an advisory 
     capacity on the review boards of private insurance companies 
     and state agencies.  It would also be beneficial for medical 
     professionals and rehabilitation engineers to serve on the 
     review boards, as well.  The presence of these experts will 
     help to educate others on the review boards about the value 
     and uses of assistive technology.  Mandate that individuals 
     serving on the review boards who set up eligibility 
     requirements for funding of assistive technology have 
     training in the uses of assistive technology.

14.  Foster relationships between people who use assistive 
     technology and charitable organizations.  The multifaceted 
     goals of these interactions include:  direct service 
     funding, general education, and influence on the public 
     policy and perception surrounding assistive technology.  
     Incorporate discussion about the usage and value of 
     technology for persons with disabilities at the professional 
     curriculum level. Include information about education in the 
     least restrictive environment is required by law and that 
     assistive technology can help achieve this objective.


II.Service Delivery Issues

   There are an abundance of inconsistencies between and within 
   various agencies, leading to an extraordinary amount of 
   confusion and frustration for individuals with disabilities 
   and their families. (Witness, NCD Public Forum:  Los Angeles, 
   California, March, 1991) 


Suggestions:
Clarification and Consistency of Policies and Programs
1. The rampant inconsistencies within and between agencies in 
   different geographic areas and even within a single agency 
   need to be eliminated.  Clear cut application and 
   documentation guidelines, requirements and criteria for 
   eligibility, and appeals procedures need to be expressly 
   defined and maintained within clear timelines. 


2. Clarification of guidelines and requirements must be made 
   within the health care, educational and rehabilitation systems 
   so that refusal on the basis that "someone else" should be 
   funding a particular device or service can be eliminated.  
   This will also eliminate the need to apply for coverage simply 
   to receive a denial so that other funding can be obtained.  

Coordination of Service Delivery
3. Interagency agreements must be established to improve and 
   increase coordination between agencies, especially funding 
   sources.  Establishment of a single point of contact to serve 
   as a coordinator for each of the varying agencies in the state 
   would be helpful.  (See also I, 4).  Encourage the 
   coordination and pooling of resources from individual agencies 
   versus the "payor of last resort syndrome".  Also, improve 
   coordination between assistive technology dealers and public 
   and private insurance providers.

4. There should be regional or national coordination of funding 
   sources so that persons with disabilities who are entitled to 
   money or other services could be registered as eligible as 
   early as birth.

Consumer-Driven Service Delivery
5. Create a consumer-driven system, so that consumers will have 
   more control and decision making power over their own lives.

6. Policies need to be more consumer-responsive and realistic, 
   and should recognize that the assistive technology needs of 
   individuals with disabilities are ongoing and changing, 
   particularly for children with disabilities.  Also, arbitrary 
   and unreasonable time restrictions should be eliminated.  For 
   instance, the requirement in some programs that five years 
   must pass before the consumer can update a piece of 
   technology.

7. Federal and state policies which do not reinforce creative 
   funding options, responsive to the unique needs of different 
   individuals and families, should be revised or eliminated.

8. Encourage school districts to establish an open, friendly, 
   consumer-responsive environment toward the use and funding of 
   assistive technology--as an important, crucial step in helping 
   to fulfill the potential of each student.

Service Delivery to Children
9. Encourage the financing of assistive technology as early in a 
   child's life as possible.  If a child enters the school system 
   already using assistive technology, convincing the school 
   board to fund new devices is much easier.  Furthermore, the 
   earlier a child begins using assistive technology the sooner 
   he or she will be able to achieve his or her potential.

10.  Technology paid for under the students IEP must be available 
     to follow the youngster home at the end of the day, the 
     week, or even the summer.  The educational value of a device 
     is not limited to a classroom.  Furthermore, as a youngster 
     moves through the school system his or her specialized 
     assistive technology must go with them.


11.  Assessment and diagnosis of a child's capabilities and needs 
     should be conducted by a multi-disciplined team of 
     professionals, educators, therapists and family members, all 
     of whom would be knowledgeable about the range of assistive 
     technology options available.

Emergency Systems/Safety Concerns
12.  Establish mandatory closed captioning of all television 
     programming, and real-time captioning of all live events and 
     emergency broadcasts.  Mandate the use of flashing light 
     alarms in all public buildings with visual instruction 
     provided.


III. Improving Funding of Assistive Technology and Related 
     Services 

   There is a lack of funds across all funding sources, public 
   and private.  Even those systems which work better than others 
   are subject to the limits of their funding supply, and claims 
   which may otherwise be eligible for funding are often rejected 
   due to the lack of funds.  (Witness, NCD Public Forum:  Los 
   Angeles, California;  March, 1991) 


Suggestions:
Legislative Changes
1. Legislative changes are needed to guarantee adequate funding 
   under existing laws for the provision of assistive technology, 
   such as the Individuals with Disabilities Education Act, Tech 
   Act, Vocational Rehabilitation and various state laws, such as 
   the state of California's Low-Incidence funding program.  
   Existing entitlements in schools and the workplace should be 
   clarified and enforced.

2. There should be clear entitlements to assistive technology as 
   a basic civil right in the home, classroom, workplace, and 
   community.

3. Legislation--federal and state, needs to be enacted to mandate 
   private insurer coverage of assistive technology.

4. It should be mandated by law that the costs of evaluations, 
   training on equipment, repair and maintenance should be 
   included in any and all funding for assistive technology.

5. Public education funding, including at the state level, needs 
   to be more flexible in allowing children to use equipment at 
   home, and take equipment with them when they move or graduate.  
   Legislative mandates and increased funding would facilitate 
   this.

6. There are numerous potential cases of individuals who could 
   benefit from assistive technology, who are denied their 
   requests.  Very few of those cases come to the attention of 
   Protection and Advocacy Systems and Client Assistance 
   Programs.   More funding is needed for the Protection and 
   Advocacy Systems to better serve individuals with disabilities 
   who have been denied assistive technology, and at the program 
   level to allow
   administrators, such as vocational rehabilitation counselors, 
   the programmatic funding to take on such cases. 


Medicaid
7. Require states to acknowledge the Rehabilitation Purpose of 
   Medicaid in medical needs determinations.

8. Declare that "exclusion lists" of durable medical equipment 
   are inconsistent with the Medicaid amount, duration and scope 
   mandates.

9. Declare that augmentative communication devices and services 
   are covered by Medicaid in a broader definition of "medical 
   necessity."

10.  Declare that persons "dually eligible" for Medicaid and 
     Medicare are entitled to full Medicaid payment of their 
     durable medical equipment needs.

11.  Eliminate barriers to independence for recipients of 
     nursing, home health, and personal care services.

Special Education
12.  Develop a review/accountability mechanism to ensure that 
     school districts consider and include assistive technology 
     as a part of the IEP drafting and review processes.

13.  Clearly state a federal policy regarding integrated programs 
     including the role of assistive technology as a support for 
     integration.

14.  Require school districts to recognize that least restrictive 
     environment is a state-wide consideration.

15.  Declare that schools cannot restrict technology to school 
     property or to school sessions.

16.  Develop review/accountability mechanisms to ensure that 
     school districts and state vocational rehabilitation 
     agencies engage in transition planning.

Vocational Rehabilitation
18.  State an operational definition of rehabilitation 
     engineering including the services that are covered, how 
     evaluations will be conducted, and how evaluation data will 
     be used in decision making.

19.  Develop a review/accountability mechanism to ensure that 
     states provide rehabilitation engineering services in 
     Individualized Written Rehabilitation Plans.


IV.  Justification Standards/Criteria

   The justification standards for assistive technology required 
   by all funding sources, public and private, are overly 
   restrictive, and serve as the most prevalent barrier to the 
   funding of assistive technology services and devices.  Private 
   and public insurers' demand for proof of "medical necessity," 
   combined with public education's requirement of "educational 
   necessity" are standards that do not respond adequately to the 
   needs of users.  (Witness, NCD Public Forum: Los Angeles, 
   California;  March, 1991) 

   State Medical Assistance Programs or Medicaid have no specific 
   guidelines for the type or amount of documentation needed for 
   any of their criteria except the criteria of medical 
   necessity.  This allows the state to keep asking for 
   additional information.  The residents' right to appeal a 
   denial of service is not activated as there has been no 
   denial.  The communication has all been between the 
   professionals, the supplier and the medical assistance 
   program.  The resident is often left in the dark during the 
   prior authorization process.  The vast majority of 
   controversies involve disputes over whether a "life skill" is 
   really a medical necessity.  (Witness, NCD Public Forum:  
   Minneapolis, Minnesota; October, 1991)


Suggestions:
1. The medical necessity requirement for funding by both private 
   and public insurers of assistive technology needs to be 
   altered to a standard that responds to the need to improve 
   function for enhanced productivity and independence.

2. The public school funding streams' restrictive definition of 
   "educational necessity" must be broadened to a more functional 
   model, allowing for the transfer of equipment out of the 
   schools and increased benefit from assistive technology usage.

3. Funding agency personnel need to be educated on the benefits 
   of assistive technology, both functionally and fiscally.

4. There is a need for legislative and regulatory clarifications 
   that the important purpose of
   the Medical Assistance programs is to ameliorate the effects 
   of a disability, including rehabilitation and assistive 
   technology.

5. There is a need to specify in regulation or statute the 
   specific documentation necessary to establish medical or 
   functional necessity to meet a rehabilitation objective, and a 
   reasonable timeline for application review and approval.  
   These requirements should be coordinated across funding 
   sources so they do not conflict with one another across 
   programs.

6. The accountability of physicians, payors and providers needs 
   to be increased so that appeals are not required to determine 
   an explanation for denial, and payors and physicians are held 
   more accountable for their recommendations.  This should be 
   mandated by law.


V. Special Populations I:  Minority/Rural Outreach

   There are specific barriers faced by individuals of minority 
   background or cultural diversity who are in need of 
   information about assistive technology.  These special 
   obstacles include: language barriers, lack of informed medical 
   advisors, and little exposure to other individuals using 
   assistive technology. (Witness, NCD Public Forum Minneapolis, 
   Minnesota; October, 1991)


Suggestions:
1. Develop and mandate outreach programs specifically for 
   individuals of minority background or cultural diversity.  
   This outreach should include written materials produced at a 
   low reading level, as well as materials and promotions in 
   Spanish and other languages.  Information should be 
   disseminated via community resources, such as churches, 
   medical clinics, social service agencies, etc.  Information 
   should include visual demonstrations of people of color using 
   assistive technology.

2. The unique cultural attitudes on disability and specific 
   cultural needs involved in providing assistive technology 
   service delivery to individuals of minority groups should be 
   studied, and taken into consideration in outreach and service 
   delivery.

2. Increase the number of minority administrators in funding 
   agencies and on funding review boards.

3. Develop a mobile traveling assistive technology demonstration 
   center to reach home-bound individuals and consumers in rural 
   areas.


VI.  Special Populations II:  Elderly Individuals and Technology

   Comprehensive public rehabilitation programs for older person 
   are widely unavailable because they are not yet perceived as 
   priority or urgent needs.  While general knowledge of 
   disabling conditions and appropriate rehabilitation services 
   among federal policy makers is evident, limited specific 
   knowledge of the economic and social benefits and costs of 
   such programs frustrate the growth of that sense of priority 
   and urgency. (Witness, NCD Public Forum Minneapolis, 
   Minnesota; October, 1991)


Suggestions: 
1. Specifically targeted outreach efforts should be made to older 
   Americans, demonstrating the benefits of assistive technology.  
   Many older Americans do not see themselves as disabled, and do 
   not understand or consider the benefits of assistive 
   technology.  These individuals need to be informed of the 
   benefits, as well as their rights to assistive technology.

2. Interdisciplinary research data must be collected on disabling 
   conditions and rehabilitation services.  To date, most health 
   data collection has focused primarily on single points in time 
   rather than transitions and change throughout a lifetime.  
   National and state data collection efforts should be revised 
   to measure and collect information longitudinally in order to 
   monitor pathology, improvement functional limitation, 
   disability and prevalence over time.

3. Government should take an active role in sponsoring rigorous 
   research on issues such late-life onset of chronic disabling 
   conditions; the relative cost, benefits and dynamics of 
   rehabilitation strategies, including assistive devices; and 
   the social and economic barriers
   to seeking assistance for disabling conditions.  Usage of 
   assistive technology, particularly home adaptions, could lead 
   to increased independence and financial savings for many older 
   Americans.

4. Health and social support professionals must be trained to 
   understand issues related to disability and aging.  Incentives 
   must be offered for professionals to seek this training and 
   pursue a career in geriatrics.

5. The public must be informed about issues related to aging and 
   disability, and encouraged to express their concerns and needs 
   to policy makers at federal, state and local levels.  

6. The federal government should create incentives through 
   waivers, special funding or other means to encourage states to 
   establish policy level coordination mechanisms between 
   agencies responsible for serving people with disabilities, and 
   agencies serving the elderly, to maximize meet the long term 
   care needs of all people with disabilities.


VII. Universal Design/Integrated Accessibility Design

   Assistive technology is an economic issue for American 
   business and public institutions. Integrated accessibility 
   implies the principle of inclusion--consumers with 
   disabilities as part of the general consumer market. (Witness, 
   NCD Public Forum Portland, Maine; July, 1991)
 

Suggestions:
1. The consideration of assistive technology must be moved out of 
   the medical/rehab model and into an integration model.  
   Integration of people with disabilities into the social and 
   economic fabric of our society is good for everyone.  
   Assistive technology will play a central roll in this 
   development.  

2. American business should be provided incentives to increase 
   the accessibility of their products and services.  Products, 
   services and their underlying technologies should be designed 
   and deployed with persons with disabilities in mind.  If a 
   task is made easier for
   a person with a disability, those without disabilities also 
   often find the same task easier for them.  For assistive 
   technology which becomes integrated in general market products 
   and services, the cost to American business is generally less 
   than one percent, either for design or manufacturing.  The 
   increased sales of accessible products to all consumers 
   including those with disabilities will always exceed 
   incremental cost by virtue of greater volume of purchases or 
   use.

3. Reduce the need for assistive technology by dedicating 
   research monies to encourage accessibility of the environment 
   as a whole.  For example, if computer software is designed to 
   be accessible for use on the general market a consumer would 
   not need to purchase specially designed software to access the 
   regular software programs.  No attention has yet been made to 
   the accessibility of many office electronics, such as 
   facsimile, answering machines, photocopiers, and business 
   telephone systems with voice, data and video integration.


VIII.Telecommunications

   Emerging telecommunications are designed in a way that 
   requires an ever greater number of functional abilities.  
   Since every human ability defines a human disability more and 
   more, people with disabilities can expect to be excluded from 
   telecommunications access, unless, through public policies, 
   and the industry, in its product designs, take action to build 
   electronic curb cuts into all products and services.  
   (Witness, NCD Public Forum Minneapolis, Minnesota; October, 
   1991)


Suggestions:
1. Equivalent access for all people with the full range of 
   current and emerging telecommunications technology is not only 
   possible, but imperative if individuals with disabilities are 
   to take command of their lives and live them more fully.

2. People with Text Telephones have little assurances that they 
   can communicate with government offices, even those listed as 
   having Text Telephones.  Government workers are often 
   untrained in Text Telephones use and hang up the phone because 
   they do not
   recognize the sound of a Text Telephone Call.  911 operators 
   do not recognize a Text Telephone call.  There are 
   non-technical barriers to access to telecommunications.  
   Equipment training for all individuals and attitudinal 
   barriers need to be addressed.

Hearing
3. The incorporation of Text Telephone access ports or keyboards, 
   hearing aid compatible handset, volume controls for handsets 
   and speakers, and the simultaneous use of visual information 
   to supplemental audio information, will enhance use of 
   telephones and other telecommunications products and services.  
   Development of text-to-speech and voice carryover technologies 
   will also enhance use.  Simultaneously, text-to-speech will 
   enhance use for those with speaking-related disabilities.  

Visual
4. The incorporation of synthetic speech, large print with simple 
   serif fonts and high contrast, tactile markings used to create 
   a frame of reference, and the simultaneous use of audible 
   information to supplemental visual information, will enhance 
   use of telephones and other telecommunications products and 
   services.  Development of text-to-speech directories for 
   telephone networks, shopping malls; or the incorporation of 
   descriptive-video services on TV, cable or videotext systems, 
   will increase access.  Simultaneously, use of text-to-speech 
   will assist persons with language-related disabilities.


Mobility
5. For persons with upper-extremity limitation, incorporating 
   light handsets which are natural to grip and hold; or keys, 
   switches and controls with sufficient concavity, size, 
   spacing, force and slip co-efficient, will enhance use.  
   Development of speech-to-text features, for no-hands use, will 
   increase access.  Simultaneously, components with "good" 
   tactile qualities will enhance use for blind/low vision users.  
   Speech-to-text will enhance use for persons with limitations 
   in speaking, as well as many with perceptual, memory or 
   sequencing limitations.

6. For persons with lower-extremity limitations, incorporating 
   components which are within line of sight and reach from a 
   "sitting" height; spaces such as public telephone sites which 
   will accommodate a variety of wheelchair designs, or 
   work-shelf areas for placing writing materials, will enhance 
   use.  A work space will enhance use for a Text Telephone user. 
   Development of easy to manipulate cordless telephones will 
   enhance use for consumers with other limitations in mobility 
   or speed.  Although many of these accommodations appear to be 
   architectural rather than technical, they are important areas 
   to address.

Speech
7. Incorporating options for text-to-speech technology; increase 
   volume output and hands-free operation with use of an 
   operator-style headset/transmitter will enhance use.  
   Continuing and improved training of telecommunications 
   personnel having contact with the public will enhance their 
   communication with persons who stutter, have soft or other 
   speech-related disabilities.  Simultaneously, improved and 
   attitude modification, will enhance communication with some 
   consumers with cognitive disabilities.  

Cognitive Processing
8. An individual with a learning disability frequently benefits 
   from redundant presentations.  A telephone with a visual call 
   progress display has increased functionality.  Add synthetic 
   speech verification of dialpad keys being pressed, as an 
   option, and functionality is increased even further.   
   Limitations in memory or sequencing are also being addressed 
   in much the same manner.  Simultaneously, audio or visual 
   features enhance use for blind/low vision or deaf and hard of 
   hearing consumers.



IX.  Technology and Long-term Care Facilities

   Persons with multiple and severe disabilities are among the 
   least frequently targeted for movement from inappropriate 
   nursing facility placements into community settings.  The 
   equipment being used in facilities is often in extremely poor 
   condition.  Lack of understanding of the difference modest 
   assistive devices can make and the knowledge of the many 
   options that are readily available to individuals with 
   disabilities is a great failure in the existing service 
   delivery systems for individuals in state facilities. 

   Many persons receiving Medicaid waiver services who could 
   benefit from assistive technology do not receive it.   
   Adaptive and assistive devices are included in only a minority 
   of states' waiver plans for ICF/MR-eligible individuals 
   although such devices are requested in almost three-fourths of 
   the states' waiver applications to serve persons with mental 
   retardation and related conditions inappropriately placed in 
   nursing homes.  (Witness, NCD Public Forum Minneapolis, 
   Minnesota; October, 1991).


Suggestions:
1. Comprehensive, practical training on the appropriate and 
   practical uses of assistive technology should be required for 
   licensing of all long-term care facilities.  Training should 
   show possibilities and applications of simple and 
   sophisticated technologies.  Training must include facility 
   staff and consumers.

2. Through specialized use of Medicaid waiver funds, other states 
   could be encouraged to develop projects similar to SPICE in 
   Illinois (see Appendix D, p. 99).  Additionally, state 
   agencies could have a better appreciation of the important 
   role that assistive technology plays in the lives of persons 
   with disabilities.  This could translate into improved access 
   to funding for equipment and devices.

3. An important role for the government could be to support the 
   creative use of Medicaid dollars to fund a combination of 
   equipment and personal attendant services, which could 
   eliminate the need for costly institutional care.  

4. Greater accountability must be demanded of facilities when 
   receiving public dollars to provide care for persons with 
   multiple and severe disabilities.  There must be some 
   definition of basic assistive technology needs which 
   institutions must address in order to continue participating 
   in the Medicaid program.

5. The question of who pays for assistive technology when a 
   person lives in a nursing home must be settled.  The idea that 
   nursing homes should be expected to finance assistive 
   technology for all residents within a pre-determined capped 
   per-diem is not feasible, regardless of the rate setting 
   methodology used.  Residents should be eligible to participate 
   in any program which helps to finance assistive technology for 
   individuals.  Artificial eligibility criteria based on age or 
   residence should not be tolerated.


X.  Alternative Solutions/Innovative Programs 

   State funding sources often require that equipment must be 
   rented only, not bought, in order to be state funded.  This 
   results in tremendous waste, as the amount individuals pay in 
   rent over the years often exceeds the actual cost of the 
   equipment.  Equipment which is returned by one individual can 
   then be rented out to another individual, again making the 
   total which the state collects far excessive to the actual 
   cost of the device.  State agencies typically do not have 
   enough devices available for rent, or varieties and specific 
   features are unavailable.  Repairs and maintenance are not 
   usually covered.  For states which allow individuals to 
   purchase equipment, there is often little or no opportunity 
   for the individual to "borrow" the equipment for a 
   pre-purchase trial period in order to test its suitability.  
   Furthermore, the scarce number of vendors (virtually none in 
   certain rural areas) often means there is no opportunity to 
   make comparisons of different devices or even to learn the 
   existence of several different types of similar equipment on 
   the market. (Witness, NCD Public Forum:  Minneapolis, 
   Minnesota; October, 1991)


Suggestions:
Funding Alternatives
1. States which currently rent equipment should offer low 
   interest or no-interest loan programs so that individuals can 
   purchase and own their own equipment.  States should
   investigate, evaluate and encourage alternative funding 
   programs for assistive technology.  

2. The federal government should offer tax incentives through the 
   IRS for individuals, agencies and companies to purchase 
   assistive technology.

3. Create incentives for manufacturers, banks and foundations who 
   can organize funding partnerships among themselves and 
   increase the number of funding sources, including loan 
   programs, available outside of state agency funding sources.

4. Federal and state government should provide grant "seed" 
   funding to encourage public libraries to develop assistive 
   technology access programs.  Funding could be made available 
   to local agencies for assisting consumers in purchasing the 
   assistive devices needed.  The nature of the funds could be 
   either grants or loans.  Funds could cover the cost of initial 
   equipment, staff training and support.  Libraries should be 
   encouraged to employ a person solely responsible for the 
   planning and direction of these services.  Local grant funding 
   could be sought in order to begin the new service and 
   integrate the service into the mainstream of public libraries.

5. Encourage states to develop a voucher program for individuals 
   with a disabilities, and allow the individuals to determine 
   which technology services or devices provide the best use of 
   their voucher.

6. Create a government program that offers manufacturers of 
   assistive technology financial subsidies to cover research and 
   development costs, the same way that the government subsidizes 
   research and development for the military.   This would 
   ultimately lower the costs of assistive technology to the 
   consumers.

Access to Information
7. Develop statewide or regional tracking systems and consortia 
   for purchased and used assistive technology, particularly for 
   children, who outgrow devices frequently.  Recycle assistive 
   technology, pool resources and share materials, equipment and 
   expertise.  These same regional or state networks or consortia 
   could offer equipment loan banks, allowing individuals to 
   "borrow" devices and equipment.  These networks could offer 
   demonstration labs, training and assessment as a centralized 
   resource for the area they
   serve.

8. Support funding for an independent computer-based technology 
   selection system that brings together persons with 
   disabilities, clinicians  who prescribe technology, 
   government, and private insurers who pay for technology, 
   allowing all parties to cooperate in selecting and paying for 
   the most appropriate, cost-effective technologies.  An example 
   of such an alternative is ECRI.

9. The state should sponsor periodic assistive technology 
   conventions to spread information about available equipment.

Enhanced Service Delivery
10.  States should purchase equipment with maintenance 
     agreements.  All funding of devices should include funds for 
     maintenance and repairs for the life of the equipment.

11.  Implement a system for training and follow-up for consumers 
     after the acquisition of assistive technology.  This will 
     insure that the ultimate benefit is achieved from the 
     device.

12.  Mandate that vendors allow consumers trial or test periods 
     before purchasing assistive technology at no charge to the 
     consumer.

13.  Usership vs. Ownership:  With "usership," a person with 
     disabilities has the ability to use and receive the benefit 
     of assistive technology as the individual's needs change.  
     This allows for aging to be factored in, changes in 
     technology, and advancements in technology.  The concept of 
     "usership" of assistive technology should be carefully 
     explored including how it is working in other countries 
     (i.e. England) where their is a system of socialized 
     medicine.

Alternative Systems Change Solutions
14.  Congress should consider technology-related assistance as a 
     cross-agency imperative.  The need for assistive technology 
     does not stop at the end of an educational process, nor when 
     the work day is done.

15.  Select an agency at the national level that can organize and 
     coordinate the regulation
     of similar assistive technology services within each state, 
     thereby standardizing services across the country.


16.  When assistive technology is required for any purpose, 
     education, employment, or personal independence, its 
     delivery should be provided and funded apart from the usual 
     provider stream.  Let technology specialists assist the 
     consumer with overall needs assessment, evaluation, 
     selection, purchase, maintenance, upgrading or replacement 
     as needed.  A separate entity should be established however, 
     which will bridge over other agencies for the provision of 
     technology-related assistance.  Funds currently appropriated 
     to individuals agencies would be concentrated in a single 
     Technology-Related Assistance Administration.

17.  A case management model should be used which is 
     consumer-driven, so the interaction between technology, 
     personal assistance services and environmental support could 
     be integrated and managed by the consumer when appropriate.  
     This allows for a range of options to address a range of 
     individual needs.


     *Note that:  Congress has already recognized that the 
     individual with a disability is in the best position to 
     identify the appropriate auxiliary aid in a given context.
     --   See 28 CFR Sec. 39.160(b) and the ADA Conference Report 
          No. 101-116, which states that the "expressed choice" 
          of an individual with a disability for an effective 
          accommodation shall be given "primary consideration"; 
          and
     --   HHS' Office for Civil Rights also has a long-standing 
          policy granting a "presumption favoring the 
          hearing-impaired individual's self-assessed need" for a 
          particular type of auxiliary aid. (Memorandum from Roma 
          J. Stewart, Director, Office for Civil Rights, dated 
          April 21, 1980).

**   American Bankers Association, Americans with Disabilities 
     Act: Alert for CEOs; Credit Union National Association, 
     Newswatch: April 30, 1990; April 22, 1991.

***  e.g., employment, human interest.

**** For example, General Motors offers assistance in vehicle 
     modification.  See brochure attached.  Also, Volkswagen 
     which was not part of this survey, offers purchasers needing 
     hand controls or a lift, a rebate to help offset its cost.

*****hereafter "cosigner" or "cosigners"

******See especially "unqualified applicant," "poor credit 
     history," "inadequate income" and "inadequate collateral."

*******"minor," "under 21," "noncitizen," "nonresident," "recent 
     grad," "if applicant is member/cardholder": 1 each

********Total exceeds base size due to multiple responses.  The 
     sum of: accept/require, 48 (94%); categoric/unconditional 
     not accept, 2 (4%); and no response, 1 (2%) equals the base 
     of 51 (100%).

********* Total exceeds base size due to multiple responses.  The 
          sum of: accept, 43 (84%); categorically not accept, 6 
          (12%) and do not know, 2 (4%) equals the base of 51 
          (100%).

********* Base of respondents (51) reduced by: lenders 
          categorically not accepting cosigners (2) or 
          categorically not accepting mitigating circumstances 
          (6), adding back one which appears in both categories.

********* A similar loan program in the state of Maine was not 
          mentioned by any respondent.

********* "Opened secondary market to affordable housing," and 
"more
      affordable rates for all":  1 each

********* "ABLE" state program in North Dakota with special
      qualifications and reduced rates.

********* "FDIC," "auditors, "Office of Thrift Supervision": 1 
each

********* Texas law prohibits: home equity loans (except to pay 
taxes or
     for home improvements) and first mortgage refinancings
     (except for remaining loan balance).

* "something like SBA/Guaranteed Student Loans" and "minority
      business/Housing programs":  1 each

       * NEW PROGRAM UNDER DEVELOPMENT:  relaxed lending 
          criteria, demonstrated understanding of obligation, 
          ability & desire to repay.

         FOR ASSISTIVE TECHNOLOGY DEVICES:  Relaxed:  income 
          standard, credit criteria, discounted loan rate, no 
          late fees.

         1ST TIME BUYER PROGRAM FOR VEHICLE MODIFICATION 
          (brochure attached):
          - Up to $1,000 reimbursed for modifications;
          - financing of full cost including modifications.

         BASIC LOAN PROGRAM:  Provides loans to low income 
          individuals for basic human needs (includes assistive 
          technology).  Exceptions for:
          - limited credit history;
          - credit problems (with good explanations);
          - length of employment/residency
          - income level.
          Applicant must qualify - cosigner not allowed (if 
          cosigner required, then regular loan program).

       **Appeals process, independent of lender, for borrowers 
          whose applications are rejected.

         Credit counselling & copy of credit report to consumer.

*** because of accessibility modifications (loan was still made).

**** No lender wants to make loan with expectation that the funds
     will be recovered through repossession.

***** See The Wall Street Journal article dated January 28, 1992,
     copy attached.

******from the Greek "tele" meaning "far away," communications 
     over a long distance.

*******"Universal Service" means "...so as to make available, so 
     far as possible, to all the people of the United States, a 
     rapid, efficient, Nation-wide and world-wide wire and radio 
     communications service with adequate facilities at 
     reasonable charges..."  (Communication Act of 1934, 42 USC, 
     Section 151 Purposes).

********From the Foreword in Telecommunications and Persons with 
     Disabilities:  Laying the Foundation - A Report of the First 
     Year of The Blue Ribbon Panel on National Telecommunications  
     Policy.  World Institute on Disability. 1991.  p. iii.

********* De Witt, J., Mendelsohn, S. 1989.  Market Study of 
               State Distribution Programs for Specialized 
               Telecommunications Equipment.  Glen Rock, NJ: 
               Private client study.

********* See Attachment A--Functional Limitations in the Use of 
          Telecommunications.  in Telecommunications and Persons 
          With Disabilities: Laying the Foundation.  Oakland, CA: 
          World Institute on Disability.  1991.