American Speech-Language-Hearing Association
National Joint Committee for the Communication Needs of Persons with Severe Disabilities

Funding for Service Delivery

Communication Services and Supports for Individuals With Severe Disabilities: FAQs

Are communication services typically considered medically or educationally necessary?

Communication services can qualify as either or both. It depends on an individual's circumstances and the availability of potential funding sources. 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. In many cases, both standards apply. However, insurance companies have no obligation to pay for services/devices that are educationally necessary; their only responsibility is for services that are medically necessary. Public schools, on the other hands, must pay for services deemed by the special education team to be educationally necessary, regardless of whether they also meet the medical necessity standard.

How can communication services, including AAC devices, be documented as "medically necessary"?
How can communication services, including AAC devices, be documented as "educationally necessary"?

How can communication services, including AAC devices, be documented as "medically necessary"?

For each case, the starting point is a review of the insurer's definition of medical necessity. These definitions can vary considerably from one insurer to the next. Typically, medical necessity is tied to an identified condition or diagnosis that limits the person's functioning in some way. In the case of communication, treatment would be medically necessary when the diagnosed condition (for example, cerebral palsy, brain injury, apraxia, ALS) impairs the individual's ability to communicate effectively. Services/devices address the medical necessity by attempting to restore lost function, forestall further functional decline, or provide an alternative means of performing the function. It is actually difficult to imagine a situation in which communication services, including AAC supports, are not medically necessary, as most instances of significant communication limitations are associated with diagnosed conditions.

How can communication services, including AAC devices, be documented as "educationally necessary"?

Devices and services are deemed educationally necessary when they allow the child to benefit from a free, appropriate public education in the least restrictive environment. The Individuals with Disabilities Education Act specifies that special education services should enable students to access, participate in, and demonstrate progress with respect to the general education curriculum. It is hard to imagine a case in which a student would have equal access to the curriculum and the ability to participate and progress without benefit of an adequate means of spoken and/or written communication! Communication services can be represented on the 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.

Does a school's obligation to provide AT devices/services mean that the district always pays for them?

Not necessarily. Some devices/services are covered by Medicaid or a family's insurance. A school cannot compel a family to use their insurance for this purpose, but families may find it beneficial to cooperate with the school to fund or co-fund equipment in this way. 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 to resolve.

Do Medicaid or Medicare programs provide reimbursement for AAC services?

They do as long as the individual's coverage includes speech and language services. AAC services provided by a speech-language pathologist fall into this category. Reimbursement for devices may be a bit trickier. In some cases, the device may also be considered an element of speech and language services, but in other cases it is considered to be durable medical equipment (DME). If the insurer considers it DME, and the individual's policy excludes DME from coverage, device access may be more difficult. Nationwide, Medi caid funds speech-language services for children birth through 21 years of age. The availability of therapy services and device coverage for individuals older than 21 years varies from state to state. Under Medi care , beneficiaries must have elected coverage under the optional Part B - which carries with it monthly premiums, an annual deductible, and co-pays - in order to qualify for most speech and language services and DME. Medicare refers to AAC devices as "speech generating devices."

If my child needs communication services, including AAC, who pays for it?

Eligibility for services depends on many factors, including a person's age, medical insurance coverage, and enrollment in programs such as early intervention, special education, or vocational rehabilitation. In almost all cases, payment will be approved only if the need for services is documented by authorized individuals (e.g., physician, case manager, educational team, etc.). Click on the links for more information about early intervention, school services, private insurance, Medicaid, Medicare, or adult services programs.

Are communication services, including AAC, covered for children age birth to 3?
How can communication services, including AAC devices, be documented as "educationally necessary"?

Private insurance

Does private insurance provide reimbursement for communication services, including AAC devices and services?
How can communication services, including AAC devices, be documented as "medically necessary"?

Medicaid

Do Medicaid or Medicare programs provide reimbursement for AAC services?
How can communication services, including AAC devices, be documented as "medically necessary"?

Medicare

Do Medicaid or Medicare programs provide reimbursement for AAC services?
How can communication services, including AAC devices, be documented as "medically necessary"?

Adult services program

Are communication services, including AAC, covered by adult services programs?

Are communication services, including AAC, covered for children age birth to 3 years?

Most states offer early intervention services for children under three years with disabilities, but the operational rules vary from state to state. In many cases, children from birth to three 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 to the family. Many states, however, require families to exhaust their private insurance, Medicaid, and self-pay options before the early intervention program will assume the cost of services or devices. For specific information on Birth-to-Three services available in your state, contact your state's Parent Training and Information Center.

For more information:

Parent Training and Information Center - http://www.taalliance.org/Centers/PTIs.htm

Are communication services, including AAC, covered by adult services programs?

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, such as Vocational Rehabilitation, independent living programs, and those serving individuals with developmental disabilities. The U.S. Department of Health and Human Services provides links to the disability programs in each state.

For more information:

U.S. Department of Health and Human Services - http://www.acf.hhs.gov/

Does private insurance provide reimbursement for communication services, including AAC devices and services?

That depends entirely on the scope-of-coverage provisions within an individual's policy. If speech and language services are a covered benefit, then AAC services-and potentially AAC devices-could be construed as a form of speech/language services. If the policy has specific exclusion of speech/language services or durable medical equipment (DME), the insurer may not be obligated to cover AAC devices and/or services. Even when the scope of coverage includes speech and language services and/or DME, the insurer will only provide reimbursement when the services/devices are determined to be medically necessary.

For more information:

How can communication services, including AAC devices, be documented as "medically necessary"?

Are services free for children age birth to 3 years?

Most states have federally-funded Early Intervention (EI) programs, but the operational rules vary from state to state. In many cases, children from birth to three 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 to the family. Many states, however, require families to exhaust their private insurance, Medicaid, and self-pay options before the EI program will assume the cost of services or devices. State EI contacts can provide detail about eligibility and coverage for services in their particular locale.

Can a healthcare provider be reimbursed for indirect services? Do Medicare, Medicaid, or private insurance pay for indirect services?

Indirect services are those services that support an individual's communication program but that involve activities other than direct patient/client contact. Some examples might be training direct care staff and families, programming an AAC device, and completing environmental inventories to determine target vocabulary words. Indirect services ensure that the communication devices/strategies are appropriately tailored to the need of the individual, and that the individual's circle of support is sufficiently educated and empowered to support the individual's communication capabilities.

Medicare reimbursement currently does not cover indirect services. 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 indirect services are covered benefits in your state. Several states' Medicaid programs will reimburse a variety of indirect services. For example, a state policy that enables reimbursement of indirect services defines the scope of AAC services as "diagnostic, screening, preventative, and corrective services provided by or under the direction of a speech-language pathologist. Specific activities include evaluation for, recommendation of, design, set-up, customization, programming, and training related to the use of AAC devices."

Availability of private insurance reimbursement for indirect services depends on the scope of a particular policy's coverage. Some policies will cover indirect services as an extension of or enhancement to direct services. Consult the private health policy's benefits manual for clarification of coverage parameters.

Are "maintenance" services eligible for coverage under insurance, special education, or other payment/reimbursement systems?

"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 than 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 if they are described as being needed for the "prevention of regression" than if they are described merely as "maintenance" services.

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