Who will pay for the AAC Device?  Once it has been ascertained that a client (child or adult) will benefit from AAC services, and a proper device as been identified, the matter of it’s cost becomes a leading issue.  This was not the case in the selection of the device.  In that process, the matching of the correct device to the user’s needs was the primary concern.  But in most cases, the cost of the selected device exceeds the user’s ability to pay.  There are, however, a number of funding sources that can be explored by the AAC Team, led typically by the Speech Pathologist.  The hierarchy of sources includes the following:  Private Purchase; CCS and MediCal; CCS alone; MediCal alone; Private Insurance; Low Incidence Education Funds; and General Education Funds, and many philanthropic organizations.

1.  Private Purchase:  When feasible, there are important advantages to be gained if the device can be purchased directly by the client or his/her caretakers using their own funds. 

a. The Time Advantage:  In a private purchase, the process, and hence the time it takes to actually procure the device, can be significantly shortened. This reduced time can be a critical issue, for example, in the case of ASL patients where the need for the device is great and immediate but frequently short lived; or in the case of young children where every day without the device may result in a significant loss of opportunity to learn basic communication skills. 

b.  The Ownership Advantage:  Additionally, when users purchase their own device, it is clearly their property and can go with them when they move.  This is not the case when the funding comes through the schools, for example, who then have the say as to when the device can be taken off campus (for example home after school); and to whom the device must be returned if the child moves out of the District. 

c.  The Accessories Advantage: There are many desirable features associated with AAC devices that may be excluded by many insurance sources, but which can be included if the device is privately purchased.  For example, word processing and similar applications, access to the Internet, and many games are not allowed by many insurance programs but can be purchased privately.

2.  California Children Services (CCS) and MediCal, for Children in need of an AAC Device:  When the AAC funding for a child is dependent upon various government or private agencies, the organization of choice is a combination of CCS and MediCal. 

         a.  MediCal is California's version the Medicaid program. This is a public health insurance program which provides needed health care services for low-income individuals including families with children, seniors, persons with disabilities, foster care, pregnant women, and low income people with specific diseases such as tuberculosis, breast cancer or HIV/AIDS.  MediCal is financed equally by the State and Federal governments.

For Clients to be eligible to apply for MediCal funding, they must first be receiving services from a Regional Center.  In this regard, it is important to get the name/number of the Regional Center Case Manager.  This information can usually be obtained from the client’s parents or caretakers.  If MediCal Insurance has not yet been secured, it will be necessary to ask the Regional Center Case Manager to apply for Medical Insurance for the client through Institutional Deeming with parent approval.

         To be eligible for MediCal Insurance, the client must have more than one handicapping condition (viz., motor, cognitive and sensory); and must be receiving a minimum of two services from the Regional Center.  A person over 18 years would also be eligible.  In all cases the SGD must be accepted as being medically necessary. To be eligible for a device, the client must have a doctor’s prescription and an evaluation by a Speech Pathologist.

         A medically necessary need is one in which the client cannot meet daily communication needs through other means (vis., oral speech or no or low tech AAC interventions); and one in which the SGD has been determined to be the most appropriate means of meeting daily functional communication goals. MediCal will help to finance doctors services, physical and occupational therapies and medical equipment.  AAC devices are included as DME (durable medical equipment). This also includes repairs and replacement of Devices although typically there is a five year hiatus for replacing devices.  This must certainly be taken into consideration by the SLP when selecting a device that may need to meet the developing communication needs of a child’s over five years; or the decline in communication abilities associated with degenerative pathologies.

         If a client does not qualify for CCS, then MediCal may finance the AAC directly.

b.  CCS is a Statewide program managed by the California Department of Health Services.  It is funded by State, County and Federal tax monies; and some fees paid by the parents. 

To be eligible for CCS funding, a child must be under 21 and have a physically disabling condition such as cerebral palsy, muscular dystrophy or some other medical condition which requires medical, surgical or rehabilitative services.  The adjusted gross income of the parents must be, at least at the present, under $40,000, or if the medical expenses must come to more than 20% of the family income.  To be eligible for a device, the client must have a doctor’s prescription and an evaluation by a Speech Pathologist.

CCS will pay for the evaluation to determine whether or not a child is eligible for their services, which include among others, doctors services, physical and occupational therapies and medical equipment.  AAC devices are included as DME (durable medical equipment). As with MediCal, This includes purchase, repairs and replacement of devices, although typically there is a five year hiatus for replacing devices.  This must certainly be taken into consideration when selecting a device that may need to meet the potential of a child’s development over five years; or the decline

If a client is not eligible for MediCal, then CCS may directly fund the AAC device.

         c.  The Process of applying for CCS /MediCal Funding begins with determining the status of the client with CCS and MediCal.

If a CCS status has not yet been determined, then it may be necessary to have the parents apply for CCS Services.  As was mentioned earlier, CCS will pay for an evaluation.  If, on the other hand, the client’s status has become inactive, it may be necessary (with the parents permission) to schedule an evaluation with CCS to activate the status.  If the status with CCS is at a Consultation level, or active with a CCS Medical Therapy Unit (MTU), then it is necessary to obtain the name and number of the Occupational Therapist, and the name and number of the Supervising Occupational Therapist for the MTU.

If the MediCal status has not yet been determined (i.e., the client has no MediCal Insurance), the parents should be advised about the benefits of applying to MediCal.  Of course this depends on the clients status with the Regional Center.  If the client is receiving services from the Regional Center we will need to get the Name and Number of the Case Manager. It will be this Case Manager who will file the application for MediCal through a process called Institutional Deeming with parent approval.

If the MediCal application is in process, then we will proceed with the required device funding evaluation (i.e., using the CCS/MediCare Guidelines.)  If or when the Client has an active status with MediCal, they will be assigned an Active Medical Number.  The next step will be to conduct a CCS/MediCal device funding evaluation.  If the client’s status with CCS is active, it is advisable to involve the CCS OT in the evaluation and trials.  We should take care to follow the CCS/MediCal AAC device funding process, and provide CCS with an Evaluation Packet.

The AAC Evaluation Packet includes the following items:

         a.  The Completed AAC Device Evaluation Report in Medicare Format.

         b.  The Primary Physician’s Prescription for the device and peripherals.

         c.  A Price Quote from a vendorized DME Device Company delineating all equipment needs/current prices and not more than 30 days old.

         d.  If the Client has a Primary Insurance Carrier, a letter of denial for funding will be included. 

3. MediCal only for funding Children in need of an AAC Device:  Clients who do not have a diagnosis that is eligible for CCS (such as Downs Syndrome, Autism or Pervasive Developmental Disorder, etc.) may be funded directly from MediCal if they are qualified.  It must first be ascertained, however, whether or not the AAC device can be funded by the client’s Private Primary Health Insurance Provider.  This involves contacting the clients Primary Health Physician to inform him/her of the evaluation.  The Physician should then be provided with the evaluation and the specifics for the prescription based on the evaluation.  The Evaluation Report; the prescription, and the Device costs quote must be submitted and reviewed by the Primary Health Insurance Carrier (usually by the Durable Medical Equipment (DME) Department).  If the request for funding is approved, then the AAC device will be procured by the Private Insurance Company.  If not then a letter of denial must be provided to the SLP.  Then the Evaluation Packet (including the AAC Evaluation Report: the Primary Physician’s prescription, the Denial letter from the Private Health Insurance Company; and the Price Quotes is sent to the Funding Department of the Device Vendor (who must have a DME Vender Number) for MediCal.

CCS only for funding Children in need of an AAC Device:  For children who are active or who qualify for CCS but are not eligible for MediCal, the funding my be provided by CCS alone. The CCS status must first be determined.  Plus to be eligible for device funding the yearly income of the parents must be below $40,000 a year.  If the child is equipment eligible under CCS then the AAC Device Evaluation should be undertaken.  The CCS OT should be notified and involved in the evaluation process.  The completed Evaluation Packet should then be submitted to CCS.

4.  Private Insurance funding for Children in need of an AAC Device:  It must first be determined whether or not the Insurance Policy covers Speech/Language, and Durable Medical Equipment.  Even so, it must also be checked to see that there is no exclusion clause specifically for AAC Devices.  An AAC Device Evaluation following Medicare Guidelines can then be conducted. A copy of the report should be sent to the Primary Physician including the specifics for a prescription.  The Physician should then submit the funding materials to the DME Department of the Insurance Company with a 30 day response request.  It is important to keep touch with the parents and the Physician until a decision by the insurance company is made.  If the funding request is denied, but the insurance does cover Speech/Language and DME, then the objections should be ascertained and addressed and the funding request re-submitted.

5.  Low Incidence Public School funding for Children in need of an AAC or AT Device:  A child who has a low incidence disability, as described by the State Department of Education, which includes severe orthopedic impairments (such as cerebral palsy,) or multiple motor, speech and sensory impairments; but who is NOT eligible for CCS, MediCal or Private Insurance services, my apply for funding through the Department of Education.  It is important in this case that the IEP Team write goals and objectives that include the use of an AAC (or AT) device.  The next step is for the AAC Specialist and the Case Manager to complete the Low Incidence Form and submit it along with the EIP report to the appropriate school Program Administrator for review.  If approved, the low incidence equipment is logged into the low incidence database and the AAC Specialist and/or the Case Manager is contacted.  When procured, the equipment is the property of the school and will be retained by the School if the Child moves out of the jurisdiction of the California State Department of Education.  The school authorities also determine whether or when the child can remove the AAC device from the school premises (for example to take it home after school).

6.  General Education Public School funding for AT or AAC Equipment Budget:  If a student does not qualify for low incidence funding, nor CCS or MediCal, and Private Insurance is not an option, General Education funding is a possibility.  To access this funding, the client must have an AAC device assessment conducted in accordance with the Medicare guidelines.  The IEP Team must write goals/objectives, which include the use of AAC or AT.  The AAC/AT Specialist and the Case Manager will complete an Equipment Requisition and send it along with the IEP to the appropriate Program Administrator for review/approval.  If approved the AAC/AT equipment is logged into the equipment database and the AAC Specialist/Case manager is contacted to obtain the equipment.

7.  Tricare funding for AT or AAC Equipment Budget:  Tricare is the Insurance Carrier for Personnel on Active duty, and their dependents.  The process for applying for Tricare funding is the same as applying to any Private Insurance Company.  Medicare guidelines should be followed in the assessment process.

8.  Medicare funding for AT or AAC Equipment Budget:  Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. Medicare operates as a single-payer health care system. Single-payer health insurance collects all medical fees and then pays for all services through a single government (or government-related) source.  To obtain Medicare funding, you obtain the aid of the Funding Coordinator of the Company Manufacturing the Device.  If the device is accepted for funding, there is a 20% copayment required from the patient.

9.  Department of Rehabilitation funding for AT or AAC Equipment:  When students are 18 years and over, the Department of Rehabilitation Counselor should be contacted to ascertain the possibility of obtaining an AAC/AT device that would enable the client to achieve a vocational goal.

10.  Other Organization often accessible for AT or AAC Equipment:  Despite the major funding sources mentioned above, there are a number of other smaller organizations that are possible funding sources.  These include but are not limited to:

a.  Disability Organizations that include groups like Easter Seals, United Cerebral Palsy Association, the March of Dimes, the Braille Institute, and Crippled Children's Services (CCS).

b.  Service Organizations:  Included here are groups like United Way,  Lions Club, Masonic Order, Elks Club, Rotary Club, Kiwanis Club and the Veterans of Foreign Wars (VFW).  In this last case, the children of veterans may be eligible for receive assistance.

c.  Private Organizations:  Various companies in Private Industry, Special Education Parent Organizations, Church groups and the PTA have also provided funding for AT.

GLOSSARY OF TERMS

Allowable:
The amount of money for which your insurance company will allow a claim to be processed. The client's co-insurance is usually based on their allowable amount. For example, if the allowable amount is $5,000.00, and the client's co-pay is 10%, the amount the client will owe is $500.00.

Assignment of Benefits (AOB):
Form signed by the policy holder that allows the insurance company to pay ZYGO Industries, Inc. or its dealers directly. Without an AOB, the policy holder may receive the insurance payment.

Certificate of Medical Necessity (CMN):This is usually a state-specific form which is signed by the physician or speech therapist.

Claim:
Billing submitted to the insurance company after the equipment has been delivered.

Client Advocate:
Person who is representing the client during the funding process. This person is usually a speech therapist or case manager.

CPT Code:
The Current Procedural Terminology code describes the type of services that are being supplied. This is generally the same as a HCPC Code.

Custodial Care Facility:
Facility that provides room, board, and assistance with daily living activities, such as feeding and dressing. This care is generally on a long term basis and does not entail the continuing attention of trained medical personnel.

Deductible:
That amount that the client must pay annually before benefits will be paid by the insurance company.

Durable Medical Equipment (DME):
Systems made to withstand repeated use that are used for the treatment of an injury or disease. Speech Generating Devices have been classified as Durable Medical Equipment.

Explanation of Benefits (EOB):
The statement from the insurance company showing the services and amounts that were paid by the policy. This is also known as a remittance.

Exclusions:
Services for which the insurance company will not pay.

Funding Questionnaire (FQ):
A questionnaire that is usually completed by a family member or other contact person which includes important information such as the client's address, physician, insurance information, and a list of the equipment that they wish to order.

HCPC:
Code that is used to describe the services rendered. For example, the Polyana with Persona has a Medicare HCPC code of E2510.

Hospice:
Supportive care given to a terminally ill client and their family. The focus of this care is to enable the client to remain in the familiar surrounding of their home for as long as they can. Hospice care may be either inpatient or outpatient.

ICD-9 Code:
International Classification of Diseases. Insurance code that describes a client's medical condition or diagnosis.

Insurance Letter of Requirement (ILR):This letter is sent to your insurance company by your funding coordinator and explains the details that should be included in a private insurance authorization. An approval form is also included with this letter. Insurance companies may complete the approval form instead of creating a letter.

Invoice:
Itemized statement explaining what items or services have been delivered.

Letter of Medical Necessity (LMN):  A letter explaining the medical need for AAC services. This letter can be written by a physician, speech therapist, or occupational therapist. These letters usually give the client's diagnosis and a brief explanation of why services are necessary.

Maximum Out of Pocket:
The maximum amount a client will pay towards their deductible and co-insurance during the year.

Managed Care Organization (MCO):  Any insurance plan in which the client will need to have services approved by their plan's referring physician or medical group.

Medicaid: 
State-sponsored medical plan. Eligibility for these plans is traditionally based on a family's income. May also be called Title 19.

Medicare:
Federally-sponsored medical plan. Clients become eligible for this program when they turn age 65 or have a qualifying disability. There are two separate programs under Medicare
Part A (hospitalization) and Part B (medical). Clients must pay a monthly fee for Part B coverage. speech generating devices are covered under Medicare Part B.

Medicare Supplement:
An insurance policy that covers Medicare co-payments and other services. This policy must be purchased by the Medicare beneficiary.

Non-Participating Provider:
Provider that has not contracted with a health insurance company to provide services at a reduced fee. Also referred to as an Out of Network Provider.

Original Documentation:
Prescription and speech evaluation that has an original signature. The signature page on the evaluation and the doctor's prescription cannot be stamped, copied, or faxed. Medicare requires that original documentation be on file with the vendor for any product.

Payment Agreement (PA):
Form signed by a policy holder stating that they agree to cover any amounts not paid by the insurance company.

Place of Service (POS):The location where the medical services will be provided or used. It is important that we know whether a client lives at home, in a group home, or in a nursing facility. Some funding sources will not cover clients that live in a nursing facility.

Pre-certification:  Please see “Prior Authorization” below.

Pre-determination:
A review done by an insurance company to determine whether a service will be considered a covered benefit.

Prior Authorization:
Approval issued by the insurance company before equipment is delivered. Authorizations are normally issued by nurse reviewers at the insurance company who review the doctor's orders and other documentation to ensure that a service is medically necessary.

Referral:
Specific directions or instructions from a client's primary care physician. Referrals may be on paper or electronic and are usually required by HMO policies.

Release of Information (ROI):  A form that is signed by a client or their guardian and gives permission for the vendor to release medical documentation to insurance companies and other funding sources.

Remittance:
A statement sent to medical providers from the insurance company to show the payment that was issued. Also called Explanation of Benefits (EOB).

Rx:
Prescription. This must be signed by a medical doctor or dentist.

Sole Source Supplier:
A provider who is the only source for a particular service or type of equipment.

Subscriber:
The employee covered under an employer's group insurance policy. Also referred to as the policy holder.

Skilled Nursing Facility (SNF):  A facility which provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but do not require the level of care provided in a hospital. If a person is in this type of facility, they are not able to use Medicare as a funding source.

Stop Loss:
Please see “Maximum Out of Pocket” above.

UPIN:
Unique Physician Identification Number. The identification number that is used to identify the physician who signed the prescription. This number is used when filing claims to insurance companies.

Usual and Customary Charges:  Also referred to as Reasonable and Customary Charges. An amount determined by an insurance company that represents a routine charge for a medical service by similar medical and professional providers in the same geographical area. Allowable amounts are normally based on the Usual and Customary Charges.