Medicare To Cover AAC Devices

January 19, 2001
by

Lewis Golinker, Esq.
Director, Assistive Technology Law Center
202 East State Street, Suite 507
Ithaca, New York 14850
v: 607-277-7286; fax: 607-277-5239
e-mail: lgolinker@aol.com

On January 1, 2001, the Medicare program began coverage and reimbursement of AAC devices. This is unquestionably good news. Loss of functional speech and the ability to write are exceedingly common effects of ALS, cerebral palsy, stroke, locked-in syndrome, Parkinson’s Disease, traumatic brain injury, multiple sclerosis and other neurologic conditions. AAC devices are widely recognized as an effective means to overcome these functional limitations and allow people with severe communication impairments to continue to communicate with family, friends and care-givers. And, the costs of these devices and the lack of Medicare reimbursement has made access to these devices difficult.

Unfortunately, this is not the end of the story. This Medicare policy change as it currently stands has an important flaw. While many AAC devices were covered, other types of AAC devices are not covered. As a result, the procedure to recommend an AAC device has become more complicated than it need be.

Even considering these limitations, this policy change should prove to be of great importance and value to people with severe communication impairments and their families.

This Medicare policy change has been long in coming. For more than 10 years, the Medicare program had guidance that described AAC devices as "convenience items," effectively barring access to them by Medicare beneficiaries. Even though Medicaid programs throughout the country and most insurers recognized the value of AAC devices to individuals unable to functionally communicate by speaking or writing, Medicare persisted with this view. The long-life of this policy had more to do with the small number of people who need AAC devices than with any scientific or policy reasons. AAC devices and the people who needed them simply were invisible to Medicare decision and policy makers whose agendas always seemed to be filled with problems that were more expensive, or that affected a larger number of beneficiaries. In fact, Medicare admitted in mid 1999 that it had no records whatsoever to explain why it called AAC devices "convenience items," yet it still took nine more months before it concluded the guidance containing this conclusion should be withdrawn.

This long overdue Medicare policy change comes amid other Medicare policy changes that also will positively benefit people one diagnosis-related group of individuals who develop severe communication impairments: people with ALS. The expansion of Medicare coverage for this important benefit became effective at the same time as general Medicare eligibility has been expanded for people with ALS. In late December, 2000, Congress accelerated the opportunity for people with ALS to become eligible for all Medicare services by eliminating the typical 24 month waiting period after onset of disability. Thus, people with ALS can become eligible for Medicare sooner, and can obtain Medicare reimbursement for the devices necessary to be able to continue to communicate. One hopes that these changes will greatly ease some of the hardships faced by people with ALS and their families.

Medicare has proposed new guidelines that have a straight-forward approach to eligibility for an AAC device: a speech-language pathology evaluation and doctor’s prescription. Medicare has provided an outline of the SLP evaluation and report, and speech-language pathologists will be offered training on how to complete these tasks to meet Medicare’s expectations. Physicians also are going to be offered training about AAC intervention, so that they will be better aware of treatment options regarding loss of speech function, and can offer more informed advice to their patients.

The Medicare AAC device guidance has one important flaw: it does not, at present, cover the full range of AAC devices currently available. This limitation is unfortunate, and efforts are ongoing to get Medicare to eliminate them. But these limitations are currently in place, and they must be taken into account when AAC devices are being considered.

Medicare will cover AAC devices that are "dedicated communication devices" and those that are not "computer" or "personal-digital-assistant (PDA)" based. Medicare also will cover all types of AAC software, as well as all types of mounts and access-related accessories.

Among the devices that clearly are covered, include all devices that offer "digitized" speech output. Two devices that offer synthesized speech and that require spelling to create messages, the Link and Light Writer, are both covered. In addition, other synthesized speech output devices, including the Dynamyte and Dynavox, the Delta Talker, Vanguard and Pathfinder, are covered.

The Freedom 2000, however, the AAC device that Stephen Hawking, perhaps the world’s most well known AAC device user, is not covered at present. Other, computer based devices, such as the Freestyle and Gemini, and the new, PDA based devices, also are not covered.

It is important that you and your speech-language pathologist first determine which is the most appropriate AAC device to meet your communication needs, but that decision must be followed right away by an inquiry whether the device is covered. If the device is not covered, it is important to discuss with the SLP whether the device is affordable, even without Medicare reimbursement. If not, it is essential that consideration is given to an alternate device.

In sum, because of the current coverage limitation in the Medicare policy, it is possible that a person with severe communication impairment will not get the AAC device first identified as the most appropriate to meet his or her needs. But for every person with these impairments, there should be a covered AAC device that will offer the full range of communication options that the person needs. This policy limitation should not force anyone to go without the ability to communicate.

Medicare provides reimbursement for medical services and devices that have been provided. This means that to file a Medicare claim, the beneficiary must "incur a charge." Typically, this means purchasing a Medicare covered item of medical equipment, such as an AAC device, and then submitting a Medicare claim for reimbursement.

Because many medical procedures and devices are very expensive, a benefits program that requires purchase to precede filing a claim has a built in "catch-22." If the person cannot afford the initial purchase price, then he or she cannot obtain the procedure or device, and cannot file a Medicare claim. Most importantly, they cannot benefit from the treatment.

Suppliers of medical services and devices who work with Medicare beneficiaries recognize this dilemma, and developed a response, called "accepting assignment." When "assignment is accepted," the suppliers require the payment of only a small percentage of the purchase price from the beneficiary, and the suppliers will allow Medicare to pay the suppliers the remainder of the item’s cost. This procedure substitutes for requiring the beneficiary to pay the full purchase price of the device, and then having the beneficiary wait for Medicare to provide reimbursement. Under this procedure, the beneficiary "assigns" his or her right to Medicare reimbursement to the supplier. The effect is that the beneficiary’s initial cost for a device is greatly reduced.

At present, there is no list of AAC device suppliers and devices matched to whether they will accept assignment or not. It is important for the speech-language pathologist to check with the supplier of any device that is being considered by the person with ALS whether assignment will be accepted. If not, this may force yet another discussion with the family about whether the device is affordable, and may require yet another alternative to be considered.

Medicare coverage of AAC devices has gone from none to some. The policy Medicare adopted and which went into effect on January 1 does leave some gaps that are being addressed with Medicare policy makers. But at present, the current policy will require people with ALS, their families, speech-language pathologists and doctors to work carefully as a team to ensure an appropriate and affordable AAC device is selected.

Additional information about the Medicare policy, and evaluation and claims procedures will be posted at www.aac-rerc.com. People with ALS and their families can direct questions about Medicare coverage of AAC devices to Lew Golinker, at lgolinker@aol.com.