finding the funds for aac
TRANSCRIPT
Finding the Funds
October, 2017
Kim Singleton, MS, CCC-SLP
Director of Assistive Technology Programs
@ the Institute on Disabilities
@ Temple University
An introduction to funding Augmentative
and Alternative Communication (AAC)
Pennsylvania’s Initiative on Assistive Technology (PIAT)
• The Commonwealth’s “AT Act” Program; a national and statewide
network
• Charged with:
• ACCESS: activities designed to help people of all ages make a decision about
if/what AT can help through (1) demonstration and (2) device lending
• ACQUISITION: activities designed to help people obtain the AT they need
through (1) reuse and (2) “state financing”
How much does AAC cost?
From $0 to…$1000...$5,000…$10,000...$15,000
Why Should SLPs Care?
• “Billing” may be a job function
(Medicare; Medicaid [ACCESS] in
the schools)
• SLP’s role as an advocate for
children and families, to obtain AT
“from the system”
• People with disabilities/families
can’t afford high cost AAC
devices on their own
• SLP’s role to help people with
disabilities/families make
informed decisions
• Knowledge about funding informs
SLPs about requirements for
assessment , treatment, and
reporting
ASHA Code of Ethics (2016)
• 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 and/or inter-professional
collaboration when appropriate, to
ensure that quality service is
provided.
• Rule of Ethics [E] Individuals shall
not delegate tasks that require the
unique skills, knowledge, judgment,
or credentials that are within the
scope of their profession.
Public Funding Sources
• Public education (special
education)
• Medicaid
• Vocational Rehabilitation
• Medicare
• Private Sources
• Private insurance
• Private foundations, charitable
organizations
• Loans (e.g. PA AT Foundation;
www.patf.us)
• Sources of used equipment
(REEP; eBay; Craig’s List and
more; www.reepnetworkpa.org)
Getting Ready to Request $$
• Know what is NEEDED
• Identify potential funding sources
• Know how what is recommended fits or
meets the mandates and restrictions of
the possible funding source(s)
• For public sources: Understand whether
the funding source is an ENTITLEMENT or
an ELIGIBILITY programs
• If you are denied:
• Ask/identify the reason for the denial.
• BE PREPARED TO APPEAL!
School
IDEA definition of AT includes aided
AAC (low to high tech), as well as
needed SERVICES in child’s IEP
Special Factors
• positive behavioral interventions
• language needs of a child with LEP
• Braille instruction as appropriate
• communication needs of a child who
is deaf/hard of hearing
consider whether the child needs
[requires] assistive technology
devices and services
Early Intervention
• Early intervention 0-2; in PA administered through DHS, Office for Child Development and Early
Learning
• Includes assistive technology as a named service
• Use of AAC must be in the IFSP and linked to outcomes
• Permits access to sources of funding (e.g. insurance) for AT devices and services listed in the IFSP
(differs from the “FAPE” standard)
• State funds are “last resort”, no infant/toddler may go without IFSP listed services because of
inability to pay
Medicaid
• Authorized by Title XIX of the Social Security Act
• A health insurance program for POOR PEOPLE (income and assets)
• Regulations are complicated and are continually revised
• 30% of costs in the PA General Fund
• In PA, “MA”, Medical Assistance” or “ACCESS”…or HealthChoices…or
“School Based Access Program”
Medical Assistance (MA) A Federal/State program
• Shared costs (formula based on average
income in the state) [PA approx. 52%FMAP
(2017); 2.6 million recipients (2015)]
• State must follow federal rules, and file a
“state plan”
• Some flexibility left to states regarding
eligibility, co-pays, scope of and limitation
on services, how program will be
administered
• Menu of both required (“mandatory”) and
optional services
Social Security (SSI) Definition (Title XVI)
• A child is disabled if s/he has a medically determinable
physical or mental impairment or combination of
impairments that causes marked and severe functional
limitations and that can be expected to cause death or
has lasted or can be expected to last for a continuous
period of less than 12 months.
• Marked limitations in two domains or extreme
limitation in one domain. Domains include:
• acquiring and using information
• attending and completing tasks
• interacting and relating with others
• moving about and manipulating objects
• self-care
• health and physical well-being
AAC and Medicaid (PA)
• AAC devices (“speech generating devices” or SGD) considered
durable medical equipment (DME) (medical in nature; not typically
useful in absence of disease; not used for educational purposes; not
used for the convenience of others)
• Not all SGDs will qualify as DME
• AAC devices (“speech generating devices” or SGDs) can be
considered Durable medical equipment (DME)
Medicaid Managed Care
• Almost all MA in PA is now delivered in a managed care model
• The “plans” (HMO/MCO) have “Special Needs Units” that may help
• The plan uses “in-network” providers
• The network must be sufficient (e.g. does the SLP in the network have
expertise in AAC?)
Waiver Programs
• “medical and non-medical services designed to
help persons with disabilities and older
Pennsylvanians live independently in their homes
and communities”
• States may “waive” certain requirements to
carve out special programs (PA has more than a
dozen waivers, e.g. BAS; CommCare;
Consolidated; etc.)
• Good news: Allows states to provide services,
not otherwise furnished, to a specific population
within the state
• Bad news: Results in a fragmented system
Waivers
• Autism waiver
• Consolidated waiver
• Person/family directed supports
waiver
• Also: Independence waiver, others…
• Resource
• http://www.phlp.org/wp-
content/uploads/2012/08/HCBS-
Waivers-BasicFactSheet-
2012.pdf
Getting SGDs through Medicaid
• Person must be a MA beneficiary
• SGD must be a covered service (generally, DME)
• SGD must be medically necessary
• SGD cannot be “experimental”
• Need a procedure code, but children under age 21 are not limited to what is on the fee schedule and
adult can request program exception
• Vendor must be an approved MA vendor or in the managed care company’s network, but exceptions
can be requested
• Repairs are covered
• Replacement allowed every 3 years but can request program exception if change in medical need
PA Medical Necessity
• The service or benefit will…
• Prevent the onset of an illness,
condition, or disability
• Reduce or ameliorate the
physical, mental, or
developmental effects of an
illness, condition, or disability
• Assist the individual to achieve
or maintain maximum functional
capacity in performing daily
activities, taking into account
both the functional capacity of
the individual and those
functional capacities that are
appropriate for individuals of
the same age
Meet the criteria “Medically necessary”
• DOCUMENT medical necessity
including the following components:
• consumer’s medical condition or
disability
• the functional limitation caused by
that condition or disability
• how the device assists in
compensating for that functional
limitation, e.g. “reduce” or
“ameliorate” the physical, mental, or
developmental limitation
• OR ”maintain existing function”
which would otherwise deteriorate
• Is the item commonly accepted by the medical or
rehabilitation community for the purpose for
which it has been described? (evidence based
practice)
• Is there some published study as to the
effectiveness of the item in addressing the
functional limitation for which it has been
prescribed?
Meet the criteria “Not experimental”
Also…
• Address less expensive (or more expensive) alternatives that were
tried, and why they were not appropriate or adequate.
• Document the consumer’s ability to use the requested AT:
• (1) the environment can support the use
• (2) the individual has the capacity to use (especially for individuals
with cognitive disabilities)
• (3) training will be provided to assure use
Getting SGDs thru Medicaid continued…
• Include a prescription from the doctor.
Draft or suggest language for the
physician to use in the letter of
medical necessity
Advantages to MA Funding (for children)
• Child “owns” device
• Eliminates issues of taking the
equipment home
• Repairs may be covered
• Replacement allowed every 3
years or when substantial
change in medical need
• May facilitate transition (e.g.
no ownership issues)
• Note: When kids are eligible for
services through school and MA,
neither system is permitted to
turn the child down because
they are eligible under the other
For Funding thru PA MA HealthChoices
1. Client's age
2. Client's diagnosis
3. Client's doctor’s prescription for the SGD
4. Client's speech evaluation
5. Results of trial of other assistive device(s)
6. Documentation of visual-motor skill and auditory
comprehension
7. Documentation of ability to use device
independently
8. Documentation of treatment plan
9. Vendor name, provider number
10. Estimated pricing
11. Letter of Medical Necessity from physician
Medicaid and Nursing Facilities
• Nursing facilities must provide for all needs
through their “per diem” Medicaid rate
• In PA, nursing facilities may apply to DPW for
additional Medicaid funds to offset the cost of
expensive SGDs (cost greater than $5000)
• However, facilities must provide all medically
necessary devices and equipment regardless of
cost and additional funding received
• The SGD must go with the person if s/he leaves the
nursing facility
• www.drnpa.org/publications/toolkits/nursing-
facility-advocate-toolkit/
Challenges with Medicaid
• “Preferred providers” or “selective contracting”, “in-network”
Managed Care models (devices and services)
• Fee schedules
• Required trials when lending programs have long waiting lists (or
don’t have the item)
• Threats: co-pays; reductions in frequency/duration of service;
eligibility changes (including elimination of the “loophole”)
Office of Vocational Rehabilitation
Purpose
• To empower individuals [with
disabilities] to maximize employability,
economic self-sufficiency,
independence and integration into the
workplace and community through
“comprehensive and coordinated state
of the art programs”
Eligibility
• You have a disability (physical,
mental, emotional impairment) that
results in substantial impediment to
employment
• You can benefit in terms of an
employment outcome from services
provided
• Vocational rehabilitation services are
necessary for you to prepare for, enter
in, or retain gainful employment
Evaluation/Extended Eval (OVR)
• Put it in the plan (Individualized Plan for
Employment [IPE])
• Specify devices and services
• Need in job development
• Worksite accommodations
• OVR has no obligation to provide AT for
students in transition
• There may be a cost-share
• “Most Severely Disabled” receive priority
• There may be waiting lists for funding
• Note: help with denials may be available
from the Client Assistance Program
Medicare
• Federal health insurance benefits program
• Created by Congress in 1965 (operational in 1966)
• Sometimes called Title XVIII (for the chapter of the Social
Security Act in which the program is codified)
• www.medicare.gov/publications
Purpose of Medicare
• Reduce out-of-pocket expenses for those who qualify
• Offers basic protection against the cost of health care, but does not cover all expenses
• Medicare Eligibility
• NOT income-based
• Must have paid into social security
• 65+ or
• Persons under 65 (as of 1972, including many adults with developmental disabilities who receive SSDI
on the earnings record of a parent) receiving SSDI for longer than 24 months (“waiting period”)
“Part B” Medicare
• Also known as supplemental medical insurance
• Out patient services, including physician services, DME, SLP, prosthetics, orthotics, home
health.
• Coordination of Benefits
• Medicare is secondary payer if you have other insurance with: auto; employer group
plans; VA; Workers Compensation; Public Health Service; Black Lung Program
• Medicare is PRIMARY payer if you also have Medical Assistance
• For MA recipients, MA may pay the Part B premium
What’s covered in Part B
• Services or supplies that are medically
necessary:
• Prosthetic devices
• Replace all or part of the function of a
permanently inoperative or
malfunctioning external body member or
internal body organ
• Artificial larynges vs SGD
• Durable Medical Equipment
• Can withstand repeated use (“durable”).
Note: Useful life of 5 years is assumed,
EXCEPT when there is a significant change
in beneficiary’s status
• Primarily and customarily used to serve a
medical purpose (more than a
convenience)
• Generally not useful to an individual in
the absence of illness or injury
• Appropriate for use in the home or
institution that is used as a home (NOT a
hospital or SNF, except for in some
prosthetics, orthotics, and supplies)[place
of service limitation]
The “Medicare Solution”
• Manufacturers developed “clones” in which
the “generic” functions were “disabled”,
”locked”, or “turned off”; the “disabled”
or “locked” features were available for
private purchase
• Steps to Procuring AAC through Medicare
• Is the item or service covered? For
example: evaluation is covered (SLP
service), device may be covered (DME),
training is covered (SLP service), repair is
covered (after expiration of warranty)
• Is the provider/vendor qualified as a
Medicare provider? (e.g. SLP AAC
evaluator?) NOTE: NO fiduciary relationship
between the vendor and the evaluator is
allowed!!!
• Is the beneficiary enrolled in “original”
Medicare or HMO or M+C plan? (may require
prior approval or specific forms/procedures)
• Does the vendor/manufacturer “accept
assignment”?
Private Insurance
• Costs
• premiums
• co-pays
• deductible
• More than 1000
different insurers have
paid for SGDs!
• Read Client's policy!
• Know the appeal
process!
• If denied, appeal!
A “contract” between you and the insurance company (or
between Client's employer “on Client's behalf”)
If what is needed is not a “named exclusion”, GO FOR IT!
Challenges in Private Insurance
• Where’s the evidence?
• Limitations on scope of coverage
• In-network limitations
• Delays in getting proof of denial or non-coverage necessary to
proceed with secondary insurances
Telecommunication Device Distribution Program
• Goal: Provide specialized telecommunications equipment free
of charge to eligible Pennsylvanians so they can access
telephone services
• Eligibility: Any disability; 6 years old; have the ability to learn
how to use the equipment; LOW INCOME
• Currently, AAC for TELECOMMUNICATION may be covered for
eligible individuals, through an exceptions process
Other Options
• Pennsylvania Assistive Technology
Foundation (PATF) – low interest cash LOANS
to individuals with disabilities,
http://www.patf.us
• Veterans’ Administration
• Champus; TriCare
• Civic Organizations
• Crowd Funding
For assistance in locating other resources for
funding AAC, contact PIAT at 800-204-7428 or
Resourceswww.aacfundinghelp.com - Website of the AT Law
Center (Lew Golinker); comprehensive information re:
insurance; Medicare; FAQs
http://aac-rerc.psu.edu/index.php/pages/show/id/5–
everything you need to know about Medicare coverage
and funding for SGDs
www.drnpa.org – check out key AT publications,
including AAC for ICF/MR residents; AAC for nursing
home residents; MA appeals
Patientprovidercommunication.org – updates on
Medicare changes
http://www.disability-benefits-help.org/faq/medicare-
vs-medicaid
www.nls.org – the website of Neighborhood Legal
Services of NY and the home of the National AT
Advocacy Project; publications address vocational
rehabilitation, special education, Medicaid, and more
www.asha.org – ASHA has general information about
coverage for services under Medicare and Medicaid
http://disabilities.temple.edu/programs/assistive/fac/
Archived webinars (2013-14) on the basics of
Medicaid managed care as well as one (2016) on
obtaining SGDs in Medicaid-funded Nursing Facilities.
Several AAC manufacturers have funding departments
and may have report writing “tools” or forms on line.
Be sure to customize these if you are using them!
“Take Away” Messages
• There are many potential
sources for funding AAC
devices and services
• It is YOUR responsibility to
help see your
recommendations carried
through (e.g. funding
obtained)
• There are resources to help
you/your client through the
funding process
• APPEAL, APPEAL, APPEAL
• Availability of funding is
dynamic; ongoing vigilance
and advocacy are needed
to retain public coverages