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Health Benefits Program Funding of Speech Generating Devices

Lewis Golinker, Esq.DirectorAssistive Technology Law Center401 East State Street, Suite 300Ithaca, New York 14850607-277-7286 (v)Lgolinker@aol.com (e-mail)

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Scope of Presentation5 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 PathologistsStudents in Speech-Language PathologyTeachers & School AdministratorsFamily MembersAdvocates

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Why Is Funding Important? Families can’t buy SGDs on their ownKnowledge about funding options allows proper assessment & treatment planningKnowledge about funding creates expectations about the outcomes clients can achieve through SLP interventionKnowledge 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 programsCover “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– Parkinson’s 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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EligibilityNo Universal Health Benefit Medicaid: poor, disabledMedicare: 65 or older

< 65: prior work + disability +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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CoverageNo Universal Benefits – item sought -- SGD --must “fit” within one or more covered benefits categoriesDME – most common “equipment” benefitProsthetic DevicesMedicaid: also consider: EPSDT; OT/PT/SLP Services; ICF/MR; NF Services

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CoverageDoes 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 EquipmentIf no coverage policy, must show item or service “fits” definition of DMENo universal definitionMost 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 controversialKey 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 beprimarily and customarily used to serve a medical purpose?-----

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Medical Purpose: SGDsMedical purpose = treatment for a condition or disabilityThis is the most common excuse to deny SGDsSGDs “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: SGDsProof: information exists about specific conditions:– CP; Autism; ALS

Proof: Functional Gap – Receptive Language vs. Expressive LanguageProof: Communication related anger, frustration; depression;self-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

HandsOther body Part

SGD

> Brain formulates a thought> Codes thought for language> Codes MotorInstructions

speech

speech

Speech organs

Nerves transmit instructions

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Medical Purpose: SGDsMedical 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 atwww.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 fastSpeech is faster and more flexible than any other method of communicationSLP 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 DevicesSGDs are Prosthetic Devices:– Tricare – by statute (only federal statute that mentions

SGDs as covered benefits)– Dept. of Veterans Affairs

No universal definitionMedicaid: “means replacement, corrective or supportive devices … to:1 artificially replace a missing portion of the body2 prevent or correct physical deformity or malfunction; or3 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: SGDsNo Universal DefinitionNY Medicaid: – "Medical assistance" shall mean payment

of part or all of the cost of medicallynecessary 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 person`s capacity for normal activity, or threaten some significant handicap ….

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Medical Need: SGDsMedicare: “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 person’s 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 activitiesMedical 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 (what’s 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.com/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/MCAppProtocol.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 Medicare’s 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 Medicare’s or Medicaid’s 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?tabid=197

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Doctor’s PrescriptionAll health-based funding programs require a doctor’s prescription to support an SGD funding requestThe SLP report should be dated BEFORE the doctor’s 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 RulesLook 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 LimitsSome benefits are limited by recipient age: e.g., Medicaid – EPSDT (only to 21st birthday); other “optional” servicesSome 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 residentsSome 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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ExclusionsInsurance – 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 Items:”Exercise

Why Aren’t SGDs Convenience Items?------

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SGDs are not “Convenience Items”

Communication is “vital” human functional abilityCommunication is the functional ability that distinguishes humans from other speciesCommunication impairments create life-death risksDoes 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 insurersUse “but for” (solely because of) test: not because of work or school needs SGDStated 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 don’t 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 don’t 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 nation’s 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 (< 5/1,000th s) percent.

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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 it’s 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

What’s 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 •Doctor’s prescription

Identifies Client Funding Sources

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If Denied: AppealAll funding programs offer appeal opportunitiesAppeals should be considered in every denial circumstanceAdvocates should be sought in every circumstance

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SLP Funding ResourcesAAC-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@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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