Below is a court ruling on medicare approval of augmentative communication devices.

The bulk of this material is a draft copy of the policy proposed by Florida Medicaid.

This is awareness information for evaluators.

An Important Court Decision About Which Every Speech/Language Pathologist and Augmentative Communication Specialist Should Be Aware

On October 24, 1996, the U.S. District Court for the Southern District of Florida issued a fully favorable decision in Hunter v. Chiles.

Hunter v. Chiles rejects Florida Medicaid's refusal to cover or provide AAC devices to children or adults.

The Court held those exclusions to be unlawful. Florida children and adult Medicaid recipients will now be able to acquire the AAC devices they need to treat their severe expressive communication disabilities.

The Hunter Court case expressly recognized communication is vital, and no rational basis exists to make age based coverage distinctions between children and adults.

The Hunter Court case also made important findings related to the relationship between Medicaid and other public benefits programs for children and adults with disabilities, namely, Maternal & Child Health programs, IDEA funded programs, and vocational rehabilitation. As to each of these programs, the Court noted that Medicaid cannot refuse to provide AAC devices based on the claim that any of these other programs is required to provide these devices. Hypothetical "payor of last resort" arguments are not excuses for Medicaid to deny payment for AAC devices.

The Hunter Court case also upheld the paramount importance of the treating doctor in making individual Medicaid treatment decisions. "The determination of medical necessity must rest with the individual recipient's physician and not with clerical personnel or government officials."

Plans are currently underway to begin funding for AAC devices for children only. Funding for AAC devices will probably begin in January of 1998.

The following is a draft copy of the policy proposed by Florida Medicaid.

Policy for Augmentative and Alternative Communications Systems

Augmentative and Alternative Communication Systems (AACs) are reimbursed through the Durable Medical Equipment/Medical Supplies (DME) program.

Assessments for the system, and ongoing training/therapy will be reimbursed through the Therapy Services program. For futher information about the speech therapy program consult the Therapy Services provider handbook.

Definitions

Augmentative and Alternative Communication Systems (AACs) are designed to allow individuals the capability to communicate. As defined by ASHA (American Speech-Language Hearing Association), an AAC attempts to compensate for the impairment and disability patterns of individuals with severe, expressive communication disorders, i.e., the severely speech-language and writing impaired.

Eligibility

In order to qualify for an AAC, a recipient must:

*be unable to communicate basic needs without the use of the AAC,

*have the physical, cognitive and language abilities necessary to use the AAC.

If a recipient is fully capable of sufficient written communication, a lower level AAC may be needed; however an AAC may not be denied based solely on the fact that the recipient can communicate in writing.

Coverage

For Medicaid reimbursement purposes an AAC includes:

*a device;

*the components, modifications and programming needed to custom fit the system to achieve an individual's specific speech-language goals;

*the accessories, modifications or construction to adapt the system to the physical characteristics and limitations of the recipient, and to the recipient's immediate surrounding (i.e. wheelchair).

Medicaid will provide one AAC once every five years and consider upgrades to software every two years. Modifications, which may be in the form of replacement of AAC or upgrades to the software, may be considered only if the new technology would improve communication significantly.

Medicaid will reimburse for replacement of devices, components or accessories when there is irreparable failure or damage not caused by willful abuse or neglect.

The Assessment Team

As part of the assessment package, Medicaid will require an assessment report from an interdisciplinary team (IDTeam) that must consist of the following members:

*speech-language pathologist,

*occupational therapist,

*any agency case manager assigned to the recipient

If the speech therapist deems necessary, the assistance of a physical therapist and/or social worker may be requested.

Role of the Speech-language Pathologist

The speech-language pathologist shall assess the capabilities of the recipient and document the following:

*the recipient's significant medical diagnosis(es);

*the recipient's significant treatment information and medications;

*the recipient's medical prognosis;

*language comprehension;

*expressive language capabilities;

*oral motor speech status;

*visual capabilities;

*the appropriate symbol set or system;

*the recipient's use of pragmatics in communication and assessment or communicative interest;

*communication needs including the need to enhance conversation, writing and signaling emergency, basic care and related needs;

*writing impairments; and,

*the client's environment.

The AAC is to be selected based on the recipient's current medical needs, and projected changes in the recipient's communication development over at least a three (3) year period.

A statement from the medical professionals is necessary to verify that they have no financial relationship nor will receive any other gain from the manufacturer.

Role of the Primary Care Physician

The treating physician shall: *review the professional evaluation findings and recommendations of the speech-language pathologist;

*prescribe the AAC recommended if she/he feels those recommendations follow a thorough and professional evaluation and are warranted.

Note: Florida Medicaid reserves the right to request an evaluation of the recipient from another physician, who is board certified as a neurologist, psychiatrist, or otolaryngologist. Also, Medicaid may request an evaluation of the recipient from an audiologist, optometrist or ophthalmologist.

Individualized Plan

The IDTeam members, headed by the speech-language pathologist, are responsible for developing the recipient's individualized plan which shall define:

*an explanation of any AAC currently being used or owned by the recipient either at home, work or school;

*the current use of the system(s) and limitations;

*the appropriate long and short-term therapy objectives;

*the most cost effective AAC;

*the recommended length of a trial period;

*all AACs that have been tried previously;

*the specific benefits of the recommended AAC over other possibilities;

*an established plan for mounting, repair and maintenance of the AAC;

*who is responsible to deliver and program the AAC to operate at the level recommended by the IDTeam;

*who will train the support staff, recipient and primary caregiver in the proper use and programming of the AAC.

Concurrence by School Personnel

If the recipient is in the public school system, the school shall:

*concur in writing with the recommended device;

*agree that the child's teacher and school therapist are knowledgeable of the use of the AAC; or

*will be trained regarding its use.

Trial Period for AACs

The trial period is an established evaluation period of time which allows the IDTeam the opportunity to evaluate the selection of the AAC for the recipient.

The IDTeam shall recommend a second trial period for a recipient when the IDTeam determines that the first system is not appropriate. If the IDTeam determines that there is no AAC that is appropriate for the recipient, then none will be recommended and second trial period is not required.

There can be as many trial periods as the IDTeam feels necessary, but only one AAC will be reimbursed during the trial period.

Rental only AACs

Rental only AACs are mandatory for trial periods. Rental only reimbursements can continue past the trial period when the IDTeam recommends and Medicaid approves a continued rental only situation.

Prior Authorization Requirements

The provider has the responsibility to submit the following information to the Medicaid fiscal agent when requesting prior authorization (PA) from Medicaid for reimbursement of an AAC:

* a completed Medicaid (PA) form;

*copy of the signed and dated prescription from the recipients attending physician , including his/her name address and telephone number and his/her identifying number (i.e., DPR or Medicaid provider number;

*a copy of the written assessment package completed by the IDTeam's speech-language pathologist;

*the name, address and telephone number of the licensed speech-language pathologist, and identifying number and who participated in the team evaluation and prepared the report;

*written concurrence from school personnel and itemized invoice listing actual costs for parts and labor, manufacturer's catalog information regarding cost and warranty information

Prior to billing foreign AAC system the provider is responsible to insure the properly selected system and all components have been delivered to the recipient and are operational in the recipient's home.

Medicaid Reimbursement

Medicaid's decision for coverage will be based on a medical rationale for the request of a particular system, and on a comparative analysis of equipment tested and the recipient's ability to use equipment as it relates to a medical need.

Limitations

The following is a list of items that are not covered by Medicaid as AACs and the list may not be all-inclusive: Televisions, telephones, VCR machines, systems designed to produce music, emergency and non-emergency alert systems, printers, facilitated communications (FC), experimental equipment, environmental equipment, training equipment or self help equipment, vision and hearing systems, furniture or other items which do not serve a medical purpose and equipment designed for use by a physician or trained medical personnel or AACs provided by schools.