Funding for Services

Defining Medically and Educationally Necessary Services

The common denominator here is the term necessity/necessary. When one seeks coverage for communication devices and services, it is essential that the documentation clearly justify the choice of device/service. The educational versus medical necessity component becomes important, given that it relates to responsibility for funding the device/service. Educational necessity is usually claimed when access to communication services and supports enables an individual to participate in and benefit from public education. Medical necessity is claimed when the communication limitation arises from a diagnosed condition with some sort of medical basis. In many cases, both standards apply. Insurance companies have no obligation to pay for services/devices that enable a child to pursue educational goals; their only responsibility is for those services/devices that are medically necessary. Public schools, on the other hand, must pay for services deemed by the special education team to be educationally necessary, regardless of whether they also meet the medical necessity definition. Let's look at each justification in a little more detail.

Devices and services are deemed educationally necessary when they allow the student to benefit from a free, appropriate public education in the least restrictive environment. Individuals with Disabilities Education Act of 2004 (IDEA 2004) specifies that special education services should enable students to access, participate in, and demonstrate progress with respect to the general education curriculum. Communication services can be represented on the Individualized Education Program (IEP) as special education, related services, or supplementary aids and services. Because assistive technology is one of the "special factors" that IEP teams must consider for all children, IEP teams are obliged to discuss communication devices and services when a child's communication limitations are so significant that they impact the child's access to, and potential to benefit from, the general curriculum.

Communication devices/services are medically necessary when the diagnosed condition (for example, cerebral palsy, brain injury, apraxia, amyotrophic lateral sclerosis [ALS]) impairs the individual's ability to communicate effectively. Services/devices address the medical condition by attempting to restore lost function, forestall further functional decline, or provide an alternative means of performing the affected function. It is actually difficult to imagine a situation in which communication services, including AAC supports, are not medically necessary, given that most instances of significant communication limitations are associated with diagnosed conditions. It is important to understand, however, that health insurers define medical necessity in different ways. Some have very narrow definitions, while others have more expansive definitions. Knowing the precise wording of each insurer's definition can be important in wording the justification accordingly.

Bottom Line: Services can be both medically and educationally necessary, and the approach to payment for services depends on the system being approached. Tailor the request to the domain of the funding source and confine the justification to one or the other.

Reimbursement for Services That Do Not Involve Direct Patient Contact

There are many dimensions to a comprehensive evaluation and treatment plan, and, although the individual with communication needs is the focus of the services, there are some activities that do not occur in the context of a traditional one-on-one session between the clinician and individual. Some of these include training of communication partners, conducting an environmental inventory to identify needed vocabulary, and programming an AAC device. These types of services ensure that the communication devices/strategies are appropriately tailored to the needs of the individual and that the person's circle of support is sufficiently educated and empowered to promote communication.

Medicare will cover such services as device programming and training. Medicaid reimbursement of such services depends on the Medicaid coverage guidelines in effect in each state; check your state's Medicaid policy to determine whether these kinds of services are covered benefits. An enabling policy might define the scope of AAC services as "diagnostic, screening, preventative, and corrective services provided by or under the direction of a speech-language pathologist. Such activities include evaluation for, recommendation of, design, set-up, customization, programming, and training related to the use of AAC devices." In fact, this is the definition that appears in Delaware Medicaid's Provider Policy Manual [PDF].

This type of language enables speech-language pathologists to seek reimbursement for services such as caregiver training and device programming that do not necessarily involve direct patient contact.

The availability of private insurance reimbursement depends on the scope of a particular policy's coverage, although more and more private insurers are following Medicare's lead. Consult the private health insurer's policy manual for clarification of coverage parameters.

The emergence of tablet technology, including iPads, has prompted many schools to pursue creative co-funding options. Most insurers will not pay for devices that use tablet technology, because they do not meet the definition of durable medical equipment: They are useful to a person in the absence of the medical condition. In many instances, the school or the family agrees to supply the tablet and the health insurer provides funding for the specialized communication software that runs on the tablet.

Bottom Line: When it is not clear what is covered, don't be afraid to ask!

Relation of Age/Skill to Funding Sources

Services for Birth-to-3

Most states offer early intervention services for children under 3 years with disabilities, but the operational rules vary from state to state. In many cases, children from birth to 3 years of age and their families can access a wide variety of services and supports, including assessment, treatment, and equipment, at little or no cost. Many states, however, require families to exhaust their private insurance, Medicaid, and self-pay options before the early intervention program will assume any of the costs of services or devices. For specific information on birth-to-3 services available in each state, contact the state's Parent Training and Information Center.

Services for School-Age Children

Educational necessity is usually claimed when access to communication services and supports enables an individual to participate in and benefit from public education. Devices and services are deemed educationally necessary when they allow the student to benefit from a free, appropriate public education in the least restrictive environment. IDEA 2004 specifies that special education services should enable students to access, participate in, and demonstrate progress with respect to the general education curriculum. A school cannot compel a family to use its insurance for this purpose, but families may find it beneficial to cooperate with the school to fund or co-fund assistive technology equipment. For example, if the school purchases the technology, it belongs to the school, but if insurance pays, it belongs to the beneficiary.

Medicaid will cover devices/services as long as they can be justified as medically necessary (even though they may be educationally necessary as well). But even when there are alternative or complementary funding sources, the school's obligation is to see that the student gets what is needed in a timely manner. It is not permissible to delay access to needed technology pending approval of other funding. In such cases, schools may need to explore temporary access solutions (such as a district's equipment inventory, an equipment loan program, or short-term rental) while waiting for more permanent funding solutions.

Services for Adults

Currently, adults with disabilities in the United States do not have a blanket entitlement to free therapeutic services or assistive technology. In some cases, however, services may be funded through state-administered programs, private insurance, Medicaid, or Medicare. Every state has agencies responsible for providing services to individuals with disabilities (e.g., through programs for vocational rehabilitation and independent living and those to serve individuals with developmental disabilities). The U.S. Department of Health and Human Services website provides links to the disability programs in each state.

Point of Information—Maintenance Services

Maintenance carries a negative connotation as a relatively passive approach designed to sustain the status quo. In fact, in many instances, ongoing services are essential to ensure that an individual's abilities do not regress or to prevent the development of problematic or dangerous secondary conditions. Funders are more likely to approve services described as being needed for the "prevention of regression" than they are to approve those described merely as "maintenance" services.

Bottom Line: Payment for communication services involves individualized decisions and the involvement of different professionals, sometimes depending on the age of the individual. Creativity is key in accessing assistance through a variety of possible sources.