Health Care, Disability and the ADA and Section 504 of the
Rehabilitation Act presented by Wendy Wilkinson  
Wednesday, December 5, 2001

Laurel:  Good Afternoon. This is Laurel Richards With ILRU In
Houston. And we want to welcome you to today's Web cast. As
you know, today we're featuring a presentation on legal protections
as they relate to disability and health care. 

I want to first of all acknowledge the support of NIDRR, the
National Institute of Disability and Rehabilitation Research, for
their funding this initiative. They have a commitment to making
research findings available to people who are not researchers, but
who have a sizable stake in the research findings.

And we also want to recognize the Research Information for
Independent Living Project, which is a joint project with the RTC
on Independent Living at Kansas University, and ILRU in Houston
which has the charge of making research information available to
people working in the independent living field and disability right
fields and rehab in general through electronic media such as this, as
well as databases.

Also, I want to thank and acknowledge the support of the Research
and Training Center on Managed Care and Disability, which is
located at the National Rehabilitation Hospital's Center for Health
and Disability Research as well as the Research and Training
Center on Health and Wellness, which is located at the Oregon
Institute on Disability and Development, Oregon Health and
Sciences University.

You can tell these are all NIDRR funded initiatives and each of
them has a significant commitment to disseminating research
findings to those of us who are working in the field who are not
researchers.

Before we get started with today's presentation, I need to cover a
couple of nuts and bolts about this, the mechanics of the
presentation.
You will notice on your screen whether you're using RealPlayer or
MediaPlayer that there is a section which has type in it, and this is
the RealTime captioning, and this is where that will be displayed.
If you wish to ignore this feature, you can minimize your screen by
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Also, we want you to feel free to submit questions or comments,
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instantaneously and it will be presented to the presenters in
RealTime during this presentation.

Also, Rachel Kosoy of ILRU will be the one managing the
questions.
And then finally, if you run into any questions whatsoever, we
have two things to assist you, one is an F.A.Q. section, which is a
list of frequently asked questions that have been posted on the
ILRU Web site at www.ilru.org, and it is very thorough, but we
also urge you to call in our TA line, as it were, and we have people
on staff who can walk you through any problems you might
encounter, the number is 
713-520-0232.

Also, one last thing, there is something called buffering and as long
as some of us are using different speed modems, and even with
broadband internet type connections, there will still be an instance
where there will be a pause in the presentation, and it's in the
RealPlayer or your MediaPlayer will say that it is buffering. Don't
worry about that.
It always happens and will continue to be a part of our life until I
don't know when. If it stays buffering for more than just a handful
of seconds, click stop and refresh. Click stop and then click refresh
or click play again and you should be in good shape. But call if
there is any significant problem.

Today it's a great pleasure to introduce Wendy Wilkinson. She's an
attorney who joined ILRU in 1991.

Laurel:  She is one of our ADA specialists. This year she has
accepted the position of Executive Director of the Southwest
Disability and Business Technical Assistance Center which is
operated out of ILRU. It is a very ambitious project. And as Wendy
makes the presentation on today's subject relating to legal
protections and health care and disability, she may also handle
questions related to what the DBTAC has in mind.

Wendy, there is kind of a left field question for you. But the topic
today is of critical importance to those of us who have disabilities
and have, and will continue to have for all our lives issues related
to health. And the discrimination or the lack of access is one of the
major barriers we're facing today. So Wendy is going to address it
from the lawyer's point of view and the advocate's point of view
and the consumer with a disability's point of view. Wendy I will
turn it over to you now.

Wendy:  Thank you, Laurel and good afternoon everyone. I'm
going to be talking about the legal protections available for people
with disabilities in managed care and in health care generally.

First, I want to say that I'm going to be focusing on cases and the
law, the cases that have been brought demonstrating how laws can
be used kind of creatively to challenge different kinds of health
care and managed care practices.

This will not be a complete synthesis of all the latest trends and I
just don't have time to sort of give everyone that comprehensive an
overview. So my intention here is to touch on some of the more
important cases, look at some creative arguments that have been
used to challenge health care practices.

First of all, I want to say as all of you know, there is no one strong
nondiscrimination mandate that applies to health care practices that
prohibits discrimination against people with disabilities.

What we have out there is a patch work of both federal
nondiscrimination laws, state law protections and also common
law protections that can be used and other things, for instance,
administratively through the Medicaid act that can be used. So it's
important to educate yourself kind of on all these different levels of
protections that can be used so that you can be more effective in
your advocacy strategies when you're dealing with your health care
organization, whatever that may be.

Now, I'm going to talk a lot about managed care, simply because in
managed care people with disabilities seem to encounter more
problems simply because of the structure and the cost containment
features that we find in those systems.

During my presentation, I'm going to break off a couple of times
and take time for questions. I also am going to be going through an
outline that was posted a little bit before we came online, and if
you go to the site where the presentation outlines are, you can open
it.
It's in a word document now. After the presentation it's going to be
converted to an HTML document that can be downloaded. That's
what I'll be following along with and using and I wanted to do that
because I am going to be providing information on different cases
and cites to cases. If you can't get access to it now, you can
certainly get it afterwards.

First, I want to talk a little bit about the common barriers of
accessing health care. Again, many are not managed care specific.
It follows a range of different issues. Many people have difficulty
simply getting effective communication encountering physicians
unwilling to provide sign language interpreters, of obtaining
materials in alternate formats, physical insignificance accessibility
of facilities and diagnostic equipment that is impossible for people
with mobility impairments to really use effectively.

Also, things like the absence or non-adherence to due process
proceed text that are provided in the Medicaid Act and are also
required of managed care organizations, whatever their funding
source.

Also, denial notices of services that are not provided reliably and
the content of the notices is uninformative so you can't go and kind
of protest and find out what it is you need to do in order to get the
services that you need.

Also, things like preauthorization for surgery, which especially in
the managed care plan, take you through a complex maze of
bureaucracy in order to get approval for a simple procedure.

Also, for innovative procedures that may minimize disability and
may only be available out of network.

Also, things like payment for home health care. There is still that
trend to institute patients, and also coverage of newer
anti-psychotic medicines.

Now, with legal protections it's important to note that they're going
to vary with the type of coverage that you have. So, some of the
answers to your questions is going to depend on whether your
health insurance is public, Medicare, Medicaid, or private. 

It's also going to depend on the type of health plan, especially at the
state level. For example, states do tend to regulate health
maintenance organizations more heavily than preferred provider
organizations. 

It's also important to know because millions of legal protections
consumers can use are also strictly not discrimination laws. I'm
going to start with public insurance and Medicaid law. You can use
the Medicaid act and it has been used on its own in conjunction
with other federal and state nondiscrimination laws to challenge
health care decisions and practices that discriminate against people
with disabilities.

And, there are certain requirements and procedural mandates that
you can challenge decisions that deny you appropriate medical
care. For instance, there is a right to a state level fair hearing to
make sure that people get full and fair consideration of their
grievances.
Something called a reasonable promptness clause that can be used
to spur on a MCO making decisions. It requires them to respond to
people in a quick manner.

Also, it requires that people receive written notice of any decision
related to coverage.

Also, it defines medical criteria for home health care providers and
assistive technology. These are just some of the baseline
requirements of Medicaid law.

Now, the balanced budget act that was passed fairly recently
imposed some additional requirements, and some of these are just
basic nondiscrimination clauses that it's prohibited in enrollment,
disenrollment and reenrollment.

And, it's also in terms of emergency care, it adopts a prudent
layperson standard, which means you can go to the emergency
room and if it's something an objective person would say that was
necessary and that you needed to go do that, then that can't be later
denied.

It also requires managed care organizations to maintain internal
grievance procedures and also, it addresses information that
managed care organizations must provide on request to the
participating providers to provide to enrollees on their
responsibilities, information on covered services, the grievance
procedures, appeal procedures, and information showing benefits,
cost-sharing arrangements, service area, et cetera.

Now, in order to enforce the Medicaid Act, it's important to note
that there is no provision that gives beneficiaries a right to sue to
enforce the federal standards, but violations can be brought, be
documented and then you would want to bring that to the attention
of the enforcement agencies.

Under something called Section 1983, because it's listed in the
United States Code is Section 1983. This can be used and in a
variety of areas, but it can be used to sue for violations of the
constitution and federal statutes and regulations. So a private
person can conceivably bring suit or force a state to bring suit to
force to comply with the Medicaid Act. To do that, they have to
profess that the provision was intended to benefit this specific
group, contain mandatory language to create a biding obligation on
the state and the language is specific enough to create an
enforceable right.

Now, in combination with the ADA and the Rehabilitation Act,
and in a case called Carter vs. Belshe in California, and what
happens in this case is that the plaintiff, there were several
plaintiffs, but I think the story of one in particular, Tina Carter,
really demonstrates what people encounter in managed care
systems.

That is, the bureaucratic rigidity and inadequate training of staff.
What happened in this case was she was initially assigned to a plan
at a considerable distance from her home. She was subsequently
allowed to switch plans, but the specialist she had been seeing
concerning a broken arm was not participating in any managed care
plan open to her.
The physician who became her PCP, primary care provider, had
never treated anyone with her particular type of disability. He was
unable to help her and authorized a specialty referral only after
repeated phone calls. Since each visit to the specialist requires
action by both the PCP and CalOPTIMA, it required constant
vigilance to get the care she needed. She would be told everything
would be taken care of and when in fact no action had been done
and when she tried to complain she found herself in this maze of
going from person to person. Copies of the handbook and notices
concerning grievance and fair hearing rights were not delivered
when requested and when she needed them. And so she was in an
information backlog.

So, a year and a half after the initial injury, she was still waiting for
an authorization for the surgery by a provider with the necessary
expertise.

Other plaintiffs in this same situation encountered similar problems
just dealing with the huge bureaucracy and lack of response in it.
And so several causes of action were brought under the Medicaid
Act.
These are listed in the outline, but they include a failure by the
State Medicaid Agency to monitor CalOPTIMA and its
contractors, failure to provide timely notice and the petitioner's
right to a state fair hearing. Failure to explain the beneficiary's right
to aid paid pending a hearing, and denial of medically necessary
care, failure to provide services with reasonable promptness and
violations of the federal comparability requirements.

And the next case I'm going to discuss dealt with due process and
the Medicaid Act that does require individuals in the system be
afforded due process.

So, what happened in Metts v. Houstoun is that, in this case the
plaintiffs alleged violations of the due process requirements and as
well as denials of medically necessary home health services,
personal care services, outpatient and in home therapies. They did
arrive at a settlement agreement and what that included was several
important due process protections. It includes a definition of denial
that encompasses decision to deny. A commitment to plain
language. Clear explanation in notices and detailed standards
intended to ensure that people receive needed medication without
interruption.

As part of the settlement, the state agreed to provide the disability
law center that brought the suit with copies of all notices of
denials, reductions, termination of benefits sent by the HMO's
participating in the managed care program. And, this was really,
really key because they could then monitor compliance after this.

And, it allowed advocates to identify patterns of not appropriate
decision-making and the state also agreed to audit 10 percent of all
decisions to deny, reduce or terminate targeted benefits.

Later, a supplemental settlement argued continuing problems with
a pharmaceutical benefit and called for a plan for progressive
sanctions for noncompliance.

Once you bring suit and they end up in a settlement which in many
cases that's how these things end up, it's really, really important
that there is close monitoring of the settlement agreement because
simply because it exists doesn't mean a state is going to follow that.

Now, I'm going to move onto the federal nondiscrimination laws.
And when I talk about federal nondiscrimination law, I'm talking
about the Rehabilitation Act of 1973, particularly Section 504 and
that addresses programs that receive federal financial assistance.
Public service, state, and local government services are subject to
Title II of the ADA and requirements under both of these laws
include nondiscrimination, modification to remove barriers for
people with disabilities and community integration. And it's also
important to remember that civil rights laws and other types of
laws may provide additional protections.

And, in my presentation or Web cast, I believe it was on November
7th, I did talk about state law protections and what's available and
it's really important you understand what might be available in your
particular state.

What constitutes discrimination in managed health care systems,
that can be kind of complex because when we talk about managed
health care, it may not necessarily rise to the level where we look at
it as sort of traditional discrimination, but because of the poor
administration, the way that managed care organizations are
structured, people with disabilities who may be higher users of
health care are going to suffer much more in these arrangements
than anyone else.

And, some things that you can argue that constitute discrimination
are marketing efforts that might be designed to discourage
enrollment of individuals who are perceived to be higher users of
health care services, capitated payment structures that are not risk
adjusted and create tremendous incentives to deny treatments,
access to specialists, appropriate medication. Also rating systems
that might be used to penalize physicians. They might provide
more comprehensive treatments for people with disabilities.
Referral processes that might interfere with established
relationships that can be vital for people with many different kinds
of disabilities in order to have really effective treatment.
Continuum of care can be really important.

Also, emphasis on primary care limitations on getting access to
your specialty care, and also just review of medical decisions of
physicians through these utilization studies can result in physicians
decisions being scrutinized, not looking at the quality of care
they're providing, but just the usage.

Also, medical necessity criteria that calls for a substantial
improvement, restoration of function and that places limitations
then on treatments that are more involved in maintaining health
and those types of things. So, those are all barriers and arguably
discriminatory against people with disabilities.

And finally, the simple complexity of just referral procedures that
you have to go through, complaint and grievance procedures and
the materials that really describe what your rights are in this
system.
And it just can create tremendous barriers for people with cognitive
or learning disabilities.

At this point I just wanted to pause briefly and see, Rachel, do you
have any, has anyone sent any questions in?

Rachel:  Yeah, we do have a couple of questions. And also, I just
want to tell people who are listening if I know the server is at
capacity, but if you keep trying, people are getting on. We are
getting a lot of calls about that. 

One question relates to something you just commented on. That is
how are doctors in managed care organizations paid? Because this
person is interested to understand how the way that her doctor is
paid may be working against her in getting proper care.

Wendy:  That's an excellent question. First, I want to say that
people are entitled to actually ask their physician how they are paid
in a managed care organization. Most states have no gag clauses
that say physicians cannot disclose how they are reimbursed. Now,
typically how physicians are reimbursed is on a capitated system. A
physician might be paid a certain amount of money for each
individual enrolled in that plan. And so what this does is it creates
a tremendous disincentive.
The more expensive procedures, prescriptions for medical
equipment, et cetera.

So, that's the typical range and like I said, people can ask and I
think it's a legitimate question everybody should ask. What is your
arrangement with my managed care organization?

Rachel:  What's the kind of arrangement that people are hoping
for?
I mean if you have a choice of doctors who are paid differently, can
you give people some guidance on what they might want to hear?

Wendy:  I mean, unfortunately, I could try to do that, but
unfortunately most of us are dumped into systems whether or not
it's because our employer chooses them or if a Medicaid or
managed care organization places us with a particular provider or
particular network.

I mean, obviously, the best would be the traditional, the old
fashioned kind of fee for service where you get to choose the
provider that you get to go to. 

What I would recommend people look for and I don't think they're
going to have much control over the payment schemes, but what
you want to look for in a plan, if you do have a choice, is where
you can get direct access to specialty providers and you want to
look and make sure that if you do have a particular doctor that
you're seeing that they're in the network.  So, I would look at other
things that you need in your plan, but I don't think that you're going
to be able to have much control over reimbursement schemes or
those types of things. That's something that's probably beyond
some of their control.

Rachel: Okay. We have a couple of questions then that have to do
with filing complaints. One is just specifically how do you go
about filing a claim of discrimination against Medicaid? Who is it
that enforces the act and how do you actually go about filing a
complaint?

Wendy: Okay, you can file, what you would want to do is, the
Medicaid act requires that each managed care organization that
they have kind of contracted with, that they have internal grievance
procedures available. So, what you would want to do is start there.
And exhaust all those procedures because the old addage that the
squeaky wheel gets the grease is really true in this case. If you
challenge a denial of necessary care, then what you want to do is
really just go to battle, go through the internal grievance
procedures because probably 60 percent of the time you can get a
reversal of a decision.

Then the next step is under the Medicaid act, everybody is entitled
to a state fair hearing. And, so then you can just move up the
administrative ladder of enforcement and request a hearing and at
that hearing sort of depending on what your issue is, you want to
do your homework beforehand, make sure you understand most
things revolve around medical necessity. You want to be familiar
with what the federal law says is the baseline states must offer. See
how it's defined in your state and just be prepared to do battle in
that way.

Rachel: Okay. And then sort of going along those lines, there is
some concern about the length of time that it seems to take to get
things resolved. And so this questioner is interested to know how
to expedite changes so that her health doesn't suffer.

In the cases you are talking about, it sounds like things took a long
time to resolve and is it possible or what do you think about going
outside of the system and then in a complaint or lawsuit, asking
Medicaid to reimburse for those or pay the doctor directly?

Wendy:  Boy, that's an excellent question, and you're absolutely
right.
In the case I described, Tina Carter, she was vigilant and it took her
a year and a half to get necessary surgery.

I just encourage people to really be objective, to not take no for an
answer and to constantly bug your provider and the managed care
organization and go up the food chain and also you could file a
complaint with the state board of insurance and just pursue all
avenues.

Now, as far as being able to go outside and get an attorney to sue or
get Medicaid to reimburse you, now, I'm going to claim kind of a
lack of expertise in this area and it's something I can look at; but as
I said before with the Medicaid act, it's really, it would be up to, it
could be like a Section 1983 complaint to get the state to if the
state isn't really monitoring how Medicaid is running its MCO's, I
mean, that might be an option. But I think it would be really
difficult to go outside and see another provider and then force
Medicaid to pay.

But there may be, there may be actually some sort of path that they
could take and what I can do and make sure you hold onto that
question, Rachel, but what I will do is some research and see what
sort of options there may be for somebody to go outside the system
and to do that.  Because you don't want people jeopardizing their
health care.
So there may be some cause of action in and I'd prefer to look at
that and then on the discussion board what we will do is post that
question with a more definitive answer.

Rachel:  Okay, great. I have some other questions, but I'm just
going to ask one more at this point and hold the others. Sounds like
people are really interested in advocating for their rights and it
sounds like people are having a tough go of it and there are some
questions about resources that can help people advocate for their
rights. And there is even a question about some sort of handbook to
explain it or can you talk about any agencies or people who can
help folks advocate?

Wendy:  Okay, first let me talk about resources. One that is a really
great handbook that maps out, and this was produced by the
national Alliance for Mental Illness. Anyway, they published
something called Legal Protections and Advocacy Strategies for
People with Severe Mental Illness in Managed Care Systems and
it's really an excellent resource and it really outlines kind of the
state of law in all these areas and talks about Medicaid, private
insurance, and it really does provide people with some great
ammunition about how to go about advocating for your rights.

What we will do after this Web cast is we will post the URL to that
because I do believe that it is available on their website. That's a
good tool.

We are also through the project that Laurel mentioned through
which we conducted this research, we're also putting together a
training manual to help people advocate for their rights in managed
care and in health care generally.

There are also other resources out there that you can draw upon and
what we will do is post some of those resources up on the web
after this presentation, but there are some really good tools out
there.

Next part of that question dealt with where can you go to get
assistance? Well, each state does have a Protection and Advocacy
Organization and we'll post the URL to the national organization of
P&As so you can get in contact with one in your state and many of
them do, and actually a lot of the cases that I talked about and will
talk about, have been brought by P&As and what they do is they
bring, they have brought some really good strong cases and have
been able to achieve some really great systematic particular change
in the states that they are in challenging Medicaid practices, MCO
practices that really hurt people with disabilities.

In the case I was talking about before, the Carter case, now, they
can't accept every individual complaint and represent everybody.
They simply don't have the resources, but they are certainly very
active on a state level trying to address systemic discrimination and
they can also be a good resource, they all do field, I believe
technical assistance calls so they can be helpful in getting, if you're
able to get legal representation in order to help you challenge some
denial of care or something like that, they could be a good
resource.
And they probably also developed different tools in their states that
people can use.

Rachel:  Those are good resources. The handbook that you're
talking about that will come out of the project you and Laurel are
working on.
When do you expect that to be ready for folks?

Wendy:  We hope that it's going to be ready by late spring. We've
got several chapters completed, but we need to fill in a few more
and actually do some updates. And when that is done, we will
make sure that every one on this Web cast and we plan to promote
it very actively and get it out, and it would also be eventually
posted on our Web site.

Rachel:  Okay, great.  I'll just throw out that the NAMI Web site if
people are interested is www.nami.org.

Wendy:  Thank you, Ms. Kosoy, that was quick thinking.

Rachel:  I'll get the P&A one when you're ready for the next
question.
Back to you Wendy.

Laurel:  I've got a question I want to get clarification, if I may.
This is Laurel. When you spoke earlier of the settlement, I guess
lawsuit settlement, did you say that they needed to be carefully
monitored to make sure that the settlement, that the agreements in
the settlement were followed?

Wendy:  Yes.

Laurel:  Who does that? How is that done? The monitoring
process.

Wendy:  In this case the disability law process. That was part of it
where they actively monitored it and took a role in the state that
was part of the settlement agreement where the Medicaid agency
had to provide certain information to the disability law project so
that they could monitor really what was happening where they had
access to the denial of service notices and so forth. So that they
could really see how people were progressing.

Laurel:  Is it true in every case that when there is a settlement.  It
has to be monitored? That there isn't an obligation, who would
know if you did it, huh?

Wendy:  Well, I mean if someone isn't complying with the
settlement agreement and you can call them on it and report them.
Then it can be technically reported that they haven't been following
it. And I'm aware of not just in the health care arena, but in the
ADA suits where you might have a nice settlement agreement in
place that really outlines steps that somebody needs to take to
comply with the ADA, for example, and these simply are not being
followed.

So, I think it's really important that when you're negotiating a
settlement agreement, if you're involved in that at that level, and
that is to put in something that really allows the parties that brought
the suit an ability to monitor the suit and an obligation on the part
of the defendant to provide the necessary information so someone
can really effectively monitor the progress of the settlement.

Laurel:  We laypeople aren't as savvy as we should be. Just to add
onto your suggestions of organizations that might help individuals
in advocating for their rights, I suspect that a number, if not most,
independent living centers have some sort, can offer some sort of
assistance in this area. Either through direct advocacy or through
peer support services that address disability rights and
self-advocating and self-empowerment.

So, I would suggest that individuals who were looking for
assistance or who may be like some of us a tad wimpy in terms of
aggressively pursuing something that their local center might also
be an area of support.

Wendy:  Absolutely, and yes, thanks for sharing that, Laurel. And
that's something that if people need to find out about the center in
their area, ILRU maintains a complete listing with contact
information.

Laurel:  Online has a map. Click Texas and there you go.

Rachel:  All right, before you move on. I found the Protection and
Advocacy Web site, and that is just like it sounds,
www.protectionandadvocacy.com

Wendy:  Thank you. Any other questions or should I move on?

Laurel:  Go ahead.

Wendy:  Now I want to move into the Americans with Disabilities
Act and program access, and the first case I'm going to talk about,
and I'm going to talk about different issues that can arise.

The first is challenging policies that discourage participation and in
the case of Burns vs. Chandler, people who are blind or had other
disabilities use Title II of the ADA in order to change a state policy
that excluded them from a Medicaid state pilot care program and
what the court found was that this exclusion of certain categories
of people with disabilities from participation was a clear intent of
discrimination and the case also suggests that advocates can use the
ADA to attack managed care plans.

For instance, their marketing strategies that I talked about before,
their policies and modes of administration that really discourage
participation by individuals.

Now onto reasonable modifications and I thought that this was
really interesting because of the complexity of the many of the
managed care organizations that people have to deal with. I wanted
to find out if there were any cases that might address whether or
not an MCO has an affirmative duty to help people navigate the
system, especially, for instance, with cognitive or learning
disabilities.

And it's important to note that these two cases that I'm going to
mention are not, they don't deal with managed care, but they do
deal with the Rehabilitation Act and Section 504 and they address
the state programs and the need to have some sort of program that
helps people navigate the system.

And the first one, is Henrietta D. vs. Giuliani, residents of New
York City with AIDS or HIV, claimed the system of distributing
benefits was through the City's Division of AIDS Services  and a
proposed restructuring would make things worse. The court ruled
that the plaintiffs did state causes of action for violations of the
ADA and the Rehabilitation Act. The staff provided assistance to
clients primarily through casing.  And really helped them get
through the system.
What the City and State were arguing is that this is a special
service, a matter of discretion, not something they had to provide.

And, the plaintiffs responded that it was really necessary for staff
because it really fulfilled the requirements of the nondiscrimination
laws. What they did is they said staff is like a ramp required for
people in wheelchairs to access public buildings because of the
complexity of the system they were trying to negotiate. So, what
the court said is that at a minimum, essentially, that staff was a
necessary modification and not a fundamental alteration of public
assistance that the City could provide.

So, that's really important because it really indicates and it can be
used in other arenas because it really indicates that, yes, people are
encountering a terrible, complex bureaucratic maze and the state
might be obligated under the nondiscrimination laws to provide
extra assistance.

In another case, also brought in New York, children who had
suffered abuse and neglect sued the State and City Child Welfare
Officials.
The court stated that plaintiffs made claims under the ADA and
Rehabilitation Act. And it arose from the defendant's failure to
make modest affirmative steps to prevent the plaintiffs' meaningful
access to the health care system.

So, they reviewed cases and looked at the nondiscrimination laws
and the court said that these cases stand for the proposition that
people with disabilities are entitled to meaningfully access to the
benefits and services provided by a public agencies receiving
federal funds.
So those two cases are really, really important.

Under another case, a failure to provide transportation also was
found as a denial of meaningful access to services. And that was
brought under the Rehab Act.

Also, just to mention Section 1935 of the Balanced Budget Act and
the Preamble to the Medicaid Regulations Supports Proposition
that states in their contract should have an affirmative obligation to
assist people with disabilities in taking advantage of public
programs.

One issue of hot contention is the application of the ADA to
managed care organizations. 

One of the first cases brought was Anderson vs. The Department of
Public Welfare. This was a class action brought in Pennsylvania on
behalf of Medicaid recipients with mobility or vision impairments
and that issue was a provision of auxiliary aid services. 

What the court said is that, and they looked at the whole program
access mandate and they decided that the ADA does not require
that each disability in the managed care program be accessible.
Because as most of you know there are going to be several
different facilities and doctor's offices and hospitals that you're
going to have access to an MCO, but it did say that, it did require
that each provider comply with certain minimum requirements.
And again they noted that it might vary according to disability
status.

The settlement agreement that was entered into provided some
time lines that the Department of Public Welfare had to comply
with, and that is to inspect their premises.

Also, within a certain amount of time a range for providers to
supply informational materials in alternate formats such as Braille.

So, anyway, you can see that the ADA could be used to challenge a
MCO and their provision of auxiliary aids and services.

As I mentioned before, in Carter vs. Belshe, also brought into this
case and the Medicaid Act was the ADA and others, the ADA also
was used. And, it was used to challenge in this case the financial
arrangements between the state and its intermediaries and the
providers of health care services.

And, what happened was they said that when the petitioner
contacted with the primary care providers, they were denied
because of the severity of their problems and what they found was
that the reimbursement scheme really created strong financial
incentives for participating providers to discriminate against
enrollees because of their disability. So, they were looking at their
financial interests and their bottom line that they didn't really want
to accept people into the plan.

And, what happened is when the plaintiffs informed CalOPTIMA
about their providers, they were switched to another plan and
finally what the court said was that their administration of the
Medicaid program subjected recipients with disabilities to
discrimination and denied them an equal opportunity to participate
in the managed care programs and essentially they got benefits that
were much less effective than that provided to others.

Other suits that can be brought under the nondiscrimination laws
include suits alleging unfair impact. And, what this means is when
you have for instance in one case there was an adoption of an
across the board limit such as restriction on hospital days that has a
greater impact on persons with disabilities although it's applied
across the board without any intent to discriminate. It has a much
more substantial impact on them.

The good news is that cases alleging unfair impact can be brought,
but when you are talking about managed care suits, you will really
want to look beyond that and think the suit should also be brought
alleging intentional discrimination. So, there is a strong argument
that those who develop these arrangements know or should know
that the effect would be to impose considerable burdens on people,
on people with disabilities in accessing health care.

In the case that, the first case of this kind that addressed this issue
was Alexander vs. Choate. And, there the Supreme Court found
that proof of hostility against people with disabilities wasn't
required to establish a violation of the Rehabilitation Act. And,
again, this was dealing with the 14 day limit.

So the good news in this case is that cases can be brought alleging
disparity impact when you have one broad rule. However, in this
case, what the court did say is that the 14-day limit, the plaintiffs
didn't bring enough evidence to show that they were unable to
benefit under this 14 day rule. They didn't get the outcome they
wanted, but still there is an important precedent in that case.

Under the Americans with Disabilities Act, Dunlap vs. The
Association of Bay Area Governments, in that case the court said
the plaintiffs did not have to prove that disability motivated the
defendants' actions and it said that simply that a person with a
disability does not need to prove that they were treated differently
from the non-disabled, but that discrimination exists if everybody
is treated alike despite the needs of a person with a disability
needing reasonable accommodation or modification.

Now, moving on to Title II of the ADA, most of you are probably
aware of the ground breaking Supreme Court decision in Olmstead.
Where the Supreme Court looked at the integration mandate with
states. Saying essentially that people with disabilities need to be
integrated into programs just like everybody else. And in this case,
it was people with disabilities that were living in an institution,
even though their treating doctors said they could live effectively in
the community if they were provided with appropriate support.
When this didn't happen, a suit was brought and it made its way all
the way up to the Supreme Court and the Court did say that a
state's failure to provide services in a community based setting
violates Title II of the ADA, the integrated mandate.

And, states are required to provide their services in the most
integrated setting appropriate to the needs of qualified individuals.
And, this includes home and community-based arrangements.
Now, the good news is we've got this decision. And the next step,
and this is something a lot of advocates are dealing with is making
sure your state complies with the mandates set out here.

So, what we have with Olmstead is a new road map that the
Supreme Court laid out that said that states need to
de-institutionalize people that were capable of living in the
community, but getting from A-Z on that is the challenge and
getting states to effectively and appropriately and in a speedy
manner implement Olmstead is a challenge facing everyone.

What's really important about that case and this Title II integration
mandate is that it's been used by Protection and Advocacy
Agencies in a number of cases to ensure that people get the
appropriate services, medication and equipment necessary to
enable them to live independently in the community. I'll mention a
couple of these cases, but they are outlined in the presentation that
I mentioned earlier.

For example, in In re J Curtis H, a person with multiple disabilities
that required wrap around services that are really just intensive
services in order to maintain him in the community, the doctor
verified that the services were necessary, that the Department of
Human Services denied the request and stated that these services
were not medically necessary. The administrative law judge ruled
for the individual and said that the services were necessary in order
for the person to remain in the community.

In Adam Cale v. Illinois Department of Public Aid, the Illinois
P&A threatened reduction in home health care services could
violate the Title II integration mandate. 

In Blackman vs. Mississippi, the Mississippi P&A there sued a
state hospital for violation of the integration mandate simply
because they did not provide all the newest anti-psychotic
medications on the same basis. What they found was that if people
could get the appropriate medication, then they could remain in the
community, but if they didn't receive the appropriate medication,
then that could lead to them being institutionalized. 

Those are creative ways to use that integration mandate and you
could look at it as giving people power to give them the services
and medications, whatever it is, that they need to remain in the
community so they don't have to go in to institutions.

One case that I want to mention very quickly that was really a bold
step in a new direction, and this case came down in Texas, and
what they did is they challenged contractual arrangements that
inhibit the provision of appropriate health care.

What happened here is that some physicians and patients got
together and sued, they said that the Medicare HMO delayed or
denied them full and equal enjoyment of medical treatment in
violation of Title III of the ADA and the Rehab Act.
They claim that they were forced to endure long waits and medical
care was denied to them while other people that didn't have
disabilities received much better quality treatment and the result
was, and the reason for this was is that the HMO's financial
arrangements made treating people with disabilities more costly to
providers so there was that associational discrimination that I
talked about earlier to treat people that needed to be treated. The
HMO moved to dismiss the case and the court denied that motion
to dismiss and said they were able to proceed.

And, the HMO presented the usual arguments that, you know, all
the decisions were based on valid data and protected from scrutiny
under the ADA's safe insurance harbor that I'll touch on briefly in a
moment. And, that the court noted that Medicare HMO's are
prohibited from discriminating in coverage on the basis of health
history or current health status and they could not engage in
traditional risk rating. And, so this was exciting that the physicians
could get together using the ADA and challenge these types of
practices.

In another case, the ADA protects people from discrimination
based on association. So in this case, what Title III says is that
public accommodations must not discriminate against an
individual or entity because of a disability or those who have a
relationship or association.

The plaintiffs in Zamora-Quezada v. HealthTexas Medical Group
of San Antonio used this to bring suit and physicians have used it
to bring suit also against managed care organizations alleging that
because they are treating people with disabilities, they're being
discriminated against. So that can be powerful and really help
advocates.

Now, I want to move into talking about private managed care plans
and the protections that are available there. Employer-provided
benefits are subject to Title I of the ADA and Title II prohibits
discriminations in terms of employment. Title III covers public
accommodations which include doctor's offices, clinic, hospitals,
and may include insurance policies. And, it has its own
nondiscrimination reasonable modification and integration
mandate.

There is also HIPAA, the Health Insurance Portability and
Accountability Act of 1996, and that contains some
nondiscrimination provisions that apply to group health plans,
protects people when they move from one employer to the next so
that it regulates the use of preexisting condition clauses. I don't
have time to go into great detail on HIPAA here, but note at the
end of the outline there is a link where you can find out more about
your rights under HIPAA. But that can be used when you're dealing
with employer provided insurance.

Now, there are when we talk about private health care, there are
some legal roadblocks and one of them is the ERISA Preemption. 
That is the Employee Retirement Security Act of 1994 and what
that does is it protects self-funded employer plans from state law.
This protection is pretty powerful. There are no jury trials,
compensatory or punitive damages, and relief is limited to the
amount of the benefit in question. And, this is really important why
it protects these plans because they are protected from state law
and state law usually contains more consumer protections.

So that's important, but people, advocates, and the legislature are
looking at ERISA more carefully now because they realize that it
really came about before cost containment measures were in place
and so forth, that really changed the nature in the face of health
care in our country.

So I just want to mention one case where the Supreme Court just
recently looked at the difference between eligibility and coverage
decisions made by health plans. Because those are covered by the
ERISA Preemption because those are part of the fiduciary duties
that health plan managers have and are covered by ERISA.
But they distinguished medical necessity determinations and what
the court said is that they don't fall under the purview of protection
of ERISA and that since that was exempted that people, ERISA
would not protect these plans and so people could, state law claims
could be brought challenging these medical necessity decisions.

Next, I just mentioned in the outline provided sort of commentary
on the ERISA Black Hole just to point out that really folks are
noticing what is going on with ERISA and that it really is this sort
of black hole that doesn't provide people with any kind of
significant protection if you happen to be in a self-funded
insurance plan.

Under the ADA, as I said, the ADA did not provide a nice, strong
nondiscrimination mandate dealing with health care. What the
ADA does address insurance however, and that's in Section 501c
of the ADA that is found in Title I - IV, and what it says is the
ADA shouldn't be construed to prohibit or restrict an insurer that
administers benefits plans from underwriting risk, classifying risks
or administering such risks that is not in a manner consistent with
state law.  It also says the organization can establish, sponsor,
observe or administer the terms of a plan by classifying risks that
are not inconsistent with state law and they can kind of keep
everything in place as it is and that the only kind I guess of caveat
where the consumer can come in and get it challenged is this is that
this safe harbor may not be used to evade the purposes of the ADA.

And, the meaning of this section really is entirely clear. What it
does say is that insurers can defend their practices if they can cite
legitimate actual data. The state can be challenged for legitimacy.
When we look at what insurers are doing and the EEOC has taken
the position that a lot of the data that insurance companies rely on
is really outdated. It really has nothing to do to whether or not a
person really does create that risk. So, it can be used, but again, this
section does contain some language that advocates can use, but
how powerful it can be, it really hasn't been used very effectively
today.

Other kind of protections that spring from the ADA, the EEOC did
issue some interim guidance on disability based distinctions and
health provider health insurance and what the EEOC said was that
distinctions in health care are subject to a scrutiny if they are
disability based. And this guidance, I look at it as sort of being on a
continuum where broad distinctions are okay, but they're going to
fly and pass ADA muster, if they apply to a multitude of different
conditions, even if they do adversely impact people with
disabilities.
Then you go to the other end of the continuum, and if they are
really identifying and isolating a particular treatment for a
particular type of disability or, you know, certain types of disability
that can be identified, then this may violate this guidance. I would
just give you a caveat here and a note, and that is what we've seen
in a lot of litigation cases unfortunately, is that courts have rejected
a lot of the guidance that the EEOC has issued. In fact, they've
even disregarded important regulatory guidance.

So I mean this does set forth the EEOC's position, and it may have
some power, but it's important to sort of understand that disability
based distinctions could be illegal.

I talked before a little bit about Zamora and just note that the HMO
did raise that safe harbor as an affirmative defense, and that they
said that all the decisions were based on data and the court did note
that there they were prohibited from engaging in any medical
underwriting and discriminating and coverage based on the health
history or current health status. But an argument could also be
made that their assertion that it uses risk classification data in
making treatment decisions is contrary to the structure of
Medicare.

And, they cited what HCFA does in the underwriting
classifications of risks.
And, the plaintiffs also alleged discrimination just based on the
clinical evaluations and not just on the experience rating that an
HMO might use to do it's justifications. And, even if a safe harbor
is applicable in a particular case, in order to prevail, an HMO
would have to show a bona fide benefit plan engaged in lawful
risks assessment and its decisions were not a subterfuge for
discrimination. That would require evidence, and also again, you
want to note that data and all those things that HMOs might rely
upon really are antiquated and, you know, so many HMOs really
may have no defense if they try to assert this safe harbor.

I want to talk briefly on the burden of proof issue. In this case, it's a
life insurance case, and a person was being treated for mild
depression, and they were refused based on an insurers policy of
automatically denying long-term disability insurance to applicants
who report receiving treatment for mental or nervous treatment
regardless of the seriousness for the prior 12 months.
And so in order to comply with the state law prohibiting unfair
discrimination, what the court said is the insurer must really justify
their eligibility criteria. So, they weren't able to do this in this case.
So, it's important that if you run into a situation where you're being
denied something and they are pointing to alleged eligibility
criteria, it really needs to be scrutinized to make sure it's necessary
and can fly by what the ADA might require.

I kind of want to jump down because I'm running out of time here,
and there are other cases that are cited there that really talk about
the burden of proof and what might happen if you bring an ADA
case and what a person with a disability might have to show and
what an HMO might have to show in order to determine whether or
not a person is going to prevail and who is going to have to bring
forth evidence of defending whether it's eligibility criteria or data.

What I want to jump down to is to look at, well first, I want to just
briefly talk about the scope of Title III, and that's an ongoing
division that's been the subject of ongoing debate and it's clear that
insurance offices are a public accommodation and covered by Title
III, that the courts are divided whether that applies to insurance
policies. That is really up in the air. The circuits, and these are
where you go. These would be the courts of appeal across the
country, and the circuits are divided over this issue, although those
going on the side that the ADA wasn't intended to cover the
contents of insurance policies are probably in the majority, but still
there is a strong argument that the contents of insurance policies
are covered by the ADA and that's important to remember.
And the first case brought on that issue is Carparts Distribution
Center v. Automotive Wholesaler's Assn.  brought in the first
circuit.

What I want to conclude with is people asked if previous questions
about how to assert their rights in managed care and so I think it's
important that bringing a lawsuit should be something that you
want to do as a last resort. Simply because it can suck up a lot of
resources, both of your time and it can be expensive, and so what
you really want to do is really work through your internal processes
that are available to you.

In private insurance, MCOs need to have internal grievance
procedures, and you can file a complaint with the state insurance
department. 

I already talked about what you can do in Medicaid, and that is you
can request a state fair hearing and also you can entitled to get an
independent review of any decision from that fair hearing.

Also, depending on if the ADA is implicated in the Rehabilitation
Act, there might be other agencies that can take these complaints.
For instance, the office of Civil Rights and I'll provide an address
where you can send, if it is something that is within the jurisdiction
of the Office of Civil Rights, and that is public insurance, and there
is an address where you can send a complaint.

Then I want to talk a little bit about what you need to have in the
complaint and where to send it and where you can call for
questions.

With that, Rachel, I'll be glad to take any more questions you might
have and refer people, if you weren't able to download that outline,
please do so and we're going to have much more detailed
information for folks in the training manual that I talked about
earlier.

Rachel:  Okay, great. People are interested in advocacy issues and
how to file complaints so it is good to know that near the end of the
hand out, around page 16, you give them some more specifics. So,
it is in writing for folks if they want to go back and refer to that,
where to complain to and how to do it.

Wendy:  Right.

Rachel:  Okay, there is another advocacy related question which
really goes back to when you were talking about Olmstead. And
this is from somebody who has basic familiarity with Olmstead and
says they have a friend in a nursing home who is only 50, but he's
there because he has cerebral palsy and he needs quite a bit of care
but that he clearly could live in the community if he had the
supports.
So he has some understanding of what Olmstead says, but really
wants to know how does he actually go about getting him out of
the nursing home?

Wendy:  Okay, what I would suggest doing first is finding out
what, through maybe the P&A in your state or a center for
independent living, and see kind of what's going on at the advocacy
level, and also find out what is going on elsewhere, contact maybe
the Department of Human Services in your state and find out what
they're doing to implement Olmstead, and how you can get this
person on a waiting list that they are supposed to have. What
Olmstead says is that states need to have a place, and I'm going to
paraphrase because I can't remember the exact quote.

They have to have a process in place where they are identifying
people that can potentially live in the community with appropriate
supports and they need to be doing this with reasonable promptness
and they also have to be looking fiscally at everything that they do
in order to begin to move people that can live in the community
into their own home, or that can live in the community from
institutions. 

So, you would want to start with like I said finding out what
advocacy organizations might be able to help you in the way of
helping advocate for him and then find out from your State Human
Services Department what's going on with that waiting list. What
they are doing in implementing Olmstead and how to get him on
that waiting list and also get him evaluated, there is requirements
for evaluation and professional assessments and so forth.

And actually what we can do is, I recently wrote something about
Olmstead for a periodical in California and that is something we
can post on our Web site and actually also give people links so they
can find out more about Olmstead and how to effectively advocate
for yourself.

Laurel:  Wendy, with regard to the assisting folks to move from
nursing homes to living in the community, for about four or five
years or so, independent living centers have been requested to
provide the number of folks they have actually helped move from
nursing homes when they complete their annual progress reports
which would lead one to believe that that is a service that RSA,
expects most centers to be doing. So, I would guess that if one
needed assistance in that area of transitioning from nursing homes
or other institutional settings that a contact of a center would be
called for.

Also, we have I guess you call it a newsgroup or discussion group
which is called the IL Coach, and a number of questions of a
technical nature or technical assistance nature are posted there and
I suspect if one posted a question such as where can I get assistance
in this area, that there would be a number of responses.

Wendy:  Yes. I think certainly centers are going to be at the
forefront of getting out there and identifying people and advocating
for them.

Laurel:  And processes.

Wendy:  Yes.

Rachel:  Okay, then we have a question about ERISA and that's
ERISA. And basically they're asking can you restate or recap what
it is? There seems to be some confusion about what plans does it
apply to? What is a self-funded insurance plan.

Wendy:  It's an Employee Retirement Income Security Act and it
was enacted, and I can't give you the date, but it's been on the
books for a long time and essentially it was enacted to, I think a
good example that's kind of in the news right now for instance with
the folks that are now recently unemployed from ENRON, it was
really, it was designed to protect people in that instance from kind
of mismanagement, if you will, of their pension funds. And, so
what it really addresses and focuses on is kind of the fiduciary duty
of these folks that administer these plans for them to act in the best
interests of the people, for the funds that they are holding. So, that
was kind of what it was intended to kind of address those types of
situations. 

And, what it does is it protects these plans and when I talk about
the self-insured plan, it's employers that fund their own plans and
administer their own plans. So, if you're in one of these, then
ERISA is what would protect you with what minimal protections it
does provide. And ERISA preempts state law.

So, if you're in an ERISA funded plan, then you can't use state law
to challenge any kind of practice that might be inhibiting you in
accessing your health care.
You can't use negligence laws or any kind of common law because
ERISA would preempt that, but it is important to note that the
recent Supreme Court decision that I noted, is it did say that these
medical necessity determinations kind of fall out of that whole
purview of protection under ERISA that a fiduciary might have.

So, there may be ways to start piercing it and also the good news is
legislatively I mean, as well as advocates are really realizing it just
came out in another generation before the advent of managed care
organizations and the problems that arose.

So right now, yes, it is a black hole and really does inhibit people
from getting adequate health care that are stuck in these plans.

Rachel:  That was helpful. Switching gears and I'm watching the
clock, but maybe you can comment briefly about somebody wrote
in about how there were reports all over the news today that the
former first Lady Rosslynn Carter has been discussing legislation
that stalled in the pipeline which is designed to require insurance
providers to offer equal benefits for mental health as they are for
providing for physical needs. And I know that.

Wendy:  Mental Health Parity Act.

Rachel:  Can you comment on that? Is it likely to pass and what are
the  implications of it?

Wendy:  I can't, I can't tell you, and I've looked at, I think the latest
I saw was November 28th, if I actually have it in my pile of papers
here, but I saw the Senate version and as for the likelihood of its
getting passed in the form that it might be in, I don't know. I mean,
I know that there is a lot of advocates and other people behind it.
And where I would suggest actually people go for information and
actually, Rachel, that might be another thing you can put your
quick little fingers to, is to look at the Bazelon Center for Mental
Health and they would have the latest and greatest of what's going
on with the Mental Health Parity Act. That's where I go when I
look at what's going on with the progress.

Rachel:  And it also is on the NAMI Web site.

Wendy:  Yeah. And they again would have the latest and greatest
and also be able to give people an overview probably of the
different bills that are going through both the House and Senate.

Rachel:  Okay, I'm going to turn this over to Laurel now.

Laurel:  Thank you, Ms. Kosoy. Wendy, I just had a couple of
questions before we close. Did I hear you correctly that going, if I
were an individual and I wanted to appeal internally with the
managed care organization, one of their decisions to restrict my, or
to deny a medical claim, did you say, what did you say was the
percentage of times that the individual won?

Wendy:  I've heard, and this is kind of anecdotally, I'm not sure
how scientific it is, that if people really do make noise, that it's a 50
to 60 percent of the time they're going to get the things that they
need. And this is anecdotally, but you do hear that, you know, often
insurance companies rely on people just sort of accepting decisions
and going away. So when someone can really effectively advocate
for themselves and understand how to do that with all the
appropriate ammunition understanding their plan, understanding
their rights, then they are more likely to get the care that they need.

Laurel:  Now, this is like for Wendy, people like me who don't like
to make waves, but is it fairly simple to get information on a
managed care organization's internal appeal process? Is that
straightforward?

Wendy:  It should not be difficult to get that information, but it
really depends on whether or not the managed care organization is
really paying attention and doing the things that they should do.
And that is having a grievance process in place and having a
mechanism where people can easily find out about it and how to
access it, and I am sure that there is not a lot of managed care
organizations that, actually shouldn't probably weigh in on that, but
I don't know. It's going to go on a case-by-case basis I suspect.

Laurel:  Is it a requirement?

Wendy:  Yes.

Laurel:  Okay.

Wendy:  There is lack of specificity in exactly how that grievance
needs to look and so that does sort of create some gray areas there,
unfortunately.

Laurel:  But 50 to 60 is a pretty high -- that's a pretty high
percentage.

Wendy:  If people are really noisy and adamant and informed then
they're going to be much more successful.

Laurel:  I think we've pretty well covered a lot of the bases as far as
questions go. Was there more you cared to add on this issue of
legal protections?

Wendy:  I don't think so. I realize when I put this outline together
that I probably went into a little bit too much detail and didn't have
time to cover all that I wanted to and I think there is a lot of
important things that we weren't able to get through, but we hope
to be able to provide people with much more comprehensive and
really helpful information that they can use to advocate for their
health care in this training manual. For now, like I said, I would
point folks, and Rachel found that great cite and you should get the
strategies which is a wonderful resource.

Laurel:  Maybe if you had to rush through this a bit, maybe you'll
come back and do a maybe select section and do in-depth
presentation for all people out there who would be interested,
which apparently is a fair number.

Wendy:  Sure. I would be glad to. I think it's an important, a very
important issue and an important arena and I think we all need to
be better informed about it and until we really get that
comprehensive mandate that we really need for people with
disabilities to get the health care that they need.

Laurel:  Before we close, do you have anything to say about the
purpose of the Disability and Business Technical Assistance
Centers nationwide and the one for the Southwest in particular?
Their specific purpose and how they can serve consumers?

Wendy:  Sure. Let me try to do it just briefly. There are ten
Disability and Business Technical Assistance Centers across the
country, and here at ILRU, we're funded 100% by the Southwest
Disability and Business and Technical Assistance Center and we
were just funded for five years and what we do is provide technical
assistance, disseminate materials and conduct training on the ADA
and other disability related laws. 

We're also involved in a new initiative, and that is to promote the
use of accessible education based information technology in public
schools and that is K-12 through post secondary. So that's a new
priority that we've been given and are beginning to address as well.
So we provide technical assistance and conduct public awareness
activities, disseminate materials on just a large number as I said of
disability related laws and now we will be getting into the area of
telling folks how to make their information technology accessible.

Laurel:  I think many of us understand how a business might take
advantage of the services such as calling in saying how do I do this
or does it require that I do that? But how does a regular person,
what kind of services can they obtain from you?

Wendy:  They can call us, the technical assistance is free. It's
confidential and the number that will connect you to the center in
your region is 1-800-949-4232.

Laurel:  Would you repeat that, please?

Wendy:  1-800-949-4232 and what we can do for people with
disabilities is inform them of their rights and opportunities for
using the ADA and these other laws to get them access to
employment, public services, businesses, housing, those types of
things. Information can be very powerful. We have a library of
probably about 130 different types of materials. Some of them that
really are targeted to consumers and that can help them understand
what their rights are in many of these different areas.

Laurel:  Is there a charge for that?

Wendy:  No. Our materials for the most part, there is no charge
unless it's one of the more voluminous, an ADA handbook or
something like that.

Laurel:  Are those downloadable?

Wendy:  Yes. And, if you visit our website at www.swdbtac.org,
you can go to our publications page and you can download a lot of
the documents there. We have a really comprehensive database of
documents and you can see the titles along with the descriptions so
you can see what might meet your needs.

Laurel:  Thank you. We're moving into the 90-minute point and we
have a hard and fast rule here at ILRU not to go beyond 90
minutes. So if that's it on your end, I'd like to do a quick wrap. Are
we okay with you?

Wendy:  Sounds good.

Laurel:  And, I do want it noted that here on an ILRU Web cast we
had an attorney discourage people from pursuing lawsuits. Let's
just get that on record. In closing, a couple of things, one, there are
a number of resources available to people who, in addition to the
ones that Wendy pointed out, who would like more background
information on disability and managed health care.
On the www.getriil.org Web site, there is a database which has,
will have additional information on research that's been conducted
in this arena.
Also, as Wendy pointed out, that ILRU has a rather comprehensive
ADA Web site including a state-by-state breakdown of laws that
are in place. 

And finally, we are about to have come out with the SCI Life
magazine and it's going to feature, and the whole issue will be on
managed health care issues and disability covering barriers to
services, preventive health care services that folks with disabilities
need to make sure they get and many are not. Consumers
perspectives of the barriers that are in place to their health care
needs, so we ask you to look for that and we'll send information on
that.

One more thing, we had planned next week to have a Web cast on
Rural Issues Related to Health Care, and that will not, will not take
place. There is a chance that, we had hoped to have a presentation
on Personal Assistance Services and Health Outcomes for People
with Developmental Disabilities. It's not clear that we'll make it for
next week or we may be required to schedule it after the New Year.

So we will post on our Web site whether or not that has been
cancelled and when will it be rescheduled. And, we will also
disseminate an announcement regarding whether or not that has
been canceled or rescheduled or whether it's going to be ongoing.

And finally, I'd like to thank our team at ILRU and at Baylor
College of Medicine for their assistance with this, including Rob
Dickehuth, Marie Bryant, Marj Gordon, Sharon Finney, Rachel
Kosoy, and Dawn Heinsohn.

So for ILRU, we thank you for attending. We urge you to complete
the evaluation, which is on line and very short, and we look
forward to having you at our next Web cast. Thank you very much.