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Health Benefits Program Funding of Speech
Generating Devices

• Lewis Golinker, Esq.
• Director
• Assistive Technology Law Center
• 401 East State Street, Suite 300
• Ithaca, New York 14850
• 607-277-7286 (v)
• Lgolinker_at_aol.com (e-mail)

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Scope of Presentation

• 5 topics
• Who needs to know about funding?
• Why is funding important?
• How do funding programs decide what they will pay
  for?
• What is my role in the funding process?
• Where do I go for help?

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Who Needs to Know About Funding?

• Practicing Speech-Language Pathologists
• Students in Speech-Language Pathology
• Teachers School Administrators
• Family Members
• Advocates

4
Why Is Funding Important?

• Families cant buy SGDs on their own
• Knowledge about funding options allows proper
  assessment treatment planning
• Knowledge about funding creates expectations
  about the outcomes clients can achieve through
  SLP intervention
• Knowledge about funding is the antidote for
  learned helplessness
• Knowledge about funding informs SLPs about
  requirements for assessment and reporting

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Why Is Funding Important?

• ASHA Code of Ethics
• Principle 1 Individuals shall honor their
  responsibility to hold paramount the welfare of
  persons they serve professionally . . .
• Rule of Ethics B Individuals shall use every
  resource, including referral when appropriate, to
  ensure that high quality service is provided.
• including referral when appropriate
• As a practical matter, only the SLP will be able
  to help clients
• Yes, funding is a burden, but . . . .

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How Does Funding Work What Do SLPs Need to Know?

• Health Benefits Programs that Cover Provide
  SGDs
• Medicaid
• Medicare
• Insurance
• Tricare
• Department of Veterans Affairs

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Remember SGDs Are NOT Assistive Technology

• Health Benefits Programs Generally Do Not
  Recognize assistive technology
• IDEA and Vocational Rehabilitation use assistive
  technology, not health programs
• Cover Durable Medical Equipment
• Cover Prosthetic Devices

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Will SGDs Be Provided?

• All Health Benefits Programs follow a 4 Question
  Test
• 1 Is the person eligible?
• 2 Is the item or service covered?
• 3 Is the item or service medically
  necessary?
• 4 Does the request meet any special
  eligibility or coverage rules that may apply?
• Must show that 1-4 are yes.

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Who Needs SGDs?

• Conditions Associated with SGD Need and Use
• ALS
• Autism other developmental disabilities
• Cerebral Palsy
• Multiple sclerosis
• Parkinsons Disease
• Brain Stem Stroke
• Traumatic Brain Injury
• Communication Impairments Associated with these
  conditions
• Dysarthria
• Aphraxia
• Aphasia
• Aphonia
• Severe Expressive Communication Disability

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Eligibility

• No Universal Health Benefit
• Medicaid poor, disabled
• Medicare 65 or older
• 24 month wait period (except ALS)
• Tricare active duty military or retiree or
  dependent
• Insurance must be covered by policy or plan

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Coverage

• No Universal Benefits item sought -- SGD --
  must fit within one or more covered benefits
  categories
• DME most common equipment benefit
• Prosthetic Devices
• Medicaid also consider EPSDT OT/PT/SLP
  Services ICF/MR NF Services

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Coverage

• Does the funding program have specific SGD
  Coverage Policy or SGD Coverage Criteria?
• Most Medicaid programs
• Medicare
• Many insurers
• Tricare
• When policy or criteria exist, coverage is not a
  key question, but policy conditions must be met
  to obtain funding

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Durable Medical Equipment

• If no coverage policy, must show item or service
  fits definition of DME
• No universal definition
• Most Common
• able to withstand repeated use
• is primarily and customarily used to serve
  a medical purpose
• is generally not useful to a person in the
  absence of illness or injury
• is suitable for use in the home.

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SGDs are Durable

• Criterion able to withstand repeated use
• Generally, not controversial
• Key statements in reporting
• Device is expected to be used daily for a period
  of years
• Device is designed to withstand years of daily
  use
• Device has a rechargeable battery to permit
  ongoing daily use

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Medical Purpose Exercise

• How Do We Establish the SGD will be primarily
  and customarily used to serve a medical purpose?
• -
• -
• -
• -
• -

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Medical Purpose SGDs

• Medical purpose treatment for a condition or
  disability
• This is the most common excuse to deny SGDs
• SGDs treat severe communication impairments
• Dysarthria -- Aphasia
• Apraxia -- Aphonia
• Severe Expressive Communication Impairment

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Medical Purpose SGDs

• Criterion Primarily Customarily Used to serve
  a Medical Purpose
• SGDs serve only a medical purpose
• SGDs treat severe communication impairments that
  interfere with meeting communication needs
  arising in the daily activities.

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Medical Purpose SGDs

• Proof information exists about specific
  conditions
• CP Autism ALS
• Proof Functional Gap Receptive Language vs.
  Expressive Language
• Proof Communication related anger, frustration
  depressionself-injurious behavior
• but for or solely because
• Use does not equal need
• Educational, vocational, social need
• SGDs Serve the same functional role as
  Wheelchairs

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brain
Nerves transmit instructions
speech
Speech organs
Brain formulates a thought Codes thought for
language Codes Motor Instructions
Hands Other body Part
SGD
speech
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Medical Purpose SGDs

• Medical Purpose Confirmed by Other Programs
• Medicare
• Medicaid
• Food Drug Administration
• Insurers with SGD Coverage Policies
• Aetna
• Many Blue Cross/Blue Shield Associations
• Care First Blue Cross of Maryland
• Harvard Pilgrim Health Plan
• Look at Insurer Approvals Database posted at
  www.aacfundinghelp.com

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AAC Devices are not useful in the absence of
illness or injury

• Normal Speech occurs at 150-200 wpm SGD use is
  at best 10 as fast
• Speech is faster and more flexible than any other
  method of communication
• SLP evaluation considers other types of
  interventions first, before AAC interventions
• Many SGDs are dedicated they all have no other
  uses

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Prosthetic Devices

• SGDs are Prosthetic Devices
• Tricare by statute (only federal statute that
  mentions SGDs as covered benefits)
• Dept. of Veterans Affairs
• No universal definition
• Medicaid means replacement, corrective or
  supportive devices to
• 1 artificially replace a missing portion of the
  body
• 2 prevent or correct physical deformity or
  malfunction or
• 3 support a weak or deformed portion of the
  body.
• Medicare (1) devices that replace all or part
  of an internal body organ (2) devices that
  replace all or part of the function of a
  permanently inoperative or malfunctioning
  internal body organ

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Medical Need SGDs

• No Universal Definition
• NY Medicaid
• "Medical assistance" shall mean payment of part
  or all of the cost of medically necessary
  medical, dental and remedial care, services and
  supplies, , which are necessary to prevent,
  diagnose, correct or cure conditions in the
  person that cause acute suffering, endanger
  life,result in illness or infirmity, interfere
  with such persons capacity for normal activity,
  or threaten some significant handicap .

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Medical Need SGDs

• Medicare Reasonable Necessary
• Medicare is prohibited from making payment under
  Parts A or B for any items or services which
  are not reasonable and necessary for the
  diagnosis or treatment of an illness or injury or
  to improve the functioning of a malformed body
  member.

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Medical Need Documentation

• SLP Assessment Report Will Explain Impairment
  Related Functional Effects
• Explains how current daily communication needs
  are not being met by current communication
  methods
• Shows impact on daily functional speaking needs
  RMRP (SGD definition)
• Shows impact on daily communication needs RMRP
  (Assessment item 1(b)

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Medical Need Issues SGDs

• Medical Need for an SGD is not to treat the
  persons underlying neurological condition. SGDs
  do not treat cerebral palsy. They treat
  communication impairments such as dysarthria.
• Funding programs that claim only treatment for
  the underlying condition is covered should be
  asked whether they cover wheelchairs PEG tubes
  or artificial limbs -- none address the
  underlying impairment

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Medical Need Issues SGDs

• Medical Need arises when an individual, due to
  severe communication impairment, is not able to
  meet all communication needs arising in all daily
  activities
• Medical Need is not medical speak
• Need is not measured by who (is spoken to),
  where (speech occurs), or what (is said).
• AMA, AAN, AAPMR all say SGDs are effective,
  medically necessary treatment
• See www.augcominc.com (whats new scroll to
  entry for April 2000)

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SLP Report for Medicare Funded SGD

• The Medicare RMRP for SGDs describes the
  components of the required SLP assessment and
  report that must be produced to support the SGD
  recommendation
• The RMRP is reproduced at http//www.aac-rerc.co
  m/pages/medicare/RMRP.htm
• The Medicare RMRP should be considered a standard
  assessment outline for all funding programs,
  unless a specific format is stated by the
  program.

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SLP Assessment Report Tools

• 3 Tools are available to help SLPs conduct the
  assessment and prepare the report required by
  Medicare and other funding programs
• Assessment/Application Protocol provides a
  detailed review of the data required, common
  means to obtain the data, and sample reports and
  report language for each section of the SLP
  assessment listed in the RMRP. The protocol
  was developed by the Medicare Implementation
  Team whose members include the SLPs who
  persuaded Medicare to cover SGDs.
• The Assessment/Application Protocol can be found
  at
• http//www.aac-rerc.com/pages/medicare/MCAppProtoc
  ol.htm

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SLP Assessment Report Tools

• AAC Report Coach provides a template for the SLP
  to quickly turn the data gathered in the
  assessment into a complete report that meets
  Medicares expectations. It is designed to allow
  the SLP to complete the report within 20-30
  minutes. The AAC Report Coach was developed by
  Pam Mathy, Ph.D., Clinical Director, Arizona
  State University, who also serves as a member of
  the MIT, and was one of the SLPs on the Medicare
  work group.
• The AAC Report Coach is posted at
• www.aacfundinghelp.com

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SLP Assessment Report Tools

• Dynavox Report Writer provides a extensive
  template for the SLP to quickly turn the data
  gathered in the assessment into a complete report
  that meets Medicares or Medicaids expectations.
  Like the AAC Report Coach, Report Writer was
  designed to help SLPs prepare complete reports
  quickly.
• The AAC Report Coach is posted at
• http//www.dynavoxtech.com/Default.aspx?tabid197

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Doctors Prescription

• All health-based funding programs require a
  doctors prescription to support an SGD funding
  request
• The SLP report should be dated BEFORE the
  doctors report (Medicare requires this, but
  should be followed for all funding programs)
• There are no requirements for content, but the
  prescription should (1) acknowledge it is based
  on review of the SLP report and (2) include
  every item (device mount software accessory)
  the SLP recommends

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Special Eligibility Rules

• Look within eligibility for benefits
• E.g., age place of service restrictions
• Look within Coverage Policies
• E.g., dedicated speech generating devices
• Forever dedicated SGDs
• Look at Exclusions
• E.g., express exclusions
• E.g., convenience items

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Age or Place of Service Limits

• Some benefits are limited by recipient age e.g.,
  Medicaid EPSDT (only to 21st birthday) other
  optional services
• Some benefits are limited only to recipients with
  certain status e.g., Tricare, before Sept. 1,
  2005 SGDs were covered only for dependents of
  active duty personnel (new rules went into effect
  on 9/1/05)
• Some benefits are limited by where the recipient
  lives, e.g., Medicare DME is not a covered
  benefit for NF residents
• Some benefits are limited by enrollment in
  special services, e.g., Medicare DME is not a
  covered benefit for hospice recipients

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Medicaid Funding for SGDs in Nursing Facilities

• SGDs are covered for all NF Recipients
• Access issue is not coverage, but who pays?
• Some states allow NF residents to bill for SGDs
  as if they were living at home access is not a
  problem
• Other states insist that NF pay for SGDs as part
  of daily rate or per diem payment problem
  here
• Any NF resident denied an SGD after assessment
  and prescription can get the device upon appeal

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Dedicated Speech Generating Devices

• Medicare insists that computer and PDA based SGDs
  be dedicated some insurers do as well
• Dedicated means able to run only SGD software
  (not a meaningful limitation in practice devices
  can be unlocked after purchase for a small fee)
• Only NY Medicaid has made non-SGD functions and
  lock/unlock an issue

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Exclusions

• Insurance policies typically state many
  exclusions, but they must be express they must
  state clearly that specific type of device is
  excluded if not clear and precise, exclusion is
  not enforceable.
• E.g., convenience items
• E.g., educational or vocational purpose

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SGDs are not Convenience ItemsExercise

• Why Arent SGDs Convenience Items?
• -
• -
• -
• -
• -
• -

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SGDs are not Convenience Items

• Communication is vital human functional ability
• Communication is the functional ability that
  distinguishes humans from other species
• Communication impairments create life-death risks
• Does policy cover Speech Language Pathology
  services (does policy recognize that impairments
  to speech are conditions to be treated?)
• Recite all the other programs that fund SGDs

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Educational or Vocational Purpose Exercise

• Why do SGDs serve a medical and not a
  educational or vocational purpose?
• -
• -
• -
• -

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Educational or Vocational Purpose

• Compare other funding programs that recognize
  SGDs as medical devices, e.g., Medicare
  Medicaid FDA other insurers
• Use but for (solely because of) test not
  because of work or school needs SGD
• Stated as alternative to primarily and
  customarily serve a medical purpose
• Factually wrong Education less than 20 of day
  work less than one third hardly primarily
• Assessment and Services required by SLP
  prescription needed by doctor all medical, not
  educational professionals

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Express SGD Exclusions

• Insurers generally have the freedom to cover
  whatever they want.
• But, insurers dont have the same degree of
  freedom not to cover items or services.
• If an insurer claims SGDs are not covered because
  they are excluded, they can be challenged

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Is There An SGD Exclusion?

• Policy must state exclusion for SGDs, or SGDs
  must fit within a broader exclusion, e.g., items
  or services for individuals with developmental
  disabilities
• If no specifically worded exclusion, clearly
  mentioning SGDs or in which SGDs unquestionably
  fit, there is no exclusion, and a denial is
  merely the opinion of the reviewer, which is
  easily challenged.
• Exclusions are non-discretionary they dont
  require interpretations reviewers just apply the
  policy

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Express Exclusions Examples

• DME Exclusions Appliances, devices and
  equipment not covered by the plan include, but
  are not limited to speech devices .

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Express Exclusions Examples

• General Exclusions The Plan does not pay for
  benefits under the Plan for any expense related
  to
• Which results from (1) pervasive developmental
  disability (2) mental retardation (3) conduct
  disorders or (4) developmental disorders

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Express Exclusions Examples

• Computer story boards or light talkers for
  communication impaired individuals
• Federal Employee Health Benefits Program, 1997
• Computer equipment/devices such as story boards
  or other communication aids to assist
  communication impaired individuals
• Federal Employee Health Benefits Program, BCBS
  Policy, 2005

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Express Exclusions Fighting Back

• Almost every state has an insurance unfair
  discrimination Statute. They prohibit
• Making or permitting any unfair discrimination
  between individuals of the same class and of
  essentially the same hazard in the amount of
  premium, policy fees or rates charged for any
  accident or health insurance policy or in the
  benefits payable thereunder, or in any of the
  terms or conditions of such policy

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Express Exclusions Fighting Back

• Unfair Discrimination arises when there are no
  factual reasons or cost reasons to justify the
  exclusion of an item or service otherwise
  coverable by the policy.

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Costs of SGD Coverage

• There are no cost reasons to justify an SGD
  exclusion
• The nations leading health actuary consulting
  firm reported  
• Our analysis indicates that the incremental cost
  of covering Speech Generating Devices (SGDs) in a
  commercial population is quite small. We
  consider the cost to be de minimis relative to
  the cost of providing most types of care to
  commercial populations.

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Meaning of De Minimis

• Milliman stated to include SGDs in a commercial
  insurance policy or health benefits plan costs
  between trace (zero) to approximately 0.02
  per member (person insured) per month. (24 cents
  per person insured, per year).
• This represents less than 5/100,000ths of the
  cost of the 423.14 average monthly premium for
  an individual health insurance policy, or less
  than 0.005 (

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Express Exclusions Fighting Back

• Premera Blue Cross (Washington)
• Has SGD clinical criteria
• Covers SGDs as DME for all conditions except
  autism
• Asserts evidence for SGD use by individuals with
  autism is experimental

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Express Exclusions Fighting Back

• The available evidence in peer-reviewed
  professional literature does not scientifically
  establish SGDs are effective The published
  literature is not considered to present
  scientifically reliable evidence (1) there
  are no controlled research studies (2) almost
  all studies are either single-subject studies or
  consist of very small sample sizes, and are
  therefore anecdotal and (3) almost all studies
  have been documented only in school settings and
  therefore provide no data on outcomes in home and
  community settings. Accordingly, the use of such
  devices in the treatment of autistic disorders or
  other pervasive developmental disorders is
  considered investigative at this time.

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Express Exclusions Fighting Back

• Any service or supply that Premera Blue Cross
  determines is experimental or investigational on
  the date its furnished, . . . Our determination
  is based on the criteria stated in the definition
  of experimental/ investigational services.
•  
• If we determine that a service is experimental or
  investigational, and therefore not covered, you
  may appeal our decision.

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Express Exclusions Fighting Back

• Experimental or investigational services include
  a treatment, procedure, equipment, drug, drug
  usage, medical device or supply that meets one or
  more of the following criteria as determined by
  us 
•         No reliable evidence demonstrates that
  the service is effective, in clinical diagnosis,
  evaluation, management or treatment of the
  condition
•         Evaluation of reliable evidence
  indicates that additional research is necessary
  before the service can be classified as equally
  or more effective than conventional therapies.
•  
• Reliable evidence includes but is not limited to
  reports and articles published in authoritative
  peer reviewed medical and scientific literature

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Express Exclusions Fighting Back Exercise

• Whats Wrong with the Exclusion?
• -
• -
• -
• -
• -
• -

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What Is My Role How Do SLPs Participate in SGD
Funding?

• SLPs Document Coverage Medical Need
• Health Based funding programs generally require 2
  SLP documents to support an SGD Funding Request
• SLP Report
• Doctors prescription
• Identifies Client Funding Sources

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If Denied Appeal

• All funding programs offer appeal opportunities
• Appeals should be considered in every denial
  circumstance
• Advocates should be sought in every circumstance

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SLP Funding Resources

• AAC-RERC
• SLP Assessment Protocol
• Medicare FAQ
• Telecommunications Equipment Distribution
  Programs
• Soon portal to funding information for all
  health based programs
• www.aac-rerc.com
• Augmentative Communication, Inc.
• Formal Request submitted to Medicare
• AMA, AAN, AAPMR letters supporting SGD
  effectiveness and medical need
• www.augcominc.com

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Advocacy Resources

• Assistive Technology Law Center
• 401 East State Street, Suite 300
• Ithaca, NY 14850
• 607-277-7286
• Lgolinker_at_aol.com
• www.aacfundinghelp.com
• Neighborhood Legal Services
• www.nls.org

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The day Will got his communication device was as
important as the day he was born one gave him
life on the other, he became a whole person.  
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DAAC Annual Conference

• Join Us in Atlanta
• FEB 9-11, 2007
• Evidence-Based decision making in AAC

Call for Posters Due 12/10 For Info Contact Dick
Lytton (rlytton_at_NEMOURS.ORG)