Medicare

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• Accessing AAC Devices Through Medicare
  • AAC Device Purchase
  • Roles and Responsibilities of Team Members
  • More About the SLP’s Role
  • AAC Rental
  • AAC Device Repair
  • Procedures for AAC Repairs

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Accessing AAC Devices Through Medicare

AAC Device Purchase

The following chart outlines the process for obtaining AAC devices that are medically necessary under Medicare. The steps progress in a sequence from the time an AT need is identified to when the equipment is provided. This is a process that involves many team members. Their roles and responsibilities are outlined in the following chart.

Chart: Obtaining Speech Generating Devices - Medicare  PDF   |   Text

Medicare refers to augmentative communication devices as speech generating devices. A speech generating device must be medically necessary and must meet all the following criteria:

• Prior to receiving a speech generating device the patient must have a formal evaluation of cognitive and communication abilities by SLP. The formal elements of the evaluation must include, at a minimum, the following elements:
  • Current communication impairment, including type, severity, language skills, cognitive ability, and anticipated course of impairment;
  • Assessment of whether the individual's daily communication needs could be met using any other natural modes of communication;
  • Rationale for selection of a specific device and any accessories;
  • Demonstration that the patient possesses a treatment plan that includes a training schedule for the selected device;
  • The cognitive and physical abilities to effectively use the selected device and any accessories to communicate;
  • For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the patient of the upgrade compared to the initially provided speech generating device.
• The patient's medical condition is one resulting in a severe expressive speech impairment.
• The patient's speaking needs cannot be met using natural communication methods.
• Other forms of treatment have been considered and ruled out.
• The patient's speech impairment will benefit from the device ordered.
• Copies of the written evaluation and recommendation from the SLP have been forwarded to the patient's treating physician prior to ordering the device.
• The SLP performing the patient evaluation may not be an employee of or have a financial relationship with the supplier of the speech-generating device.

Laptop computers, desktop computers, PDAs (personal digital assistants) and other devices that are not dedicated speech generating devices are not covered because they do not meet the definition of DME.

Computer based and PDA-based AAC devices/speech-generating devices are only covered when they have been modified to run AAC software exclusively.

Accessories are covered if the medical necessity for each accessory is clearly documented in the formal evaluation by the SLP.

Roles and Responsibilities of Team Members

Facilitator*

*The facilitator is the person who drives the process. The person could be the consumer, a family member, a case manager, etc.

• Completes the Essential Information Form. Detailed instructions for completing this form are included.
  • Essential Information Form | PDF | Large Print | Text
• The facilitator will need:
  • Consumer identification information
  • Consumer support/contact information
  • Insurance information
  • Physician information
  • A prescription (the service requested is Augmentative/Alternative Communication Assessment).
• Identifies the service provider options based on the following criteria:
• Medicare provider
• Provides services to the relevant MCO(s)
• Delivers the type of service needed. The AT Provider section of the Website may assist the facilitator with this process.
• Calls the service provider and schedules the evaluation, providing all of the information outlined on the Essential Information Form as well as the specific reason for the evaluation. The facilitator will need to know:
  • Whether the individual had an AAC system at one time or currently uses an AAC device.
  • If the consumer currently has an AAC system, who provided the device? With the manufacturer and the serial number (which is on the device), the manufacturer will be able to identify how and when the device was provided. It is important to take the device to the evaluation (even if the device is not working.)
• Once an appointment is scheduled, informs the appropriate parties (family members, care staff, etc.) of the appointment. Key informants (such as a primary caregiver or case manager) should attend and participate in the evaluation.
• Arranges for transportation to the evaluation, if necessary.
• During the intake process, the consumer will be asked to provide written permission on a form that indicates that the service provider may bill Medicare and accept the assignment of benefits.
• Since Medicare covers 80 percent of the costs of the allowable service, the consumer and/or a secondary payor (Medicaid, other insurance, state agency) will be responsible for the remaining 20 percent. The facilitator may need to make arrangements for this payment if the consumer does not have Medicaid as a secondary insurance.
• Secures a copy of the LMN from the vendor, signifying that the claim submission process for the AT device has been completed. If a copy of the LMN is not received within 30 days of the evaluation, contacts the vendor.
• If there has been no action on the claim after 30 days of the submission of the LMN, contacts the Medicare Intermediary office.

Service Provider

• Verifies insurance information provided on the Essential Information Form and schedules the appointment.
• Reviews the intake information and obtains signatures on the assignment of benefits form on the day of the evaluation.
• Requests a copy of the prescription (Rx) for the evaluation from the facilitator. Without an Rx, the service may not be provided.
• Completes the evaluation with input from the facilitator, the consumer, and the caregiver(s).
• Provides the facilitator and the caregiver/consumer with a summary of the recommendations. Recommendations should include the following information:
  • The specific type of equipment and component(s) needed
  • Estimated date of delivery
  • Training that is needed once the equipment is obtained.
• Completes an evaluation report and sends a copy to the facilitator, the physician, the vendor, and the consumer/caregiver.
• Sends information to the physician to support formulation of the LMN.
• Sets up the communication device per the specifications outlined in the assessment.
• Provides information about the care and the operation of the equipment as well as warranties, repairs, and follow up upon delivery.

More About the SLP's Role

The SLP is the key person in the Medicare claims process related to AAC devices. Medicare guidance related to AAC devices is unique because it designates a non-physician, the SLP, as the primary determiner of a beneficiary's medical need. For everything else Medicare covers, the beneficiary's doctor holds responsibility. There are four specific steps the SLP must complete as part of the Medicare claims process:

• Complete an assessment for an AAC service pursuant to the DMERC Regional Medical Review Policy (RMRP) outline. A protocol has been developed to help SLPs conduct a complete assessment and prepare a complete application report consistent with Medicare's requirements. It is posted at http://www.aac-rerc.com/archive_aac-rerc/pages/MCsite/MCAppProtocol.html.

As part of the evaluation process, the SLP will determine the most appropriate device that will meet the beneficiary's daily communication needs, as well as determine the beneficiary's need for AAC software and/or accessories.

The SLP also must determine whether the beneficiary can obtain the most appropriate device, which requires consideration of the following points:

• Does Medicare cover the device or is it currently excluded from coverage?
• If covered, will the manufacturer/vendor accept assignment for the device?
• If not covered, or no assignment will be taken, can the beneficiary afford the full purchase price of the device? (If not, the SLP will need to consider an alternative device.)
• Complete a written report and supporting information pursuant to the DMERC RMRP outline. The protocol posted at http://www.aac-rerc.com/archive_aac-rerc/pages/MCsite/MCAppProtocol.html is intended to help ensure this report is complete. As part of the report, the SLP should address AAC accessories that are needed in addition to the need for the device.
• Forward the report to the beneficiary's treating doctor along with a request for a prescription containing the information on the Essential Information Form. The physician must include the statement that each of these items is reasonable and necessary for the treatment of the patient's expressive communication diagnosis (dysarthria, aphasia, aphonia) and is necessary to achieve the functional communication goals stated for the patient in the SLP's treatment plan.
• Inform the beneficiary and his/her family of the information that must be assembled to support a claim, including the assessment report, prescription, and co-payment or full payment amount.

Important Consideration: Medicare coverage of SLP services extends to reimbursement for the AAC evaluation. However, not all SLPs will qualify as Medicare SLP service providers. An evaluation and report recommending an AAC device, AAC software and/or accessories can support a Medicare claim for these items of equipment even if the SLP is not a Medicare provider his/herself. In this circumstance, the device can be reimbursed but the SLP will not be reimbursed for his/her evaluation. The SLP's duty in making an AAC device recommendation is to identify the most appropriate device that meets the individual's daily communication needs, which may or may not be the most technically advanced device. Medicare makes this duty more of a challenge because its guidance currently excludes some of the AAC devices that produce synthesized speech output. For this reason, additional consideration must be given to whether the device is affordable. A manufacturer/supplier is unlikely to accept assignment of benefits for a non-covered device, so the beneficiary will be required to pay its full catalogue or retail price. That requirement may make the device unaffordable, and the SLP cannot meet his or her obligations to a Medicare beneficiary by recommending a device that the beneficiary will not be able to acquire. If the device is not covered and not affordable, the SLP and family may choose to identify another device to meet the person's daily communication needs. The goal should be to recommend the best match between the client's communication needs and an appropriate AAC device, which may include consideration of the coverage status of the device in some cases.

Vendor

The AAC vendor, in most cases, is the manufacturer and is not directly involved in the assessment process. The AAC manufacturers have funding specialists who will submit the documentation and claim to Medicare, Medicaid, or any other private insurance company. The vendor should:

• Be enrolled as a DME provider with Medicare. If the consumer is also covered under an MCO, the vendor must be a participating provider with that MCO.
• Receive a copy of the Essential Information Form.
• Contact the physician to request the LMN and CMN if it has not been received.
• Submit all paperwork to Medicare.
• Order the equipment.
• Contact the facilitator, the service provider, and the caregiver/consumer when the equipment is ready to be delivered.

Note: The AAC manufacturer typically functions as the vendor. There are instances, however, in which the manufacturer is not an enrolled provider. In these cases the facilitator will have to use a DME vendor who will work with the manufacturer in supplying the equipment needed.

Physician

• Provides a prescription for the evaluation, equipment, and/or services needed.
• Provides LMN to vendor based on results of the evaluation.
• Completes the Medicare CMN for new devices and at such times that repairs/modifications are needed.
• More about the Physician's Role

The physician is a necessary part of the Medicare claims process. No Medicare payment will be made for an AAC device, AAC software, or accessory without a physician's prescription. Thus, if a Medicare beneficiary has multiple physicians, any one can sign the prescription. It is expected that the doctor will base the prescription on the SLP report. The SLP report that is prepared following the evaluation should be submitted to the doctor for review. It is recommended that the doctor be asked to prepare the prescription with information verifying:

• The physical or communication diagnosis
• That the doctor referred the consumer for SLP evaluation (if that occurred)
• That the doctor reviewed the SLP report
• That the doctor concurs with the recommendation of the SLP and prescribes EACH item—device, switches, software, etc.—that is recommended; and that each of the these items is reasonable and necessary for the treatment of the patient's expressive communication diagnosis (dysarthria, apraxia, aphasia, aphonia), and that each item is necessary to achieve the functional communication goals stated in the SLP's treatment plan.

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AAC Rental

Medicare will provide reimbursement for the rental of AAC devices. Device rentals will be subject to the same documentation requirements as device purchases, requiring provision of the SLP's evaluation report and the physician's prescription.

Medicare will provide reimbursement for the rental equipment based on the code in which the device "fits." Medicare's fee schedule for rental represents the full amount of Medicare reimbursement, either to the beneficiary if assignment is not accepted or to the supplier/manufacturer if assignment is taken. If assignment is taken, the beneficiary or supplemental insurance will have to meet the 20% co-payment amount.

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AAC Device Repair

Medicare will cover the AAC device and accessory repairs—both parts and labor—for devices and accessories that are beyond their warranty periods.

Medicare assumes that DME will have a useful life of five years. This means that Medicare will not replace items of DME within a five-year span, except when a substitution request is based on change of beneficiary condition. The impacts of this practice are significant:

• Medicare apparently will not replace a non-repairable device if it is within its five year expected life span.
• While a denial of a replacement device in this circumstance is appealable, it is unlikely a manufacturer/vendor will accept assignment for a replacement device within the five-year period. For this reason, the consumer must be able to afford a replacement device, and then pursue an appeal.
• If the consumer cannot afford a replacement device, they may ask the SLP and/or a facilitator for help. This may include identifying another device that is affordable (even if it is not able to meet all of the person's needs) or identifying sources of financial loans, device loans, used devices, or other funding sources. The goal, of course, is to ensure that the beneficiary is not without functional communication for the duration of the five-year period.
• To prevent this situation from occurring, beneficiaries should be told of this risk during the discussions about the device selection, and should be encouraged to purchase supplemental insurance that will cover replacement if the device becomes non-repairable and Medicare refuses to replace the device.

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Procedures for AAC repairs

When a device is not working properly, complete the following steps to gain assistance from the manufacturer. Do not return the device to the manufacturer until you have completed the following steps. Most of the communication device manufacturers have an 800 number, which can be found in the user's manual and/or on the device.

• A table of AAC product companies and their contact information is available.
  • AAC Companies Guide | PDF | Large Print | Text
• Call the Technical Support or Customer Service departments to get information about getting the device repaired. Many companies will attempt to do some troubleshooting over the phone. (Before calling the manufacturer have the device at hand.)
• Identify the make, model and serial number of the device.
• Does the device need to be returned to the manufacturer?
• Do you have a return authorization number?
• Complete the AAC Request for Repair form.
  • Request for Repair Form | PDF | Large Print | Text
• Follow the manufacturer's specific instructions for returning the device.
• The device will be repaired once the following documentation is in place and the 20% balance is provided to the manufacturer.
• Collect the following documents:
  • An original Rx from the doctor (not a fax) prescribing the repair of the device.
  • A letter from a licensed SLP stating the need for the repair
  • An assignment of benefits form signed by the beneficiary or his legal guardian
  • Copy of the Medicare card and a copy of any other insurance cards
  • Copy of the Essential Information Form.

  Determine if Medicare purchased the device. If not, then documentation is needed to justify the device according to Medicare standards.

• Determine how the 20 percent co-payment will be handled (e.g., Medicaid, end-user).
• If Medicaid is the secondary insurance, the vendor must get pre-authorization from Medicaid for the 20 percent co-payment.
• If there isn't a secondary insurance the 20 percent is collected up front and the facilitator may need to help in this process.
• Determine if the manufacturer will accept the assignment of benefits for the repair. If not, arrange for payment for the repair.

  (FYI: Zygo expects payment up front for the repair from the consumer but will submit a claim to Medicare on behalf of the consumer and Medicare pays the consumer.)

• Once the manufacturer receives the device and has all of the completed documentation and payer information/payment, the device will be repaired and returned to the consumer.

Chart: Repairing Speech Generating Devices:  PDF   |   Text

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