We are pleased to welcome Joanne Lasker, Ph.D., CCC-SLP as our guest host for the SLP chat tonight, Monday, March 22, 2004. She will be addressing the topic of Funding for AAC (Augmentative and Alternative Communication) Dr. Lasker is an assistant professor in the Communication Disorders department at Florida State University. Her primary areas of specialty are adult neurogenic communication disorders and augmentative and alternative communication (AAC). Dr. Lasker has been involved in the assessment and treatment of people with severe communication disorders for the past 10 years. Her research interests include investigating attitudes toward augmentative and alternative communication, implementation of AAC strategies with adults who have acquired neurologic disorders, and functional intervention approaches for people with severe communication problems. She has presented internationally and nationally on these topics. Dr. Lasker has taught courses and seminars in neuroanatomy, acquired cognitive and linguistic neurological disorders, motor speech disorders, dysphagia, and augmentative and alternative communication (AAC). She is currently a member of the AAC Medicare Implementation Team working to disseminate information about new Medicare guidelines regarding funding for AAC devices. Dr. Lasker has provided us with additional resources and references which may be found below the chat transcript. <Robin> Welcome! We are chatting tonight with Joanne Lasker, Ph.D., CCC-SLP, about the topic of Funding for AAC (Augmentative and Alternative Communication). <JoanneLasker> Hello Robin and everyone. <Robin> Dr. Lasker, could you give us an overview of this topic, please? <JoanneLasker> Sure. I guess the first thing is to be sure people know what we mean by AAC. After that, I am happy to discuss anything about the methods SLPs can use to assist clients in funding AAC systems. <JoanneLasker> How many of you have had courses or experiences with AAC? <dawn_c-j> yes <Jennifer> yes <Robin> limited experience, no course <AdrienneFSU> yes ~) <Debra> yes <JoanneLasker> So, everyone knows that AAC stands for? <Jennifer> yes <JoanneLasker> "augmentative and alternative communication" <sarah> I have a son age four who uses Chat PC. <JoanneLasker> Great, so most of you have some background. <David_G> I work daily with students with devices. <JoanneLasker> One of the things I'd like to stress is that funding AAC devices for anyone -- child or adult -- should no longer be considered an impossibility. There are multiple ways funding can happen and an appropriate device/system can be acquired. <JoanneLasker> David - how did most of your students get their devices? <David_G> The districts pay via CSE (Committee on Special Education). <JoanneLasker> David, I see. <Robin> What is the price range for AAC systems? <JoanneLasker> Robin - devices/systems range greatly in price -- from $200 - $8000. <Robin> That is a wide range! <JoanneLasker> Robin - Yes, it's a huge range. <JoanneLasker> Since many devices are big investments, it's important to evaluate clients properly. <sarah> My son's device was covered under insurance plus the school system provided one. <Robin> Thats great, sarah. >JoanneLasker> Sarah - did the school system only let your son use his device in school? <sarah> No, it was also for home use if needed. <sarah> It took a lot of work on my end fighting for it in both areas. <JoanneLasker> Sarah - I'm sure it did take a lot of work. I'm hoping that it becomes more routine for SLPs to help with the process and to know what to do. <David_G> Joanne-a lot depends on the district. <JoanneLasker> So, let's talk about some sources of AAC funding other than school districts. Does anyone have experience with other funding sources? <David_G> Insurance? <dawn_c-j> medicaid <dawn_c-j> medicare <JoanneLasker> Yes, these are all important sources of funding for AAC systems. I'd like to clarify some of the differences between Medicare and Medicaid and third party insurance. Would that be helpful? <Jennifer> yes <David_G> Great <JoanneLasker> Medicare is a federally funded program intended (generally) for people who are 65 years or older and/or people who receive social security disability. Medicaid is state administered. Each Medicaid state program is differently managed with different rules. Medicaid is based on income level. That program is intended for people on limited incomes. Third party insurance is private health insurance that a person or a person's family might have. The big news in AAC funding is that as of January, 2001, Medicare is funding devices for adults with acquired disabilities. The exciting thing is that, as a result, many other programs and insurances now follow Medicare's lead. Funding is more widely available. <dawn_c-j> Joanne you were saying to properly eval, what do you mean? <JoanneLasker> Dawn, I meant to do a good AAC evaluation which considers the capabilities of the client. Good evaluations include trials with several devices to consider which would be best for the client to meet his or her daily communication needs. It's also important that AAC systems are able to accommodate user's changing abilities. <dawn_c-j> Joanne, I have never seen a AAC eval, other than those presented by the company selling the device, is that what you mean? <JoanneLasker> Dawn - This is an excellent point. It is the SLP's role to do a thorough evaluation. Evaluations by vendors (or people representing certain AAC companies) tend not to be "unbiased". Vendors may be motivated to recommend their own companies' systems (even if a different system is more appropriate). <David_G> Dawn-at our BOCES we have an actual AAC team that comes into evaluate and recommend a specific device. <JoanneLasker> Yes, often school districts have teams who do the evaluation and make the recommendations. Adults or people with acquired disabilities may be referred to an area SLP who will do an evaluation. <sarah> Having a good AAC eval is very important . The team that evaluated my son privately found that he was capable of handling a device that is very advanced, the Chat PC2, where the school argued that it was too advanced for a 3 year old. The system they tried to give him was a lower technology device. <dawn_c-j> Yes, I have to evaluate the client myself and do not feel secure in the final decision because I have not had any real training in the different devices. <JoanneLasker> Dawn - It is tough to evaluate, because it does involve some level of prediction. You can't always know for sure what the future holds. You just have to make an educated decision based on what you know about the client, the AAC system, and the circumstances. The more you know about the AAC technology, the easier it is to evaluate. It's very helpful to have several pieces of technology available for a client during the evaluation and to know enough about the device so that you "try out" a bunch of scenarios. <David_G> Joanne-can you touch on what you look for in an eval? <JoanneLasker> David - This is a huge question. For an overview, I would refer you to an AAC website, www.aac-rerc.com as well as one of the standard textbooks on AAC by Beukelman & Mirenda that was published in 1998 entitled Augmentative and Alternative Communication: Management of Severe Communication Disorders in Children and Adults (2nd edition). Personally, what I look for is whether the client can use the system functionally in a variety of situations. I also want to see how much cueing/support the client needs to be successful with the device. <David_G> Thanks <AdrienneFSU> Is it common for insurance companies, etc. to question the SLP's recommendation? Especially if the device is expensive? <JoanneLasker> Adrienne - In my experience, I have never had a device/system rejected (turned away) by any funder. <AdrienneFSU> That's good <Robin> Thats a pleasant surprise. <JoanneLasker> Nowadays, with the change in the federal law, most places know that funding is "the standard practice." If Medicare does it, many other insurers follow suit. Of course, I've had to justify my requests on clients' behalfs. That's where a good report comes in. <JoanneLasker> Of course, I've had to justify my requests on clients' behalfs. That's where a good report comes in. <AdrienneFSU> Joanne, can you talk about considering the future of the user, i.e., if abilities will decline, or if child will need more? <Robin> Right, how do you justify funding for a different device if abilities change? <JoanneLasker> Yes, Adrienne it's important to consider the future of the user. For those adults with degenerative conditions, whose skills will be declining, we need to find a device/system that will meet their changing needs. Devices tend to be considered "useful" for a period of 5 years. (The length of usefulness of a device is covered under Frequently Asked Questions on the www.aac-rerc.com website). <JoanneLasker> But for the user in school, let's say, as abilities change, new systems may be required. We expect that language abilities in a child will change over time so it's important to get a device/system that will "grow with" a child in school. <sarah> Joanne, that was the case with my son. The device he has can grow with him for many years. <JoanneLasker> Sarah - I'm glad about that. <tberry> I'm sorry I'm coming in so late. I work as an AAC diagnostician for a public school system. I'm still confused as to who is responsible for funding the device if the patient is receiving outside services and ST in the school. If I complete the evaluation but the patient has a device at home, is the family required to send the device to school? <JoanneLasker> Tberry - so you're saying the kid has a device but his parents won't let him bring it to school? <tberry> yes <AdrienneFSU> That's a shame tberry! <tberry> It happens more than I realized. <Robin> how frustrating <JoanneLasker> Tberry - that's unusual. Most parents would want their kid to communicate effectively in all settings. <tberry> Yes, but they see the expense and I think there's the issue of who's going to fix it. <David_G> Tberry-its the school's obligation to provide one for school use. <JoanneLasker> Or is it an issue of who paid for the device originally? <tberry> that too <JoanneLasker> Tberry - oh, I see. So they don't want to let the school system "shirk its responsibility" for acquiring a device for their kid? That's a really sad situation. Sounds like there's a lot of acrimony and bad feeling there. <tberry> Correct. So you see the problem. I think it's a lack of giving the right information to the parents. <David_G> Joanne-I think you hit the nail on the head. <JoanneLasker> In an acrimonious situation, I think that some of these issues might need to be raised at the IEP meetings. It seems like the team needs to handle this issue as whole. <Robin> So in this case, the school funds one device for use in school and the one at home is funded by insurance? <tberry> Can that happen? <JoanneLasker> I have to say honestly that this is the first time I've heard of that arrangement, but I tend to do a lot more work with adults than with children. <David_G> If he brings it to school-no need for the district to buy one. <David_G> This way theirs is safe at home <sarah> Joanne -- speaking as a parent I believe that there is often no one in the school who is able to handle any problems that might occur with the device. I am the expert and am the primary programmer of the device my son uses. <JoanneLasker> Sarah raises the issue of programming the device. It's great that you're the primary on it. Are you willing to train other professionals (teacher, etc.) so your son can use it at school as well? <sarah> Joanne- yes I have trained his teacher and SLP. <JoanneLasker> Yes, the more people who know about the device the better. Sometimes it's one primary person who handles programming and managing the AAC system. If it is a family member, the benefit might be that the "primary knowledgeable" person doesn't change from year to year in school. <David_G> Sarah-all our speech staff are trained on the devices we have in the school-and we have 2 AAC people on staff to address problems. <JoanneLasker> I'm not sure I have a solution to tberry's situation. tberry - I'd be concerned about a kid having to use two different systems. Might the parents be convinced that he/she would be better off and more effective learning and using a single system? Perhaps some education/information sharing would help? <tberry> We try to match as close as possible. Believe it or not, many times we don't get all the information from the parents that the patient has a device at home or is being trained by outside services. <JoanneLasker> Oh, so they want you to purchase a duplicate device for school! <tberry> Correct Joanne. <JoanneLasker> I have heard of it going the other way around with schools not allowing the devices to go out to the home. <David_G> Joanne - by us it varies by district-but most will send it home. <JoanneLasker> Generally speaking, I have found that school districts do fund devices for kids (after the proper evaluations have been done). <sarah> Tberry- my son has two Chat PC2s, one at home and one at school. I make sure they both are programmed the same way. <JoanneLasker> Sarah - that's a lot of work for you. <Robin> Sarah, it sounds like you are doing a GREAT job for your son. <sarah> Robin- thanks <sarah> Yes, but I am lucky that the insurance paid for my training and that I can be at home to be his full time advocate. <David_G> Joanne-we were discussing a case today-parents sued to have a cochlear implant done- as educationally necessary. The district had to pay for the surgery, so paying for AAC devices should be a snap! <tberry> Since I am the only AAC person to follow-up with these issues, it is difficult to keep up with who has what. I still think it's up to the outside and school providers to keep an open line of communication and work on a team approach so everyone is on the same page. <JoanneLasker> Tberry - you've hit the nail on the head there! <dawn_c-j> Yes tberry, I am going to double check on the clients day program and see what they are using. <tberry> Dawn, I've trained the SLPs to make it a standard practice to ask for progress reports from other services and information regarding the device at the onset of new tx. <dawn_c-j> That's a good tip tberry. <JoanneLasker> I would stress the importance of everyday functional communication opportunities and how important it is that nonspeaking individuals can communicate with everyone and at any time. <AdrienneFSU> Joanne, can you talk about the paper trail? How does the SLP coordinate payer/device manufacturer/etc.? <JoanneLasker> Thanks for this question, Adrienne. The paper trail will vary with each funding approach. For most systems, SLPs need to write a report and often a doctor's prescription is required. For many Medicaid systems, prior approval is required for purchase. Medicare works a bit differently. <Robin> Joanne, do Medicare, Medicaid and the various insurances usually pay for the total cost of a device? <JoanneLasker> Medicare has set certain "fee schedule amounts" for what they believe certain devices are worth. They pay 80% of the device cost or that fee schedule amount (whichever is less). Secondary insurance, private insurance, Medicaid, or the client pays the other 20%. <sarah> Robin-- my son's device was covered at 80%, but with his other medical bills he had reached stop loss so it ended up being paid at 100%. <JoanneLasker> Private insurers vary in what they will pay. I've had many pay the entire cost. Also vocational rehabilitation will sometimes split the cost with another funder. <JoanneLasker> For litigation issues or cases in which funding has been denied, Lew Golinker, Esq. is a lawyer who specializes in handling these cases. His information is on the website I'll post. So, different funders pay differently. That's what makes this so confusing. Every case can be different. <AdrienneFSU> Better to have many avenues than none! <JoanneLasker> The bottom line really is that AAC is now "affordable" for pretty much everyone - child, adult, acquired disorder, developmental disorder. <AdrienneFSU> That's great. And how much time does this usually take? <JoanneLasker> Most funding issues (once all the paperwork is prepared) can go through the system so that a device is acquired within 2-3 months. <Robin> Thats a long wait for an adult with acquired disability. <sarah> Or a child whose speech is developmentally delayed. <JoanneLasker> Robin - for adults with a chronic condition the wait is really not bad. I've had reports turned around in 4-5 weeks with the device mailed promptly. For people with degenerative disease, we have ways to make the process go faster. For example, adults with ALS qualify for social security disability without the traditional 2-yr waiting period. <sarah> Joanne--please stress that a no from the insurance company is only the first step, please encougage the caregiver to keep fighting. <sarah> Joanne-- I can assure you it is worth every phone call or appeal that you have to make. <JoanneLasker> Yes, Sarah raises a good point about fighting for funding. A denial from an insurer does not mean the device is unattainable. Always request an appeal and consult Lew Golinker who specializes in how to handle the appeals process. <dawn_c-j> Joanne or anyone- have you ever been approved for a device for someone with apraxia? <sarah> Dawn-- my son has apraxia and was approved. <dawn_c-j> Oh - thanks sarah. <JoanneLasker> So the question is about a child with apraxia of speech? <dawn_c-j> A young adult with developmental delays. <JoanneLasker> I've had many devices approved for this disorder. <dawn_c-j> Good to know <JoanneLasker> Apraxia, aphasia, dysarthria, aphonia are all communication diagnoses that can benefit from the use of AAC. <dawn_c-j> I thought it was just for a non-verbal diagnosis. <JoanneLasker> Actually, many people with AAC needs have some usable speech. Their speech is just not adequate to meet their daily communication needs. So, the term "non-verbal" can be misleading. <dawn_c-j> I am right in the midst of making 3 recommendations in a residential setting for developmenatally delayed young adults. <sarah> Dawn-- most private insurers will not cover for developmental delay. <dawn_c-j> I am going thru Medicaid for these clients sarah. <sarah> Dawn-- can not help you there. <JoanneLasker> Sarah and Dawn - If the report is not written to explain the problem with the "keyword" diagnoses, some insurers will refuse, but this can be fought and overcome. "Cognitive status" should not be an issue -- everyone has the right to communicate. We as SLPs need to work to write the report to show how the client can use the system in meaningful ways to fulfill daily communication needs. Also, remember that many people with developmental delays will not perform well on standardized cognitive tests. We may need to demonstrate that, despite low standardized test scores, our clients can effectively use AAC to communicate. In other words, demonstrate that they have the necessary cognition to use the AAC system to meet their daily communication needs. There are examples of reports that include this on the website I'll post. <sarah> Joanne-- It was recommended for me to write a letter to the insurance company stating that the device was for my son's safety since he would be unable to tell anyone his name, address, etc. if lost or hurt. That it was a need for his health and safety. <JoanneLasker> Sarah - Yes, we need to be specific about how the device will be used. When we ask for funding for a device, we used to have to say it was all for "medical necessity." Some agencies still like to see that, but now Medicare has said that merely "communicating in a functional way to accomplish daily living needs" is a suitable goal. On a report, we should explain how the system will be used in specific situations, e.g. communicating in emergencies, talking to grandchildren on the phone, conducting transactions in the community. <dawn_c-j> These people live in a group home, I am not so concerned with the insurance angle right now, but I also understand the value of a thorough and precise report. <Robin> Joanne, how does the SLP working in the field keep up to date with new AAC devices and learn to identify which device is best suited for their client/patient? <JoanneLasker> To keep up to date with the field of AAC and what's available, I suggest that SLPs visit AAC booths at ASHA or state conferences or attend a CAMA conference (a Communication Aids Manufacturers Association) conference. <JoanneLasker> Also, the websites are great sources of information. When you're considering a device, it makes sense to visit the website for that vendor. Many vendors also have Funding Departments to help you with the funding process. Visiting a local assistive technology lab (associated with a school district) can help you get "hands-on" experience with the systems. <dawn_c-j> which websites? <JoanneLasker> Dawn - I meant the websites for the different device manufacturers and CAMA -- I'll post that one -- it has lots of links. <sarah> Dawn--It is also very easy to get on the manufacturers' catalogue mailing list. My son has had his device for 8 months now and I still get their updates. <JoanneLasker> Sarah - yes catalogues are also a good source of information. <Robin> We have been chatting for nearly an hour....Joanne, is there anything else you'd like to share with us tonight? <JoanneLasker> Seems like we've certainly covered a range of topics. <tberry> My 1st time in the chat room. Thanks everyone. Good nite. <Robin> Thanks for coming tberry, and sharing your experiences. <David_G> Joanne-this was great! <AdrienneFSU> Thanks for all the info! <sarah> Thanks <Robin> Sarah, your input as a parent was invaluable...thank you for joining us. <sarah> Robin thank for this forum. I will be in on other chats. <Robin> Courtney and lpoulin....you arrived late...any questions for Dr. Lasker before we say goodnight? <lapoulin> No, I'll read the transcript. Thank you for asking. <sarah> Joanne do you know of any web site geared toward program devices? <JoanneLasker> Do you mean websites that will teach you how to use the device? <JoanneLasker> There are a few websites from particular companies that have some tutorials on them. Offhand, I don't know their names. If you have a device, I'd go that website and look under Support. <lapoulin> I've downloaded the Springboard demo on my computer. It's been very helpful. <sarah> My biggest problem with my son's device was to program it toward a preschooler, so I guess I am looking for a site that helps suggest ideas and train of thought to set up his page to flow more smoothly and quicker for him. <Jennifer> What graduate school have good programs in AAC? <JoanneLasker> What part of the country are you interested in going to? <Jennifer> anywhere. <AdrienneFSU> Florida State U has a great AAC professor! And an AAC lab with MANY devices. <AdrienneFSU> not that I'm biased... <JoanneLasker> Thanks for the plug, Adrienne! Yes, FSU is good. Also Penn State, University of Nebraska, Southwest Missouri State, University of Wisconsin at Stevens Point. <Jennifer> I will look at the program online, thank you. <Robin> Dr. Joanne Lasker, thank you for sharing your expertise with us, once again! <dawn_c-j> Joanne I learned a few new things before I make my decisions. <Jennifer> Thanks for the helpful websites. <dawn_c-j> Thanks everyone for your input. <JoanneLasker> Sarah - Good luck to you and your son! Sounds like you're doing an amazing job with him! <dawn_c-j> and thanks again sarah. <lapoulin> I'm glad I found this site.....thank you so much! <JoanneLasker> Okay, everyone, thanks for participating! We'll be posting some information for you on this site. <Robin> Thanks again Dr. Lasker! Good night all! ADDITIONAL RESOURCES AND REFERENCES http://www.aac-rerc.com/ - Has lots of information about Medicare funding. Is in the process of being updated to include all current information. Contains sample funding reports, frequently asked questions, etc. http://www.aacproducts.org/index.lasso - This is the Communication Aid Manufacturers Association site. Has links to many vendors and AAC workshop information. Beukelman, D. R. & Mirenda, P. (1998). Augmentative and alternative communication: Management of severe communication disorders in children and adults (2nd edition). Baltimore, MD: Paul H. Brookes Publishing Co. |
