Monthly Archives: July 2015

Legislation Introduced to Address Medicare CRT Wheelchair Accessories Issue

CRT Stakeholders and Friends,

We have good news to report.

Legislation has been introduced in the House of Representatives by Representative Lee Zeldin (R-NY) to provide the technical correction to stop CMS from applying competitive bid pricing to Complex Rehab wheelchair accessories. The bill number is HR-3229.

You can download and read the related press release and the text of the bill as well as a copy of the NCART Position Paper that we have been using during our meetings with Congress.

This is an important first step, but further work lies ahead. We will be updating our advocacy materials and sharing more information as we move forward.

On a related note, we expect the Senate to be circulating a “sign-on” letter to CMS on this issue later this week. This will allow your Senators to add their signatures asking CMS to rescind this inappropriate policy. Stay tune for further instructions.

Thanks to all those individuals and groups who have been in contact with their Members of Congress on this issue over the past several months. Your collective outreach is producing results.

Don

Donald E. Clayback
Executive Director | NCART
Office 716-839-9728 | Cell 716-913-4754
dclayback@ncart.us | www.ncart.us

Happy 25th Birthday ADA!

ADA25

CRT Stakeholders and Friends,
Yesterday June 26th marked the 25th Anniversary of the signing of the Americans with Disabilities Act (ADA). It’s passage was a major achievement for the rights of people with disabilities and for our country.

The ADA is focused on “ensuring equality of opportunity, full participation, independent living, and economic self-sufficiency”. While there is more work to be done to meet those objectives, the anniversary is a great reminder of their importance and promise.

A great website to visit to see the ADA’s history is the ADA Legacy Project at www.adalegacy.com. The site focuses on “preservation, celebration, and education”. You can also make a donation to help further the work of the Project.

With CRT Awareness week coming up August 17th we will be premiering a new video incorporating the ADA and CRT. As we know they are significantly intertwined. Without access to the right wheelchair, seating and positioning, and other adaptive technology the ADA can be an unfulfilled promise for many people with disabilities.

The video will include comments from recently retired U. S. Senator Tom Harkin (D-IA), the Senate sponsor of the ADA legislation. Senator Harkin served in Congress for 40 years (30 in the Senate and 10 in the House) and earned a reputation as a true champion for the rights of people with disabilities. He weighs in on the importance of CRT.

Promoting and protecting access to CRT is critical to building on the successes of the ADA and improving the ability of people with disabilities to be independent, productive, and fully engaged in their communities. That’s the mission of NCART. We are grateful for your participation and those of other CRT Stakeholder organizations in these initiatives.

So Happy 25th Birthday ADA!

We look forward to seeing legislators and policy makers at both the federal and state levels fully embrace the goals of the ADA and work to address the issues that continue to create barriers for people with disabilities to get the CRT they need and depend on.

Don

Donald E. Clayback
Executive Director | NCART
Office 716-839-9728 | Cell 716-913-4754
dclayback@ncart.us | www.ncart.us

Report on Washington, DC CRT Educational Exposition

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CRT Stakeholders and Friends,

We wanted to give a quick report on this past Monday’s Complex Rehab Technology (CRT) Educational Exposition held on Capitol Hill and hosted by the United Spinal Association, the National Multiple Sclerosis Society, and NCART. The expo was based on the theme that if Congress is unable to come to CRT, CRT will come to Congress.

Bottom line it was a successful event!

We were pleased to have many Congressional staff visit the Exposition to learn about CRT in person. On display were CRT manual wheelchairs, power wheelchairs, wheelchair accessories, and other CRT items. Over the course of three hours attendees were able stop in and talk directly with consumers, clinicians, providers and manufacturers to hear about the access challenges that exist and how we need Congress to help.

The good news: It was very encouraging to hear comments from the Congressional staff saying they NOW see how CRT is different and needs to be recognized as such.

We will be following up with those attendees and sharing additional information with them on the pressing need to stop Competitive Bid pricing from being applied to Complex Rehab wheelchair accessories scheduled for January 1st.

Thanks to the United Spinal Association and the National Multiple Sclerosis Society for being co-hosts and for the sponsorship of Representatives Jim Sensenbrenner (R-WI) and Joe Crowley (D-NY).

Thanks also to all the CRT stakeholders who reached out to their Members with an invitation to attend. Even if your Members were not able to stop by, your contact with them keeps the CRT message on their radar screen.

The event served to continue to increase CRT awareness within the hall and minds of Congress. That awareness needs to continue to grow and is key to us being successful in preserving access to CRT.

Regards,

Don

Donald E. Clayback
Executive Director | NCART
Office 716-839-9728 | Cell 716-913-4754
dclayback@ncart.us | www.ncart.us

Action Needed: Invite Congress to the Capitol Hill CRT Expo on Monday July 20

CRT Stakeholders and Friends,

In order to gather more Congressional support on CRT issues we are holding a Complex Rehab Technology Exposition on Capitol Hill next Monday July 20th. This invitation provides more details, but here are the highlights:

Title: “Promoting Independence for People with Disabilities: Educational Display of Individually-Configured Complex Rehab Technology”

July 20, 2015 from 12:00 to 3:00 PM; Rayburn Building Room B-340; Refreshments Provided

The Exposition will allow attendees to walk around at their own pace and visit 4 different displays of CRT systems and accessories, including individually configured manual and power wheelchairs. Consumers, clinicians, providers, manufacturers, and other advocates will be in attendance to provide demonstrations and answer questions
Attendees will see and hear what CRT is all about, including: what it looks like, who uses it, how it differs from standard Durable Medical Equipment (DME), the benefits it provides, and how it’s configured to meet the individual needs of people with disabilities
Will cover two critical issues we need Congress to take action on this year: (1) a legislative technical correction to stop CMS from inappropriately applying Competitive Bid Program pricing to CRT wheelchair accessories on January 1, 2016 and (2) passage of the “Ensuring Access to Quality Complex Rehabilitation Technology Act of 2015” (H.R. 1516 and S. 1013)
Your help is needed. We want to get as many offices to attend as possible. Please contact the offices of your Members of Congress (your Representative and Senators) and personally invite them to visit the Expo between 12:00 noon and 3:00 PM. You can use the sample email at the end of this email as a guide.

This is a great CRT educational opportunity for Congress. Your personal invite will make a difference. Thanks for reaching out to them today if you can.

Regards,

Don

Donald E. Clayback
Executive Director | NCART
Office 716-839-9728 | Cell 716-913-4754
dclayback@ncart.us | www.ncart.us

Sample Email To Congress:

Dear ______________,

I’d like to invite you to attend a Capitol Hill Complex Rehab Technology Exposition being held Monday July 20th from 12:00 noon to 3:00 PM in the Rayburn Building Room B-340.

The event is entitled “Promoting Independence for People with Disabilities: An Educational Display of Individually-Configured Complex Rehab Technology” and is designed to allow Members of Congress and Congressional staff to learn more about Complex Rehab Technology (CRT) and the benefits it provides to people with disabilities. It is being presented by the United Spinal Association, the National Multiple Sclerosis Society, and the National Coalition for Assistive and Rehab Technology (NCART), in coordination with the offices of Representatives Jim Sensenbrenner and Joe Crowley.

This will be a great opportunity to see and hear about CRT and the access challenges this specialized equipment faces. It will also cover two critical issues we need Congress to take action on this year: (1) a legislative technical correction to stop CMS from inappropriately applying Competitive Bid Program pricing to CRT wheelchair accessories on January 1, 2016 and (2) passage of the “Ensuring Access to Quality Complex Rehabilitation Technology Act of 2015” (H.R. 1516 and S. 1013).

Attached is the invite with more details. Please let me know if someone from your office will be able to attend.

Regards,

NCART Comments on CMS Proposed Rule for Miscellaneous DME Items

Download These Comments

July 9, 2015

Submitted electronically to: CodingComments@cms.hhs.gov

Subject: Miscellaneous Code Comments
To Whom It May Concern:

The following comments are submitted on behalf of the National Coalition for Assistive and Rehab Technology (NCART) in regards to the notice CMS posted online entitled “Healthcare Common Procedure Coding System (HCPCS) Codes Used for Processing Medicare Claims for Miscellaneous Durable Medical Equipment (DME)”.

NCART is a national association of suppliers and manufacturers focused on ensuring individuals with significant disabilities and chronic medical conditions have appropriate access to Complex Rehab Technology (CRT) products and services. We collaborate with consumers, clinicians, and physicians along with federal, state and private policy makers to establish and protect appropriate coverage, coding, and payment policies for CRT. Our membership includes over 300 Medicare CRT supplier locations across the country and the country’s leading CRT equipment manufacturers.

CRT products include medically necessary and individually configured manual wheelchairs, power wheelchairs, seating systems, and other adaptive equipment such as standing devices and gait trainers. People with high‐level disabilities such as ALS, Cerebral Palsy, Multiple Sclerosis, Muscular Dystrophy, Spinal Cord Injury, and Traumatic Brain Injury depend on CRT to address their medical needs, maximize their function and independence, and minimize health care costs. The provision process is service‐ intensive involving evaluation, configuration, fitting, adjustment, or programming and the equipment must then be supported with ongoing service and repair.

Flaws In This Process

At the outset, NCART agrees with the need to develop additional distinct HCPCS codes in order to appropriately capture items that are currently billed as “miscellaneous” items. However we have serious concerns with the process CMS is using.

We are very concerned that CMS continues to make coding, coverage and payment decisions which significantly impact access to important technology for people with disabilities in a manner that prevents stakeholder inclusion, and meaningful, upfront, open discussion to arrive at the best outcomes. This case is an illustration; minimal public notice and a limited time period for written comment with no opportunity for meaningful public exchange.

This notice was not broadly communicated to the affected community of stakeholders, and instead was merely included in a CMS “All Medicare” email weekly newsletter. Further, providing a short period of time for the public to provide comments on a coding proposal with such broad implications to beneficiary access is insufficient.

When it comes to ensuring access to the specialized technology (i.e. Complex Rehab Technology) that people with high level disabilities depend on, the importance of an appropriate HCPCS coding system cannot be overstated. As we move forward we would appreciate the opportunity to collaborate with CMS to develop an enhanced process for discontinuing/revising existing HCPCS codes and for the development of new, distinct codes when the necessity for such codes is identified.

With this in mind we make the following comments and recommendations and ask that in the future sufficient time be allowed for greater stakeholder inclusion in order to produce the best outcomes for the Medicare program and its beneficiaries.

Comments and Recommendations on Proposed Miscellaneous Codes

There are many hundreds of items affected by this proposal, and in this particular case, our focus is on the development of revised miscellaneous HCPCS codes that impact wheeled mobility and seating accessories, components, and parts.

NCART agrees with the need for more HCPCS codes for miscellaneous DME and otherwise not classified wheelchair components and accessories. Our members have long held the position regarding the need for additional codes in general, and miscellaneous codes in particular, that would allow for more accurate tracking, and allow Medicare and other payers to identify new HCPCS coding needs.

However, NCART believes the coding and payment changes being proposed regarding miscellaneous codes will disproportionately negatively impact people with disabilities since miscellaneous wheelchair items are more prevalent on complex rehab wheelchairs. Due to the small population of people with disabilities that may need any one item, utilization is typically low for many important complex rehab technologies. As a result, CRT products are less likely to meet CMS’s threshold for establishing a unique HCPCS code and therefore are billed under a miscellaneous HCPCS code.

Needed Changes to the Proposed Codes and Descriptors

The specific codes being proposed are problematic and inadequate. Under the proposed coding changes, CMS is planning on 6 new HCPCS codes:

1.) KXXX1‐ Durable Medical Equipment, Miscellaneous, the Purchase Price Does Not Exceed $150
2.) KXXX2‐ Durable Medical Equipment, Miscellaneous, the Purchase Price Exceeds $150
3.) KXXX3‐ Wheelchair Component or Accessory, Miscellaneous, the Purchase Price Does Not Exceed $150
4.) KXXX4‐ Wheelchair Component or Accessory, Miscellaneous, the Purchase Price Exceeds $150
5.) KXXX5‐ Repair Part For Use With Beneficiary Owned Durable Medical Equipment, Other Than Wheelchair, Not Covered Under Supplier Or Manufacturer Warranty, Not Otherwise Specified
6.) KXXX6‐ Repair Part For Use With Beneficiary Owned Wheelchair, Not Covered Under Supplier Or Manufacturer Warranty, Not Otherwise Specified

As already stated, NCART agrees that more HCPCS codes are needed. In the area of miscellaneous codes, NCART recommends that CMS establish codes using a different way of stratifying the technology.

Rather than using payment categories to differentiate codes, NCART recommends that CMS use the following descriptors/differentiators to properly segregate the products under the following codes:

1) KXXX1‐ Durable Medical Equipment, Miscellaneous
2) KXXX2‐ Durable Medical Equipment, Component or Accessory, Not Otherwise Specified
3) KXXX3‐ Durable Medical Equipment, Repair Part for Use with Beneficiary Owned, Not Covered Under Supplier or Manufacturer Warranty, Not Otherwise Specified
4) KXXX4‐ Standard Wheelchair, Component or Accessory, Not Otherwise Specified
5) KXXX5‐ Standard Wheelchair, Repair Part for Use with Beneficiary Owned, Not Covered Under Supplier or Manufacturer Warranty, Not Otherwise Specified
6) KXXX6‐ Complex Rehabilitative Wheelchair, Component or Accessory, Not Otherwise Specified
7) KXXX7‐ Complex Rehabilitative Wheelchair, Repair Part for Use with Beneficiary Owned, Not Covered Under Supplier or Manufacturer Warranty, Not Otherwise Specified

Needed Changes to the Fee Schedule Methodology and Payment Category Assignment

CMS indicates that fee schedules will be developed for KXXX1‐KXXX4. NCART strongly disagrees with the notion of developing a fee schedule for miscellaneous HCPCS codes. Not only are these codes used to bill a wide range of products, as new codes are created and new technology brought to market, the products that are being billed under these codes will change. To develop a fee schedule is inappropriate, arbitrary and will create a barrier to innovation and access to existing technology.

Items billed under miscellaneous codes do not necessarily have anything in common other than they are “not otherwise classified”. CMS indicates they used billed amounts from July 1, 1986 through June 30, 1987 to establish fee schedule amounts for certain proposed new codes. It is unclear what code was used for miscellaneous wheelchair accessories or options during this timeframe, as K0108 was not implemented until 1993. Further, NCART believes that there is no evidence that the items billed under miscellaneous codes from 20 to 30 years ago are the same ones being billed today. The only guarantee from the method CMS has applied to establish fee schedules is that it will result in over‐payment for many items and deny access to others.

Under this CMS proposal, many items would be paid at levels that are significantly less than their acquisition cost. The maximum that a provider can recoup if they bill a KXXX4 through the term of the capped rental is $560.83, even though acquisition costs may exceed this by a substantial amount.
Suppliers will not be able to provide items at a loss and, as such, beneficiaries will be forced to suffer financial hardship to obtain the items privately or be denied access to the item.

The proposal would increase program integrity risk by establishing reimbursement ceilings and six point plan logic (routinely purchased or capped rental) on miscellaneous codes. CMS would virtually eliminate any billing less than the allowable amount. In light of the harm that would occur to beneficiaries and the risks that would result to the system, there is no reasonable basis for implementing a fixed allowable for items billed under any miscellaneous code.

In light of the harm that would result, there is no reasonable basis for developing fee schedules for these codes. NCART believes all of the miscellaneous codes should be priced based on contractor individual consideration to ensure that an appropriate amount is paid for the item being provided and that access can be preserved.

Regarding the proposal to assign miscellaneous codes to six point plan payment categories under Section 1834(a)(1)(B) of the Social Security Act (routinely purchased and capped rental), NCART must express its concern and strong opposition. We assert that making classification decision for miscellaneous codes solely on MSRP is unfounded. To classify items as capped rental purely based on the MSRP of that item is not compliant with CMS’ own rules regarding payment category assignment. Regardless of the code used to bill items in 1986 and 1987, these items have been routinely purchased by Medicare more than 75% of the time. Further, to classify any accessory as capped rental when it is being provided with a base item that is classified as purchase adds a significant burden and cost to suppliers. CMS allows capped rental items billed with certain power wheelchairs, when the beneficiary has elected to purchase at initial issue, to be billed as a purchase.

NCART recommends that CMS allow this same provision for any option or accessory being provided with DME or wheelchair base item that is purchased. CMS should allow the beneficiary to choose rental or purchase depending on their individual situation, or length of need for the item being billed for all options, accessories. We also agree that all repair parts should be purchased when provided on beneficiary owned bases.

Summary

In closing, NCART believes that adequate and appropriate HCPCS codes are the foundation for coverage and payment policies that ensure appropriate access and the best health outcomes for Medicare beneficiaries. CMS has a responsibility to make coding decisions that do not impede appropriate access and unfortunately this proposed miscellaneous ode set will result in serious access issues to a vulnerable population. We believe that many of the current policies fail to meet the needs of people with disabilities.

It is very important for HCPCS codes to recognize technological differences between products which address different clinical needs. We recognize the challenge that can occur in trying to properly administer the program as it relates to the primary Medicare beneficiary population. However NCART also believes that CMS must take the needs of the smaller, but equally important, population of Medicare beneficiaries who are eligible for the program based on disability.

In order to preserve access, provide better tracking, and improve the efficiency of the Medicare program we recommend the following modifications to CMS’ coding proposal:

1.) Modify the proposed Codes and Descriptors to read as follows:
a. KXXX1‐ Durable Medical Equipment, Miscellaneous
b. KXXX2‐ Durable Medical Equipment, Component or Accessory, Not Otherwise Specified
c. KXXX3‐ Durable Medical Equipment, Repair Part for Use with Beneficiary Owned, Not Covered Under Supplier or Manufacturer Warranty, Not Otherwise Specified
d. KXXX4‐ Standard Wheelchair, Component or Accessory, Not Otherwise Specified
e. KXXX5‐ Standard Wheelchair, Repair Part for Use with Beneficiary Owned, Not Covered Under Supplier or Manufacturer Warranty, Not Otherwise Specified
f. KXXX6‐ Complex Rehabilitative Wheelchair, Component or Accessory, Not Otherwise Specified
g. KXXX7‐ Complex Rehabilitative Wheelchair, Repair Part for Use with Beneficiary Owned, Not Covered Under Supplier or Manufacturer Warranty, Not Otherwise Specified

2.) Continue the current policy of determining payment amounts for miscellaneous codes based on contractor individual consideration.

3.) Provide that the payment methodology allows the option for payment to be made as a purchase.

As stated above, NCART has a sincere desire to join other impacted stakeholders in collaborating with CMS to address issues within the HCPCS coding area in order to produce the best outcomes for the Medicare program and Medicare beneficiaries. Please let us know how we can be of further assistance.
Sincerely,

Donald E. Clayback Executive Director 716‐839‐9728
dclayback@ncart.us | www.ncart.us

Invitation to Complex Rehab Technology Exposition and Demonstration

Promoting Independence for People with Disabilities: Educational Display of Individually‐Configured Complex Rehab Technology

July 20, 2015 from 12:00 to 3:00 PM
Rayburn Building Room B‐340
Refreshments Will Be Provided

The United Spinal Association, the National Multiple Sclerosis Society, and the National Coalition for Assistive and Rehab Technology (NCART), in coordination with the offices of Representatives Jim Sensenbrenner and Joe Crowley, invite Members of Congress and Congressional staff to learn more about Complex Rehab Technology (CRT) and the benefits it provides to people with disabilities.

• People with high‐level disabilities such as ALS, Cerebral Palsy, Multiple Sclerosis, Muscular Dystrophy, Spinal Cord Injury, and Traumatic Brain Injury depend on CRT to address their medical needs, maximize their function and independence, and minimize health care costs. The provision of CRT is service‐intensive involving evaluation, configuration, fitting, adjustment, or programming. The equipment must then be supported with ongoing service and repair.

• This Exposition will allow attendees to walk around at their own pace and visit 4 different displays of CRT systems and accessories, including individually configured manual and power wheelchairs. Consumers, clinicians, providers, manufacturers, and other advocates will be in attendance to provide demonstrations and answer questions.

• Attendees will see and hear what CRT is all about, including: what it looks like, who uses it, how it differs from standard Durable Medical Equipment (DME), the benefits it provides, and how it’s configured to meet the individual needs of people with disabilities.

CRT is very different from standard Durable Medical Equipment and faces its own unique access issues within the Medicare program. Come learn about the challenges this sector of needed specialized equipment faces and how Congress can take action this year on two critical issues:

• A legislative technical correction to stop CMS from inappropriately applying Competitive Bid Program pricing to CRT wheelchair accessories on January 1, 2016.

• Passage of the “Ensuring Access to Quality Complex Rehabilitation Technology Act of 2015” (H.R. 1516 and S. 1013).

Individuals expecting to attend are asked to reply to Mickae Lee at NCART at mlee@ncart.us or 585‐784‐0208

Download this Invitation to Share

Independence Week CRT Update

CRT Stakeholders and Friends,

July starts with a big week for our country as we celebrate Independence Day. It’s also a very important month as we celebrate the 25th Anniversary of the signing of the Americans with Disabilities Act on July 26th. Let’s make it a big month for CRT advocacy!

CRT Legislation

Progress continues toward passage of the “Ensuring Access To Quality Complex Rehabilitation Technology Act” (HR-1516/S-1013). As we leave the month of June we are up to 117 Members signed on in the House (49 Republicans/68 Democrats) and 10 Members in the Senate (5 Republicans/5 Democrats). You can view the current list at www.access2crt.org to see if your Representative and 2 Senators are on board.

Our biggest need continues to be to add more co-sponsors. That’s where your help is needed. The good news is we can get quick additions by just focusing on the 68 Members (56 House and 12 Senate) from last year who have not yet re-signed. See the list of co-sponsors by state to see if your Member is one of them. Since there were only a few minor changes to the 2015 bill as compared to 2014, the only reason these 68 Members have not re-signed yet is because we have not done enough follow up. Please find the minutes it takes to send the email and get these offices back on board.

We know everyone is busy, but we really need you to contact your Members over the month of July. We have seen time and time again that your personal outreach and persistence will pay off. You can use the tools at www.access2crt.org to make those calls and send those emails to get your Members signed on. Your efforts will produce results.

Medicare CB Pricing to CRT Wheelchair Accessories

It is extremely disappointing that CMS has said NO to Congress’ formal request (a 101 signature bipartisan letter) that CMS rescind plans to inappropriately apply competitive bid pricing to Complex Rehab wheelchair accessories beginning 2016. This violates the intent of 2008 federal legislation (MIPPA) and subsequent CMS policy that excluded individually configured Complex Rehab wheelchairs and accessories from competitive bidding. This inappropriate application would eliminate access as payment rates would drop 20% to 50% and the negative impact would extend well beyond Medicare beneficiaries to also hurt people with disabilities in Medicaid and private insurance programs.

Given CMS’ refusal, Congress now needs to legislate a technical correction to clarify that CMS cannot apply competitive bid pricing to accessories used with Complex Rehab power and manual wheelchairs to prevent CMS’ application of these payment reductions scheduled for January 1, 2016. An NCART Position Paper is being used to educate Members of Congress and others on this issue.

Congressional CRT Exposition

To enhance the CRT educational process in Congress we are holding a “Congressional CRT Exposition” on Capitol Hill on Monday July 20th. The exposition is being hosted in conjunction with United Spinal Association, National MS Society, and NCART in coordination with our legislative champions Congressmen Jim Sensenbrenner and Joe Crowley. The event will feature hands-on displays of CRT manual wheelchairs, power wheelchairs, seating and positioning products, and other equipment highlighting how CRT is different from DME. Consumers, clinicians, providers, manufacturers, and other advocates will be in attendance to provide demonstrations and answer questions.

This will be a great opportunity to further demonstrate what CRT is all about. We will be able to communicate in person what the technology looks like, who uses it, the benefits it provides, how it is configured to meet a person’s individual needs, and other important parts of the CRT message. We are preparing a “CRT Expo Invitation” that CRT stakeholders will be able to email to the offices of their Members to get them to stop in for a visit. You can use that as the tool to let your Members know of the event and encourage their attendance. You’ll have the invite to share next week.

National CRT Awareness Week

Our annual National CRT Awareness Week has been scheduled for August 17th to 21st. The focus is on Members of Congress who are back in their home districts for the August recess. It’s a great time for CRT stakeholders to connect with their representatives on a local level and secure additional support for our CRT issues. Start making plans to connect with your Members now. If you can’t connect that week, make the contact sometime during the month. You don’t need to fly to Washington to have an impact! Additional tools and suggestions to follow.

Thanks for your continued advocacy work on the CRT front. Have an enjoyable holiday weekend and please remember the dedicated military men, women, and families who make (and have made) sacrifices for our values, independence and quality of life.

Regards,

Don

Donald E. Clayback
Executive Director | NCART
Office 716-839-9728 | Cell 716-913-4754
dclayback@ncart.us | www.ncart.us