Delaware Medicaid's AAC Policy

VI. Augmentative & Alternative Communication Devices & Services

A. SCOPE OF COVERAGE

Augmentative and alternative communication (AAC) devices are defined as electronic or nonelectronic aids, devices, or systems that assist a Medicaid beneficiary to overcome or ameliorate (reduce to the maximum degree possible) the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities. Meaningful participation means effective and efficient communication of messages which takes into account the beneficiary's preferences. Examples of AAC devices include:

• communication boards or books
• electrolarynxes
• speech amplifiers
• electronic devices that produce speech and/or written output

AAC devices include devices that are constructed for use as communication devices as well as systems that may include a computer, when an important use of the computer will be as the beneficiary's communication device. AAC devices also include related components and accessories, including software programs, symbol sets, overlays, mounting devices, switches, cables and connectors, auditory, visual, and tactile output devices, and necessary supplies, such as rechargeable batteries.

AAC services are treatment to assist Medicaid beneficiaries in meeting the full range of their communication needs. AAC services are within the scope of practice of speech-language pathologists. The goal of AAC services will be accomplished by:

• developing and improving expressive communication and/or language comprehension skills and abilities that may be adversely affected by (for example) congenital or developmental disabilities
• maintaining and protecting beneficiaries' existing expressive communication and/or language comprehension skills and abilities from loss or deterioration due to (for example) progressive impairments and disabilities; and
• restoring beneficiaries' expressive communication and/or language comprehension skills and abilities damaged or lost due to (for example) diseases, disability, or traumatic injury.

The scope of AAC services includes diagnostic, screening, preventive, and corrective service provided by or under the direction of a speech-language pathologist. Specific activities include evaluation for recommendation of design, set-up, customization, and training related to the use of AAC devices.

Settings in Which AAC Services May be Provided

AAC services are covered under multiple Medicaid categories, including, but not limited to:

• an individual's home as part of home health services, which includes supplies, equipment, and appliances suitable for use in the home;
• inpatient hospital services;
• out-patient hospital services;
• nursing facility services; and
• intermediate care facilities for persons with mental retardation, developmental disabilities and related conditions.

Because all AAC devices are customized to overcome or ameliorate each beneficiary's communication limitations, and are for the sole and exclusive use of a single beneficiary, the cost of AAC devices for residents of nursing facilities and/or ICF/MR-DD facilities is not included in the facility's "per diem" or daily rate for that beneficiary.

Treatment Plan & Physician Endorsement of Medical Necessity Required

Assessment is necessary prior to the development of the treatment plan and physician endorsement. For detailed information, refer to Section B, Assessment, Data Reporting and Procedural Requirements.

A speech-language pathology treatment plan is required for all requests for DMAP funding for AAC devices and AAC services. Other health professionals, as appropriate, may participate in the development of the treatment plan. The treatment plan must be prepared by a speech-language pathologist who:

• has a Certificate of Clinical Competence from the American Speech-Language Association;
• has completed the equivalent educational requirements and work experience necessary for the certificate; or
• has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

A physician must document endorsement of such plan through either completion of a DMAP approved form or letter of medical necessity. For individuals enrolled in a managed care plan, the endorsing physician must be the primary care physician.

The AAC devices and AAC services must be an integral part of the treatment plan. The treatment plan must address each beneficiary's unique communication abilities and the expressive communication or receptive (language comprehension) limitations that preclude or interfere with meaningful participation in current and projected daily activities. It must

• conform to the scope of coverage stated in this policy;
• be based on the evaluation criteria and data reporting requirements stated in this policy;
• satisfy the medical need criteria stated in the policy, and
• indicate that the beneficiary has demonstrated potential to benefit from AAC devices
• and/or services at a basic and reasonable level.

Eligible Individuals

AAC services will be provided to beneficiaries with significant expressive communication or receptive (language comprehension) impairments: beneficiaries who currently lack adequate functional communication skills and abilities through gestures, speech and/or writing. These impairments include but are not limited to: apraxia of speech, dysarthria, and cognitive communication disabilities.

Trial Use Periods for AAC Devices

A trial use period for AAC devices is not required but may be recommended by the speech-language pathologist who conducts the AAC evaluation as described in section C, Review Criteria of this policy. The results of trial use periods are often instructive in determining the most appropriate AAC intervention, and thus are preferred. If the results of the assessment are clinically inconclusive, Medicaid may require a trial use period.

Medicaid authorization for rental of AAC device(s) will be approved for trial-use periods when the speech-language pathologist prepares a request consistent with the requirements as described in the Trial Use Period Request section of this policy. The reasons for a trial use period request include, but are not limited to: the characteristics of the beneficiary's communication limitations; lack of familiarity with a specific AAC device; and concern that the beneficiary has not had sufficient experience with the requested device to permit determination of the device's appropriateness.

Trial Use Period Request

If a speech-language pathologist or Medicaid seeks a trial use period, a plan for this period must be developed by the speech-language pathologist that includes:

• the duration of the trial period;
• description of the speech-language pathologist's qualifications that satisfy Medicaid's provider participation requirements defined in this policy;
• description of the speech-language pathologist's AAC services training and experience (and the AAC services experience of all other professionals, as appropriate) involved in the assessments of the beneficiary's functioning and communication limitations;
• beneficiary identifying information, such as name, Medical Assistance ID#, date of the assessment, medical diagnosis (primary, secondary, tertiary), and significant medical history;
• the AAC device(s) to be examined during the trial period, including all the necessary components (e.g, mounting device, software, switches or access control mechanism);
• description of the AAC devices assessment components, such as vocabulary requirements, representational system(s), display organization and features, rate enhancement techniques, message characteristics, speech synthesis, printed output, display characteristics, feedback, auditory and visual output, access techniques and strategies, and portability and durability concerns, if any.
• the identification of the service provider(s), e.g., speech-language pathologists, educators, residential providers, etc. who will assist the beneficiary in learning and using the AAC device(s) during the trial period;
• the identification of the AAC service provider(s) who will assess the trial period; and
• the data collection schedule and the evaluation criteria, specific to the beneficiary, that will be used to determine the success or failure of the trial period.

Trial use period proposals must request Medicaid funding for rental of, or otherwise state the source of all necessary components of, the AAC devices, including AAC services provider(s) who will assist the beneficiary during the trial use period.

Trial periods may be extended and/or different AAC devices provided, when requested by the speech-language pathologist responsible for evaluating the trial use period.

Trial Use Period Results

Results of trial use periods must be submitted with a prior approval request. The results must include the following:

• identification of the requested AAC devices including all required components, accessories, peripheral devices, supplies, and the device vendor,
• identification of the beneficiary's and communications partner's AAC devices preference, if any,
• justification stating why the recommended AAC device (including description of the significant characteristics and features) is better able to overcome or ameliorate the communicate limitations mat preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities, as compared to the other AAC devices considered; and
• justification stating why the recommended AAC device (including description of the significant characteristics and features) is the least costly, equally effective alternative form of treatment to overcome or ameliorate the communication limitations that preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities.

Purchase or Rental

The speech-language pathologist is required to estimate whether it is more cost effective to rent or purchase the requested AAC device. In addition to price, material factors in determining cost effectiveness include availability, expected useful life, upgradabilty, and warranty availability and terms. The determination to rent or purchase will be based upon cost effectiveness and must also take into account the comparative delay in providing the device to the beneficiary. No AAC device will be denied approval solely because it is not available for rental.

AAC devices purchased by the Medicaid program become the property of the beneficiary.

Repair and Replacement

AAC Device(s) Repair

Medicaid will pay for repair to keep AAC device(s), accessories and other system components ("devices") in working condition. Repair will be covered for the anticipated useful lifetime of the device(s), and for as long thereafter as the device(s) continue to be the appropriate treatment for the beneficiary. Medicaid payment for repair will include diagnostic testing of the device, parts, labor and shipping, when not otherwise available without charge pursuant to a manufacturer's warranty.

Medicaid AAC device repair will be subject to the following procedure:

• When a device ceases to function properly, the beneficiary, a person acting on behalf of a beneficiary, or Medicaid staff will notify the device manufacturer or the manufacturer's designee for the purpose of repair, and follow the manufacturer's or designee's instructions to send the device for assessment
• When a device is received by the manufacturer or manufacturer's designee for the purpose of repair, the manufacturer or designee will conduct an assessment of the device to determine whether it can be repaired, and if so, prepare a written estimate of the diagnostics, parts, labor, shipping, and total cost of the repair, as well as the effectiveness (i.e., estimated durability) of the repair.

If Medicaid was the original payment source for the device, the manufacturer or manufacturer's designee for the purpose of repair will:

• repair the device if the total cost of the repair is less than or equal to $300.00; or
• notify the beneficiary or the person acting on the beneficiary's behalf that the total cost of the (non-battery) repair, including shipping, will be greater than $300.00, and that prior approval must first be obtained before the repair can proceed.

When the repair is completed, the manufacturer or representative for the purpose of repair will return the repaired device to the beneficiary.

If Medicaid was not the original payment source for the device, the manufacturer or manufacturer's designee for the purpose of repair will notify the beneficiary or the person acting on the beneficiary's behalf of the repair cost and that prior approval must first be obtained before the repair can proceed.

If the manufacturer or manufacturer's designee for repair concludes the device is not able to be repaired, written notice will be provided to the beneficiary or person acting on the beneficiary's behalf that prior approval must be sought to replace the device.

Procedure for Repair or Replacement of AAC Device Batteries

If the assessment conducted by the manufacturer or manufacturer's designee for repair identifies the device battery as the malfunctioning or non-functioning part, the following procedure will be followed;

• repair of the battery will occur independent of the $300.00 period approval threshold; and
• independent of whether Medicaid was the original payment source for the device, or replacement of the battery will occur without the need of prior approval.

Repair or replacement of an AAC device battery will be performed, and the device returned to the beneficiary, or person acting on the beneficiary's behalf, as soon as possible.

Rental of AAC Device During Assessment Repair and/or Replacement Period

When the manufacturer or manufacturer's designee receives notification from the beneficiary or a person acting on the beneficiary's behalf that an AAC device is malfunctioning or nonfunctioning, and is being returned for assessment, the manufacturer is authorized to provide the beneficiary, on a rental basis, an AAC device during the assessment, repair and/or replacement period. The rental period is authorized to continue without regard to the need for prior approval for the repair and/or replacement of the beneficiary's AAC device. Rental of an AAC device during the assessment repair and/or replacement period is not limited to devices for which Medicaid was the original payment source.

AAC Device Repairs Greater Than $300.00 and AAC Device Replacement

Requests for prior approval for AAC device repairs greater than $300.00 and for AAC device replacements must be accompanied by the following information:

• description of the speech-language pathologist's AAC services training and experience (and the AAC services experience of all other professionals, as appropriate) involved in the assessments of the beneficiary's functioning and communication limitations; and
• beneficiary identifying information, such as name, Medical Assistance ID#, date of the assessment medical diagnosis (primary, secondary, tertiary), and significant medical history.

The speech-language pathologist also must report whether there have been any significant changes in any of the subject areas identified in the Required Assessment & Data Reporting section of this policy. The information must include the items specifically listed in the Sensory Status, Postural, Mobility & Motor Status, Current Speed, Language & Expressive Communication Status, Communication Needs Inventory, Summary of Communication Limitations, AAC Devices Assessment Components, and the Treatment Plan and FoIlow-Up sections and whether the device remains the speech-language pathologist's recommendation for beneficiary's use.

AAC Devices Replacement or Modification

Modification or replacement of AC devices will be covered by Medicaid subject to the following limitations:

• All modification or replacement requests will require prior approval;
• Prior approval request for replacement AAC devices may be submitted for identical or different devices;
• Requests for prior approval for replacement of identical AAC devices must explain how replacement is more cost-effective than repair of current device(s). Data must be provided about age, repair history (frequency, duration and cost), and repair projections (estimated durability of repairs).
• Requests for prior approval for modification or replacement of AAC devices with different devices due to changed circumstances may be submitted at any time and must include the following additional information:
  1. a significant change has occurred in the beneficiary's expressive communication impairments and/or receptive communication limitations. Modification or replacement requests due to changed individual circumstance must be supported by a new assessment of communication limitations; or
  2. although there has been no significant change in the beneficiary's communication limitations, there has been a significant change in the characteristics, features or abilities of available AAC devices (i.e., a technological change) that will overcome or permit a significant further amelioration of the beneficiary's communication limitations as compared to the current AAC device. A detailed description of all AAC device changes and the purpose of the changes must be provided. In assessing such requests, Medicaid will place particular emphasis on whether the existing device reasonably achieves its purpose.
• requests for prior approval for replacement of AAC devices due to loss or damage (either for identical devices or different devices) must include additional information including a complete explanation of the cause of the loss or damage, and a plan to prevent the recurrence of the loss or damage.

B. ASSESSMENT, DATA REPORTING AND PROCEDURAL REQUIREMENTS

Role Of The Speech-Language Pathologist

An assessment of individual functioning and communication limitations that preclude or interfere with meaningful participation in current and projected daily activities is required for Medicaid funding for AAC devices and AAC services. The assessment must provide the information detailed in the Required Assessment & Data Reporting section of this chapter. It must be completed by a speech-language pathologist (with input from other health professionals, e.g., occupational therapists and rehabilitation engineers).

Prior Approval

All requests for AAC device(s):

• require prior approval;
• require physician endorsement consistent with the definition of AAC as discussed in section A, Scope of Coverage;
• must include a sign-off by the beneficiary, guardian or similar representative as well as the vendor, and
• repairs that are greater than $300.00, and requests for modification or replacement of AAC devices require prior approval.

Required Assessment & Data Reporting

The following data are required to be submitted in support of a prior approval request for AAC devices:

Speech-Language Pathologist Identifying Information

• Description of the speech-language pathologist's qualifications that satisfy the requirements of this policy.
• Description of the speech-language pathologist's AAC services training and experience (and the AAC services experience of all other professionals, as appropriate) involved in the assessments of the beneficiary's functioning and communication limitations.

Beneficiary Information

1. Identifying Information:
   • Name
   • Medical Assistance ID number
   • Date of the Assessment
   • Medical diagnosis (primary, secondary, tertiary)
   • Significant medical history
     
2. Sensory Status:
   • Vision
   • Hearing
   • Description of how vision, hearing, tactile and/or receptive communication impairments or disabilities affect expressive communication
     
3. Postural, Mobility & Motor Status:
   • Motor status
   • Optimal positioning
   • Integration of mobility with AAC devices
   • Beneficiary's access methods (and options) for AAC devices
     
4. Current Speech, Language & Expressive Communication Status
   • Identification and description of the beneficiary's expressive or receptive (language comprehension) communication impairment diagnosis
   • Speech skills and prognosis
   • Language skills and prognosis
   • Communication behaviors and interaction skills (i.e., styples and patterns)
   • Indication of past treatment, if any
   • Description of current communication strategies, including use of an AAC device, if any
     
5. Communication Needs Inventory
   • Description of beneficiary's current and projected (e.g., within 2 years) communication needs
   • Communication partners and tasks including partners' communication abilities limitations, if any
   • Communication environments and constraints which affect AAC device selection and/or features (e.g., verbal and/or visual output and/or feedback; distance communication needs)
     
6. Summary of Communication Limitations
   • Description of the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities (i.e., why the beneficiary's current communication skills and behaviors prevent meaningful participation in the beneficiary's current and projected daily activities)
     
7. AAC Devices Assessment Components
   • Vocabulary requirements
   • Representational system(s)
   • Display organization and features
   • Rate enhancement techniques
   • Message characteristics, speech synthesis, printed output display characteristics, feedback, auditory and visual output
   • Access techniques and strategies
   • Portability and durability concerns, if any
     
8. Identification of AAC Devices Considered for Beneficiary
   • Identification of the significant characteristics and features of the AAC devices considered for the beneficiary
   • Identification of the cost of the AAC devices considered for the beneficiary (including all required components, accessories, peripherals, and supplies, as appropriate)
     
9. AAC Device Recommendation
   • Identification of the requested AAC devices including all required components, accessories, peripheral devices, supplies, and the device vendor
   • Identification of the beneficiary's and communication partner's AAC devices preference, if any
   • Justification stating why the recommended AAC device (including description of the significant characteristics and features) is better able to overcome or ameliorate the communication limitations that preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities, as compared to the other AAC devices considered
   • Justification stating why the recommended AAC device (including description of the significant characteristics and features) is the least costly, equally effective alternative form of treatment to overcome or ameliorate the communication limitations that preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities
     
10. Treatment Plan & Follow Up
    • Description of short term communication goals
    • Description of long term communication goals
    • Assessment criteria to measure beneficiary's progress toward achieving short and long term communication goals
    • Description of amount, duration and scope of the AAC services required for the beneficiary to achieve short and long term communication goals
    • Schedule of data collection
    • Identification and experience of AAC services provider responsible for training (these services providers may include, e.g.: occupational therapists, rehabilitation engineers, the beneficiary's parents, teachers and other services providers)

C. REVIEW CRITERIA

Medicaid funding for AAC devices will be approved when the devices are established to be medically necessary and the least costly, equally effective, alternative form of treatment to overcome or ameliorate the communication limitations that preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities.

Medical Necessity

The medical need for AAC devices and services must be established by a speech-language pathologist (and other health professionals, as appropriate) according to the evaluation and data reporting criteria stated in section B, Required Assessment and Data Reporting, and be supported by a physician's completion of a DSS-approved form or letter of medical necessity.

In general, medical necessity is established when the requested device or service meets the criteria of the DSS-approved medical necessity standard. See Appendix H in the General Policy for the DSS-approved medical necessity standard.

Subject to these criteria, assessment of “medical necessity” for AAC devices and services will be guided by the following specific standards:

Medical Need Criteria for AAC Devices

Medical need will be established for beneficiaries:

• who have a diagnosis of a significant expressive or receptive (language comprehension) communication impairment or disability;
• whose impairment or disability either temporarily or permanently causes communication limitations that preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities;
• who have had a speech-language pathologist (and other health professionals, as appropriate) who:
  1. perform an assessment and submit a report pursuant to the criteria set forth in section B, Required Assessment and Data Reporting;
  2. recommend speech-language pathology treatment in the form of AAC devices and AAC services; and
  3. prepare a speech-language pathology treatment plan that describes the specific components of the AAC devices and the required amount, duration and scope of the AAC services that will overcome or ameliorate communication limitations that preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities.
• whose requested AAC devices and AAC services constitute the least costly, equally effective form of treatment that will overcome or ameliorate communication limitations that preclude or interfere with the beneficiary's meaningful participation in current and projected daily activities.

General Principles Governing Medical Need Determination

• The cause of the beneficiary's impairment or disability (e.g., congenital, developmental, or acquired) or the beneficiary's age at the onset of the impairment or disability may be relevant considerations in the determination of medical need.
• Whether a beneficiary's daily activities, communication partners and communication environments are related to or intersect with other benefits and/or services programs (e.g., school, early intervention services, adult services programs, employment) does not preclude a determination that the beneficiary has a medical need for AAC devices and AAC services.
• No cognitive, language, literacy, prior treatment, or other similar pre-requisites must be satisfied by a beneficiary in advance of a request for AAC devices and AAC services.
• The unavailability of an AAC device, component or accessory for rental will not serve as the basis for denying a prior approval request for that device, component or accessory. The prior approval request must document the manner in which a comparable device may be substituted for assessment purposes in the event that a trial period is required.
• The unavailability of a warranty for an AAC device or other component or accessory will not serve as the basis for denying a prior approval request for that device, component or accessory, although Medicaid encourages providers to consider the availability of a reasonable warranty as a factor within the device selection process.

Additional Information Needed - Request for Peer Review

• When the medical need for an AAC device cannot be established pursuant to the criteria stated in the Medical Need Criteria for AAC Devices in this section, based on the information submitted in support of a prior approval request, Medicaid will determine and take the following steps:
  1. if information required by the Medical Need Criteria for AAC Devices in this section is not included in the prior approval request, then Medicaid will make contact directly with the speech-language pathologist who conducted the assessment for the beneficiary, identify the specific additional information that is needed, and request that the additional information be submitted; and/or
  2. if an interpretation is required of information in the prior approval request. Then Medicaid will seek the advice of speech-language pathologist(s) with extensive AAC experience recommended to Medicaid by the American Speech-Language & Hearing Association (ASHA), the United States Society for Augmentative & Alternative Communication (USSAAC) and/or RESNA, who will provide the required information
• Requested additional information and/or interpretations must be produced as soon as practicable but in no event more than 21 working days from the date of the request
• Requests for additional information and/or requests for interpretations of information submitted will be made prior to issuance of any denial of a prior approval request

Time Limits and Notice for Decision Making

• Review of prior approval request required by the Medical Need Criteria for AAC Devices in this section will be completed within a reasonable amount of time (in most cases no longer than 60 days). If review has not been completed within 45 days, the beneficiary, guardian, or similar representative will be notified of the status of the pending application.
• Requests for additional information and/or request for interpretations will be made as soon as the need is identified.
• Decisions on prior approval requests that are not timely issued may entitle the beneficiary to pursue an appeal.
• Written notice of decisions to deny prior approval or to approve a funding request with or without modifications will be provided directly to the beneficiary and vendor. Written notice will be provided to other persons, as appropriate.

D. GLOSSARY

Augmentative and Alternative Communication (AAC)

AAC approaches support, enhance, or augment the communication of individuals who are not independent communicators in all situations. An individual's AAC system should not be a single technique, device, or strategy, but rather an array of techniques, devices and strategies from which the individual chooses in order to effectively address the demands of a given communication opportunity.

AAC Devices

Electronic or non-electronic aids, devices or systems that assist a beneficiary to overcome or ameliorate (to the maximum degree possible) the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities. Examples of AAC devices include: communication boards or books, electrolarynxes, speech amplifiers, and electronic devices that produce speech and/or written output AAC devices include devices that are constructed for use as communication devices as well as systems that may include a computer, when an important use of the computer will be as the beneficiary's communication device. AAC devices also include related components and accessories, including software program, symbol sets, overlays, mounting devices, switches, cables and connectors, auditory, visual, and tactile output devices, and necessary supplies, such as rechargeable batteries.

AAC Services

Treatment to assist beneficiaries in meeting the full range of their communication needs. The scope of AAC services includes diagnostic, screening, preventive, and corrective services provided by or under the direction of a speech-language pathologist. Specific activities include evaluation for, recommendation of, design, set-up, customization, programming, and training related to the use of AAC devices.

Beneficiary's Preferences

The means and mode of message transmission a beneficiary prefers to use in a given communication interaction.

Current and Protected Daily Activities

The activities of daily living in which the individual now participates and in which it is anticipated the individual will participate when the individual's communication limitations have been overcome or ameliorated via the application of AAC approaches.

Expressive Communication Limitations

Difficulties in language production via any expressive communication modality (speech, writing, sign language, gesture, facial expression, graphic symbol selection).

Meaningful Participation

Effective and efficient communication of messages, taking into account the beneficiary's preferences regarding means and mode of transmission.

Receptive Communication Limitations

Difficulties in language understanding via any communication modality (speech, writing, sign language, gesture, facial expression, graphic symbol selection).