Transcript Document
NASDDDS
National Association of State Directors of Developmental Disabilities Services 113 Oronoco Street, Alexandria, VA 22314 Tel: 703·683·4202; Fax: 703·684·1395 Web: www.nasddds.org
Mary Sowers NASDDDS July 14, 2014
Medicaid Basics Medicaid HCBS Basics Medicaid Authorities: Opportunities for Assistive Technology Coverage New HCBS Regulations Questions NASDDDS National Association of State Directors of Developmental Disabilities Services 2
Medicaid can be an important source of public financing for assistive technology In addition to medical and rehabilitative uses, AT can also play a key role in assisting individuals return to or remain in their homes and communities and avoid institutional utilization To understand how AT is covered in Medicaid, it is important to understand some Medicaid basics NASDDDS National Association of State Directors of Developmental Disabilities Services
Established in 1965 as a companion program to Medicare “Grants to States for Medical Assistance Programs” – Medicaid Federal/State entitlement partnership program Medicaid mandates some eligibility groups and services, States may elect to include other groups and benefits NASDDDS National Association of State Directors of Developmental Disabilities Services 4
Medicaid State Plan has, historically, referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute With additions to the SSA, a state’s Medicaid State Plan can include more services and benefits than those in 1905(a). There are now HCBS state plan benefits, described more fully below, at 1915(i) and 1915(k) of the SSA. NASDDDS National Association of State Directors of Developmental Disabilities Services
Under the traditional Medicaid State Plan, states often cover some AT through Home Health Services and/or Durable Medical Equipment Coverage and payment for items varies by state Medically-necessary DME for use in the home or to function in the community. States may have a list of preapproved items with established process for modifications or exceptions. Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid.
NASDDDS National Association of State Directors of Developmental Disabilities Services
States may offer HCBS through a number of statutory authorities, as well as some time limited grant programs Increased demand from individuals and families, the Olmstead decision, other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade. The two primary HCBS sources for AT include: 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option NASDDDS National Association of State Directors of Developmental Disabilities Services
◦ ◦ Section 1915(c) of the Social Security Act, originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1 million people In federal fiscal year (FFY) 2011, total state and federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion 1 1 CMS, Truven Health Analytics, Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011, Steve Eiken, Brian Burwell, Lisa Gold, Kate Sredl, Paul Saucier, October 2013 NASDDDS National Association of State Directors of Developmental Disabilities Services 8
Title XIX permits the Secretary of Health & Human Servicesto waive certain provisions required through the regular State Plan process: ◦ For 1915(c) HCBS waivers, the provisions that can be waived are related to: Comparability (amount, duration, and scope) – provides ability to target benefit Statewideness Income and resource requirements NASDDDS National Association of State Directors of Developmental Disabilities Services 9
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF), Intermediate Care Facilities for the Mentally Retarded (ICFs/MR), or hospital Level of Care (LOC) Serves diverse target groups – including individuals with intellectual and developmental disabilities, individuals with physical disabilities, individual who are aging and those with mental health support needs Services can be provided on a less than Statewide basis Allows for participant-direction of services NASDDDS National Association of State Directors of Developmental Disabilities Services 10
Costs: HCBS must be “cost neutral” as compared to institutional services, on average for the individuals enrolled in the waiver LOC: Institutional levels of care define waiver LOC and the populations that may be targeted Choice: HCBS participants must have the choice of all willing and qualified providers NASDDDS National Association of State Directors of Developmental Disabilities Services 11
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite Care For chronic mental illness: Day Treatment/Partial Hospitalization Psychosocial Rehabilitation Clinic Services AND, Other Services – can be State-proposed service specifications NASDDDS National Association of State Directors of Developmental Disabilities Services 12
AT is commonly covered in 1915(c) waivers States cover a wide array of technology, including commercially available technology when it is addressing an identified need in an individual’s plan of care. States frequently include annual, multi-year and/or lifetime dollar limits on AT Prior authorization is also common for technology costing over certain amounts. NASDDDS National Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology, but states may amend/change as needed: Assistive technology device means an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of participants. Assistive technology service means a service that directly assists a participant in the selection, acquisition, or use of an assistive technology device. Assistive technology includes- (A) the evaluation of the assistive technology needs of a participant, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant; (B) services consisting of purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices for participants; (C) services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (D) coordination and use of necessary therapies, interventions, or services with assistive technology devices, such as therapies, interventions, or services associated with other services in the service plan; (E) training or technical assistance for the participant, or, where appropriate, the family members, guardians, advocates, or authorized representatives of the participant; and (F) training or technical assistance for professionals or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of participants. NASDDDS National Association of State Directors of Developmental Disabilities Services
CMS Review/Approval Process: ◦ ◦ ◦ ◦ CMS approves a new waiver for a period of 3 years (possible 5 years for programs serving Medicare/Medicaid eligible individuals) States may request amendments at any time States may request that waivers be renewed; CMS considers whether the State has met statutory/regulatory assurances in determining whether to renew Renewals are granted for a period of 5 years Each of these opportunities for change or renewal offers an opportunity to add or improve AT coverage NASDDDS National Association of State Directors of Developmental Disabilities Services 15
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007), 1915(i) permits states to offer HCBS as a state plan option.
The Affordable Care Act of 2010 amended 1915(i), providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c) NASDDDS National Association of State Directors of Developmental Disabilities Services
◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ May target services to specific groups (waives comparability) Evaluation to determine program eligibility Assessment of need for services Plan of care Health and Welfare and Quality Requirements Self Direction Same allowable services Both use a preprinted application format NASDDDS National Association of State Directors of Developmental Disabilities Services 17
◦ Financial Eligibility Criteria ◦ Program Eligibility ◦ Institutional care requirements ◦ Length of time for operation ◦ Financial estimates ◦ Waiver of statewideness NASDDDS National Association of State Directors of Developmental Disabilities Services 18
1915(c) Must have eligibility criteria at least as stringent as the institutions.
LOC must be: equal to or greater than institution but not less than institution 1915(i) Needs based, not tied to institutional criteria But, institutional criteria must be more stringent than 1915(i) needs-based criteria, therefore: Needs-based eligibility criteria must be: less than institution NASDDDS National Association of State Directors of Developmental Disabilities Services 19
1915(c) Can cap the numbers served May have a waiting list Can cap individual expenditures 1915(i) Cannot cap the numbers served or individual expenditure All eligibles are entitled to the program May NOT have a waiting list Eligibility assessment must be independent NASDDDS National Association of State Directors of Developmental Disabilities Services 20
1915(c) 3 years initial 5 years upon renewal 1915(i) If state targets, 5 years until renewal Indefinite if state does not target NASDDDS National Association of State Directors of Developmental Disabilities Services 21
1915(c) 1915(i) Reasonable estimates of cost and utilization.
Program must be cost neutral compared to institutional care Reveal payment methodology on Attachment 4.19 B of the State Plan.
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1915(i) permits all statutory and “other” 1915(c) services Under 1915(i) and (c) states can “target” services to specific populations ◦ Example: autism services, recovery services May have multiple iSPAs or HCBS waivers Same prohibitions on covering services that otherwise would be covered through IDEA or the Rehabilitation Act NASDDDS National Association of State Directors of Developmental Disabilities Services 23
1915(c)
May waive statewideness
1915(i)
May not waive statewideness NASDDDS National Association of State Directors of Developmental Disabilities Services 24
As of June 2014, 14 states have approved 1915(i) SPAs: California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin NASDDDS National Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment Assistive technology may be included in services covered by managed care entities States may also allow managed care entities to provide cost effective alternatives to covered services – Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for service arrangements In some states, self-direction, through the management of an individual budget may afford even greater opportunity for individualized AT.
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs.
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c)*, 1915(i) and 1915(k) authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate Medicaid To enhance the quality of HCBS and provide protections to participants NASDDDS National Association of State Directors of Developmental Disabilities Services 28
States can now combine multiple target populations within one 1915(c) waiver Gives CMS with new compliance options for 1915(c) waiver programs, not just approve/deny Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example) NASDDDS National Association of State Directors of Developmental Disabilities Services 29
Conflict-free case management ◦ Was just in guidance, now it is in rule Implements the final rule for 1915(i) State plan HCBS— same requirements on HCB settings character, person centered planning Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements NASDDDS National Association of State Directors of Developmental Disabilities Services 30
◦ ◦ ◦ HCB Settings Character What is NOT community What is likely not community What is community ◦ Person-centered planning Codifies requirements Transition planning-coming into compliance with the HCB settings requirements NASDDDS 4/17/14 31
42CFR441.310(C)(4) Is integrated in and supports access to the greater community Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services NASDDDS National Association of State Directors of Developmental Disabilities Services 32
As states identify strategies to meet the obligations of the new regulations, they may look to technology to assist individuals to more effectively engage in their community, get and maintain employment, develop social networks, and communicate with friends, family and co-workers.
NASDDDS National Association of State Directors of Developmental Disabilities Services
Determining whether, what and how your state covers AT can be daunting Building relationships, becoming informed and educating others are key to having a voice in future AT coverage strategies NASDDDS National Association of State Directors of Developmental Disabilities Services
A key message to policy-makers….AT may be the necessary difference for individuals to live, work and meaningfully engage in community NASDDDS National Association of State Directors of Developmental Disabilities Services
A number of states, such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation.
◦ ◦ To learn more about state activity and options: www.medicaid.gov
Coleman Institute http://www.colemaninstitute.org/
2014: State of Aging and Disabilities
Assistive Technology and Medicaid July 14, 2014 www.nasuad.org
NASUAD Overview
• Founded in 1964 to represent state agencies on aging. • In 2010, changed name in recognition of the fact that most state agencies served aging and disability populations.
• 56 members Represents State and Territorial Agencies on Aging and Disabilities.
• Board of Directors – Executive Officers, 10 regional representatives and 10 regional alternate reps.
Our mission
To design, improve, and sustain state systems delivering home and community based services and supports for the elderly and individuals with disabilities and their caregivers
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Key Resources
• NASUAD.org
• HCBS.org
• NASUADiQ.org
• Friday Update • Integration Tracker • Expansion Tracker
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Join us at the 30
th
conference annual HCBS
• September 15-18, 2014, Crystal City, VA • 5 pre-conference intensives • 130 sessions covering all populations receiving LTSS • 1,000 attendees representing state policymakers, federal officials, staff, academics, businesses, etc.
• For more information: www.nasuad.org
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State Aging & Disability Agencies
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Populations Served by the State Agency
100% 80% 60% 40% 20% 0% Older Adults Individuals with Physical Disabilities Individuals with TBI Individuals with I/DD Individuals accessing mental/behavioral health services Page 43
100% 80% 60% 40% 20% 0%
State Agency Funding Sources for FY 2013
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Managing relationships identified as key job responsibility
State Agency Director Job Responsibilities
60 50 40 30 20 10 0 Manage relationships Set state aging policy Manage internal operations of State Agency Strategic planning Manage external operations of State Agency Set state long-term services and LTSS policy Set state disability policy Other Page 45
State Medicaid HCBS Options
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Status of Medicaid HCBS Options in States
50 40 30 20 10 0 HCBS §1915(c) State Plan Personal Care Services MLTSS §1115 Dem. for LTSS (other than MLTSS) State Plan §1915(i) State Plan §1915(j) State Plan §1915(k) In Place in 2013 Plan to implement in 2014 Under Consideration Do not have/do not plan to implement Page 47
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Alzheimer's Disease Autism Intellectual/Developmental Disabilities Older Adults Older Adults and Adults with Disabilities Adults with Physical Disabilities Severe Emotional Disturbance Traumatic Brain Injury
Compared to SFY 2012, in SFY 2013, the Waiver Caseload: Increased
% of States 25.8% 13.8% 33.3% 62.9%
Decreased
% of States 0.0% 0.0% 0.0% 0.0%
Stayed the Same
% of States 16.1% 13.8% 16.7% 14.3%
Not Applicable
% of States 58.1% 72.4% 50.0% 22.9% 54.5% 56.7% 17.9% 21.4% 9.1% 0.0% 0.0% 3.6% 21.2% 20.0% 10.7% 25.0% 15.2% 23.3% 71.4% 50.0% Page 48
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities 2012 - 2013 Percent Change in Waiver Expenditures
Alzheimer's Disease Autism Intellectual/Developmental Disabilities Older Adults Older Adults and Adults with Physical Disabilities Adults with Physical Disabilities Severe Emotional Disturbance Traumatic Brain Injury
Less than 5% % of States
12.5% 8.0%
5%-8% % of States
0.0% 0.0%
8%-15% % of States
0.0% 4.0%
More than 15% % of States
0.0% 0.0%
Not Applicable % of States
87.5% 88.0% 20.0% 17.9% 29.6% 8.0% 14.3% 3.7% 12.0% 14.3% 14.8% 0.0% 7.1% 18.5% 60.0% 46.4% 33.3% 12.5% 8.3% 4.2% 8.3% 4.2% 12.5% 4.2% 0.0% 0.0% 8.3% 0.0% 4.2% 66.7% 87.5% 79.2% Page 49
State Assistive Technology Coverage
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2012 Survey of Assistive Technology and State Agencies
• Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities: – Seventeen states fund some type of personal emergency response system (PERS). – Six states fund technology to support home and/or vehicle modifications. – Three states (Colorado, Iowa, and Minnesota) use telehealth/telemedicine. – Three states (Colorado, Maine, and Minnesota) use telemonitoring or wander locating. – Two states (Minnesota and Texas) use remote medication management / automated medication dispensing. Page 51
Adult Day Health (includes health component) Adult Day Social (does not include health component) Adult Foster Care Assisted Living Assistive Technology Behavioral Supports Environmental Modifications Home-Delivered Meals Personal Assistance Services Personal Emergency Response Systems Physical Therapy Recreation Therapy Residential Habilitation Respite Specialized Equipment and Supplies Speech Therapy Supported Employment Transportation Extended State Plan Waiver Benefit: Personal Care Extended State Plan Waiver Benefit: Nursing Extended State Plan Waiver Benefit: Home Health Extended State Plan Waiver Benefit: Other N=40
State Services Available to Specified Populations through Medicaid HCBS Waivers Older Adults
# of States 28 26 14 28 27 10 31 31 32 34 12 2 3 35 28 10 4 32 9 8 7 4
Individuals with Physical Disabilities Individuals with I/DD Individuals with TBI
# of States 23 16 15 25 27 12 32 23 32 28 13 3 4 30 30 11 6 28 9 10 7 3 # of States 14 15 12 5 27 26 27 10 27 21 18 4 25 27 23 15 28 27 6 8 4 6 # of States 12 11 5 7 19 12 16 8 17 11 8 0 9 14 16 6 10 16 4 4 4 3 Page 52
State Examples: Oklahoma (ID/DD)
• Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems: – live video feed; – live audio feed; – motion sensing system; – radio frequency identification; – web-based monitoring system; or – other device approved by OKDHS/DDSD. • The system shall include devices to engage in live two-way communication with the member being monitored as described in the member’s Plan. Page 53
State Examples: Oklahoma (ID/DD)
• • • • • • Assistive devices for members who are deaf or hard of hearing: – visual alarms; – telecommunication devices (TDD's), telephone amplifying devices; and – other devices for protection of health and safety.
Assistive devices for members who are blind or visually impaired: – tape recorders; – talking calculators; – lamps, magnifiers; – Braille writers, paper and talking computerized devices; and – other devices for protection of health and safety.
Augmentative/alternative communication and learning aids such as language boards, electronic communication devices and competence based cause and effect systems.
Mobility positioning devices such as wheelchairs, travel chairs, walkers, positioning systems, ramps, seating systems, lifts, bathing equipment, specialized beds and specialized chairs.
Orthotic and prosthetic devices such as braces and prescribed modified shoes.
Environmental controls such as devices to operate appliances, use telephones or open doors.
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State Examples: Pennsylvania (Seniors)
• TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence, quality of life and reduce the need for nursing home placement. By utilizing in-home technology, more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization. TeleCare services are specified by the service plan, as necessary to enable the participant to promote independence and to ensure the health, welfare and safety of the participant and are provided pursuant to consumer choice. • TeleCare includes: – 1) Health Status Measuring and Monitoring TeleCare Service; – 2) Activity and Sensor Monitoring TeleCare Service; and – 3) Medication Dispensing and Monitoring TeleCare Services.
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State Example: New York (Aged and Physical Disabilities)
• Assistive Technology Supports are specialized equipment and supplies that enable a client to increase, maintain, or improve his/her functional capabilities. It includes the evaluation and purchasing (not leasing) of the assistive technology. It includes selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing the assistive technology device, and any training or technical assistance for the client and family members, guardians, etc.
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State Example: South Carolina (TBI or Spinal Cord Injuries)
• Supplies, Equipment and Assistive Technology means medical supplies and equipment and specialized appliances, devices, or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others. It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items. Excluded are items not of direct medical or remedial benefit to the participant.
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Medicaid and Managed LTSS
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Medicaid Managed Care
• Managed Care in Medicaid can mean different things, including: – Comprehensive contracts with health plans; – Contracts with limited benefit plans, such as: • Prepaid Inpatient Health Plans (PIHPs); • Prepaid Ambulatory Health Plans (PAHPs); – Primary Care Case Management and other “managed fee-for-service”; – Program for All-inclusive Care for the Elderly (PACE) Plans; and – Others.
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Managed Care and MLTSS Growth Continues, but Slows
• Historically, Medicaid Managed Care was largely limited to Children, Parents, Pregnant Women, and other “less complex” populations; • States began including primary and acute care for some seniors and individuals with disabilities, which could include DME and other medically-oriented AT; • A growing number of States are expanding managed care to encompass comprehensive benefits, including LTSS.
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Medicaid Managed Care Statistics (FY 2011)
• 41 percent of enrollees age 65+ were in some form of managed care; • 87 percent of non-disabled children were in managed care; • Comprehensive MCO enrollment: – 14% of aged beneficiaries; – 33% of individuals with disabilities; – 48% of adults without disabilities; and – 63% of children without disabilities.
Source: MACPAC, June 2014 Page 61
Status of Medicaid Managed LTSS in States
10 5 25 20 15 21 17 10 0 Do not have /Do not plan to implement In Operation in FY 2013 Plan to Implement in FY 2014 or later Page 62
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Geographic area currently served by Medicaid MLTSS program
15 12 10 10 5 0 Statewide 3 1 Limited geographic area Other, please specify: Pilot program only Page 66
50 45 40 35 30 25 20 15 10 5 0
Status of state's care coordination for Medicare-Medicaid eligible beneficiaries
26 14 9 N/A Participating in Duals Demonstration Participating in an Alternative Duals Coordination Initiative Page 67
Medicaid MCOs Bring Challenges and Opportunities
• MCOs are frequently given latitude to: – Establish selective provider networks; – Negotiate rates and contractual requirements with providers and suppliers; – Develop prior authorization and utilization controls.
• Medicaid MCOs are given strong incentives to provide care in a cost-effective manner, creating a value-proposition dynamic: – AT providers can benefit when they demonstrate value by reducing other costs, such as hospitalization, post-acute, and nursing homes – However, this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and, in many cases, without performance standards Page 68
State AT Involvement and Medicaid
Marty Exline Missouri Assistive Technology July 14, 2014 Missouri Assistive Technology Blue Springs, Missouri 64015 816-655-6700 [email protected]
Challenges & Opportunities
• • •
What AT is covered in my state’s HCBS waivers?
State’s Waiver applications State annual 372 report to CMS Contact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 3.5
• Home Accessibility Adaptations • Environmental Accessibility Adaptations • • • • Vehicle Modifications Specialized Medical Equipment & Supplies Personal Emergency Response Systems Assistive Technology
DD Waiver-Environmental Accessibility Adaptations (EAA)
Source: FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total Total Waiver Expenditures Total Unduplicated Participants Total EAA Costs
$512,677,539 $15,588,016 $1,513,136 $2,421,925 8,126 1,406 160 207 $238,037 $85,277 $0 $79,516 $5,840,897 1,314 $90,612
Unduplicated Participants Receiving EAA
69 22 0 23 20 $538,041,513 11,213 $493,442 134
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver
Policy: to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
• • • Piloting an MFP “AT and Access Evaluation” 3 –Step Process VATP reviews Eval Report device loans for trials reuse project • • DD Technology Workgroup State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
• • • • • • • •
AT in all DD HCB waivers Developed guidelines for coverage Provider of AT for DD waivers Training Money Follows the Person Stakeholder Group Training for MFP Contact Agencies MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
•
In regular meetings with Medicaid to reconfigure all HCBS waivers.
• •
Has hosted meetings at their facility AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
• • • •
Provider for NE Aged & Disabled Waiver Collaborated to develop referral process, guidelines, regulations, forms, etc.
Provides assessments for home modifications and AT $5,000 cap on service, so provides funding coordination
State AT Considerations
• • • • • •