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
<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
<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
<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
<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
<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
<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.