Following Funding Source Guidelines And Where To Find Them

Before setting out to write a report for a speech generating device (SGD) for your client, you must identify the funding source or sources that your client is eligible for, as well as the corresponding SGD policy guidelines for each funding source. These SGD policy guidelines are essentially the directions for what must be contained in your evaluation. They will tell you what you need to document in your report and can be thought of as the rules you must follow in order to get an SGD funded. We will look at the various SGD funding options and where to look for the policy guidelines specific to each source.

A review of the various funding sources of SGDs and their definitions (keep in mind your client may have a combination of funding sources):

• Medicare is a federal program. Medicare eligibility is not based on an individual's income, but it is based on age, on disability status, or condition.
• Medicaid is a state-run, voluntary joint program between the federal and state governments, that is based on income, and for those individuals with disabilities. Although it is voluntary, all 50 states do participate in Medicaid. Each state Medicaid program must follow Federal CMS guidelines but they can pass their own laws and put guidelines in place for how their individual Medicaid program will be run.
  • There are two types of Medicaid programs you will encounter:
    • The first is straight Medicaid, administered directly by the state
    • The second is a Medicaid managed care organization or MCO. An MCO is a hybrid of state Medicaid and a private insurance company. MCO plans are part of a growing trend in which Medicaid has contracted with private insurance companies to run their Medicaid programs. These MCO plans often look like private commercial insurance but they are really a Medicaid plan. The purpose of an MCO is to reduce administrative costs for the state.
• Private insurance – There are many private insurance options that exist. The main thing to keep in mind with regard to private insurance is that there are personal policy differences that exist from client to client. AAC must be a covered benefit under your client’s policy.
• Tricare is a funding source for active-duty military, retired military and their dependents.

Once you know the client’s funding source or sources, where do you start looking for SGD policy guidelines?

Medicare

Medicare is the gold standard, and Medicare guidelines are the most commonly adopted guidelines for other funding sources and are most likely to cover the bases needed. Many insurer clinical guidelines are based on Medicare guidelines. Two Medicare guidelines that govern AAC device coverage are:

1. The Medicare Local Coverage Decision for Speech Generating Devices (formally referred to as the Regional Medical Review Policy, or RMRP) which states the SLP assessment and reporting requirements to support a Medicare claim for an AAC device.
   Download the PDF
2. The Medicare National Coverage Decision for Speech Generating Devices, or NCD which describes the scope of Medicare coverage of AAC devices.
   Download the PDF
   
   The requirements of both guidelines must be met for a Medicare claim to be approved.

If you are in doubt about the guidelines to follow, or if you can’t find funding guidelines for a different funding source, follow Medicare guidelines. Tricare, is an example of a funding source that follows Medicare guidelines.

Medicaid

To locate the SGD policy guidelines if your client has Medicaid:

Each state Medicaid program must follow Federal CMS guidelines (the CMS LCD and NCD guidelines linked above), but they can pass their own laws and put guidelines in place for how their individual Medicaid program will be run. As mentioned above, there are two different types of Medicaid programs that you may encounter:

Straight Medicaid

If your client has straight Medicaid, to locate the SGD policy guidelines:

• • You would need to check your state’s Medicaid website to determine what laws and guidelines they use for DME or SGDs
  • Some states will have a manual or guidance specifically for speech generating devices, but some may have a DME guide with a section devoted to SGDs
  • You can search your state’s Medicaid website for the provider manual, each state’s provider manual will be different but should address SGDs within it

Medicaid MCO

As previously discussed, Medicaid MCO is a hybrid of state Medicaid and a private insurance company. Therefore, it is important to keep in mind that an MCO will contain all that straight Medicaid requires and also, most importantly, it will contain MORE than what straight Medicaid requires. It all depends on the state and how much latitude the state gives the MCO in administering the program. To be thorough, if your client has Medicaid MCO, you need to reference several policy guidelines, including, the Federal CMS (Medicare) guidelines, the insurance company’s guidelines, AND the state Medicaid guidelines.

• • In an MCO, because the state will contract with a private insurance company to administer the state Medicaid program, the insurance company will have their own medical necessity guidelines, and prior approval process. The insurance provider program manuals and insurance company’s guidelines should be reviewed for the requirements for medical necessity.
  • In addition to the private insurance company guidelines, the MCO will follow the state Medicaid guidelines (accessed as mentioned above in discussion of accessing straight Medicaid guidelines).
  • You need to reference the Federal CMS (Medicare) guidelines as well, linked above in discussion of Medicare guidelines.

Private Insurance

If your client has private insurance, you can check the provider section of the insurer website for SGD policy guidelines to see if they have the policy posted. Even though many insurers post their clinical guidelines, some may not have a clinical policy or guidelines specifically for SGDs. Some insurers may not have a separate SGD policy but instead will include it in their DME policy, so you should look at the boarder DME policy if a specific SGD policy is not available.

Finally, it is important to keep in mind that all of the funding sources mentioned may review, update, and make changes to their guidelines (some do this yearly and some do it even more often). For example, Medicare publishes updates quarterly. Even if you have recently had an SGD approved through a certain funding source, checking to see if there have been any updates to their policy guidelines since you last submitted could save you time in responding to a denial or deferral for not including necessary information required in the policy guidelines.

Resources for information on SGD funding

• AACFundingHelp.com
• AAC-RERC website. Medicare Funding of AAC Technology. Information obtained on 01/27/2021. Supported in part by the National Institute on Disability and Rehabilitation Research (NIDRR).
• CMS.gov
• American Speech-Hearing Association (ASHA)

– Beth Studdiford, M.S., CCC-SLP. Read additional articles by Beth.