Winter 2014: AT Policy Advocacy

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AT Program News serves the state Assistive Technology Act Programs, the Alternative Financing Programs, and their community partners

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The SGD Medicare Coverage Update

 

AAC technology changes fast. Medicare policy? Not so much.
 

Amy Goldman

Amy Goldman provides context and analyses of Medicare's struggle to respond to changing times.


2014 has been a critical year for how Medicare handles its coverage of SGDs, and the result has been significant impact on individuals with complex communication needs. Currently the Centers for Medicare and Medicaid Services (CMS) is taking comments on a National Coverage Determination (NCD) for SGDs and so the situation remains dynamic. Below is an explanation of the issues and the history that has led to this policy moment. CMS needs to hear from as many knowledgeable people as possible before December 6th about their experiences and the SGD functions that individuals need.

What are SGDs?

SGD stands for "Speech-Generating Device." SGDs output audible speech for use by individuals who cannot speak with their voices or whose vocal speech is difficult to understand. The earliest voice output technologies were either specially engineered devices or computers or PDAs (personal digital assistants) with specialized software. Today most SGDs are portable devices, many make use of tablet computers or smart phone technologies.
 

2001: SGDs are Covered as DME


Prior to 2001, SGDs were considered “convenience items” by Medicare and not covered. As a result of concerted advocacy efforts and the education of health policymakers in the Centers for Medicare and Medicaid Services (CMS), in 2001 Medicare issued a National Coverage Determination (NCD) in which it agreed to cover medically necessary “speech-generating devices” as durable medical equipment (DME)– that is, medically necessary items that are “medical in nature." Required elements in the assessment process to satisfy the medical need for the device were also agreed upon (see www.rerc-aac.com). 
Portable speech generating device with dynamic display
This policy meant that Medicare would NOT pay for devices that were useful to those without disabilities. If beneficiaries needed specialized software that ran on a typical computer, Medicare would pay for the software but not the computer.

Consequently,
 manufacturers that built their devices on computer components “locked down” the generic functions (such as Internet access) to satisfy the DME requirement. Medicare beneficiaries, however, had the option to pay out of pocket to "unlock" the hardware at their own expense, once they owned the equipment (and access additional features). That practice remained unchallenged until recently.
 

Fast Forward to 2014


As in the general society, communication modes that do not require speech--e.g. texting and email--are now increasingly important for persons with disabilities. Advanced telecommunications now facilitate communication with healthcare providers, caregivers, friends and family. People with complex communication needs have more communication options today to direct their care, talk to their healthcare providers, and establish and maintain relationships with friends and family.

Wego tablet-style communication device

Tablets and smartphones have emerged as the latest technology for augmentative and alternative communication (AAC). While tablets are rarely covered by public insurance or private insurance, SGD companies have expanded the functionality of their products to compete with the communication capacities of these less expensive (mass produced) devices and to keep up with new opportunities made available by the Internet and social media for communication. "Locked" versions have continued to be available for Medicare funding purposes.
 

February's Medicare "Coverage Reminder"


Last February, however, regional Medicare Administrative Contractors (MACs) issued a "coverage reminder" to “clarify” the 2001 NCD, stating it would not cover SGDs if they have even the capacity to be "unlocked."  SGDs purchased by Medicare must not be upgradable by anyone, at any time in the life of the product, and manufacturers were told they would need to submit their devices for recertification/reclassification as SGDs. This policy blindsided the AAC tech community, AAC users, and those who provide AAC services.
 

April's Medicare "Capped Rental" Decision


In addition, effective April 1, 2014, CMS announced SGDs as available for coverage only through "capped rental." This was reported as an adjustment to align SGD coverage with existing policy for certain durable medical equipment. Rather than providing for ownership from the point of delivery, capped rental delays a beneficiary's ownership of DME for 13 months, and requires a monthly justification of need and eligibility for SGDs (until the rental period concludes and ownership is transferred). This is a significant administrative burden for vendors and consumers alike. In addition, capped rental denies DME to beneficiaries living in nursing facilities or receiving hospice services for 60 days or longer (Medicare’s “place of service” limitation). For individuals who begin their 13 month rental period at home and then move to a nursing facility or begin hospice services, the risk is alarming. They can lose the highly-customized SGDs they rely on to communicate with caregivers, medical personnel, and family at a critical juncture in their health status. Read "FAQs for Clinicians re: CMS capped rentals in the United States"
 

September's Letter from Congress to Medicare


Advocates grew frustrated. CMS’s failure to adequately respond to inquiries about the rationale for the policy changes stoked their efforts to educate Congress on the devastating impact and see if CMS would provide answers to lawmakers. On September 11th, 27 senators and 173 representatives signed on to a bipartisan letter to CMS detailing concerns over these policy changes. The letter additionally questions the recent denials of "eye tracking" technology for individuals who need it as their only means of accessing an SGD.
 
The letter observes that the Social Security Act allows for creating a process for patients to upgrade their Medicare-covered DME at their own expense. It questions the coverage of SGDs under capped rental when the Social Security Act allows for the purchase of items that are "uniquely constructed or substantially modified to meet the specific needs of an individual patient" (as SGDs routinely are). It also asks for the reporting of anticipated savings based on these coverage denials and an assessment of the impact of Medicare's SGD policy changes on individuals.  [Read the September 11th, 2014 Letter from Congress.]
 

November's Medicare Action on SGD Coverage

 
In response to a myriad of advocacy efforts that brought pressure on the agency, on November 6th, CMS issued a statement rescinding the February “clarification” and opened a benefit category determination process and 30-day comment period on SGDs. Disability advocates were initially encouraged. CMS appears to be reconsidering what constitutes a SGD:
 
"Since 2001, the technology of devices that generate speech and the ways in which the devices are used by patients to meet their medical needs has changed significantly. For example, patients now use speech devices to generate text and email messages for the purpose of communicating with their caregivers and physicians. Therefore, in light of the changes in technology and use of devices that generate speech, we are internally generating a reconsideration of this NCD to address coverage of devices that generate speech as well as other forms of communication."

Medicare has also directed its payment contractors to revert to their pre-February 2014 treatment of SGD claims during this period. Advocates believe this action reverses--at least for the time being--the policy of refusing to cover SGDs that may be "unlocked." 
 

BUT Capped Rental Remains Unchanged


While seemingly positive, however, this reversal does NOT take action on capped rental. If capped rental remains in place, Medicare beneficiaries will not own their SGDs for a minimum of 13 months and will, therefore, not have the option to unlock these devices for 13 months. Individuals in facilities or receiving hospice care beyond 59 days will continue to be denied coverage, and those who need eye-tracking to access an SGD have no assurance of coverage (eye tracking denials have been overturned on appeal, but CMS has not clarified its policy to its Medicare contractors).

In effect, the November 6th announcement does not provide changes that offer immediate relief for those who need SGDs for communication. It remains to be seen whether the recognition of the importance of full access to communication methods inclusive of Internet access will promote Medicare coverage of SGDs, or will further confound the “DME” status of these devices. 
 
Comments are rolling in to CMS.
Read comments
Submit yours by December 6th.

Stay up to date at Patient Provider Communication

Amy S. Goldman is a member of the Medicare Implementation Team. The Team is a small group of clinicians, researchers, educators and advocates who, between 1999 and 2001, helped Medicare staff develop the current SGD coverage criteria and, subsequently, address other issues related to Medicare recipients’ access to SGDs. It was recently reconvened to address the 2014 Medicare rule changes.

The Complex Rehab Technology Legislative Update


As of October 31st, 160 Representatives and 21 Senators have signed onto the Ensuring Access to Quality Complex Rehabilitation Technology Act (S. 948/H.R. 942), representing bipartisan support and support from key Congressional Committees.
 

What is Complex Rehab Technology? Why is access important?

 
Complex Rehab Technology (CRT) is the umbrella term for medically-necessary highly-configurable equipment such as certain customizable manual wheelchairs and power wheelchairs, adaptive seating and positioning systems, and other devices including gait trainers and standers.
 
Manual wheelchairs that are complex rehab technology
 
According to the National Coalition for Assistive and Rehab Technology (NCART), approximately 6% of manual wheelchairs and 15% of power chairs provided by Medicare fall into the category of CRT. While most wheelchairs purchased by Medicare are provided to the elderly, CRT is equipment used by persons of all ages who have disabilities and chronic medical conditions. CRT supports independence, access to school, work, and the community, and--significantly--the prevention of costly secondary conditions and illnesses. NCART reports the US spends $11 billion per year treating pressure ulcers, with the average hospital stay running $38,000. CRT provided by skilled providers prevents pressure sores and other conditions while greatly enhancing quality of life.

A man is getting fitted for a wheelchair with molded supports. Image is a link to a video about CRT.
"A wheelchair is not just a wheelchair. It's a part of me"
--Frank Alberding
 

What does this bill seek to do?

 
To ensure continued and improved access to appropriate CRT for Medicare beneficiaries who are prescribed equipment, advocates are requesting a separate benefit category be created, distinguishing CRT from Durable Medical Equipment (DME). CRT recipients need access not only to devices, but also skilled providers--often an interdisciplinary team--who can provide evaluations, fitting and modifications as well as training on the use of new equipment. The functional needs of persons prescribed CRT is best matched to devices and their features by  professionals who have no financial relationship with suppliers. A separate CRT benefit category would allow for a separate billing structure, coding, and improvements in coverage policies. The current outdated policy that lumps CRT with DME does not acknowledge the full range of services required (follow up care, repair, etc.) or the range of equipment complexity; it could lead to limited product choice and fewer services. Already the number of qualified CRT providers is shrinking.
 
In 2008, Congress acknowledged that CRT is unique, and created a CRT exemption from Medicare competitive bidding. Congress also created a separate benefit category for orthotics and prosthetics (O&P), recognizing the need for customization and specialized services. O&P now has its own polices, accreditation standards and reimbursement system. CRT, advocates argue, has  similar needs as O&P.

The Ensuring Access to Quality Complex Rehabilitation Technology Act calls for:
  • A separate benefit category from DME to allow for targeted policies and oversight;
  • Separate billing codes for CRT items to allow for a new payment system that reflects necessary services;
  • Establishing clinical conditions for service requiring evaluations by licensed PT or OT with no financial relationship to the CRT supplier;
  • Exemption from Medicare's "in-the-home" restriction on wheelchairs to allow for addressing needs outside the home environment;
  • Improved safeguards through higher quality standards than current DME standards, requiring qualified staff at each supplier for training and CRT repair;
  • Independent accreditation to assure supplier compliance with new standards;
  • Allowing persons in skilled nursing facilities to obtain CRT as part of a plan of care to transition to home and community.
Advocates believe that post election congress may move forward a larger Medicare bill--the mostly likely vehicle for this legislation.
 
Learn more about CRT and the latest advocacy strategy at this NCART webpage
List of national organizations supporting this legislation.

National CRT Leadership and Advocacy Conference. March 10-12, 2015. Click for Details.

The National Coalition for Assistive and Rehab Technology (NCART) and the National Registry of Rehabilitation Technology Suppliers (NRRTS) are partnering to hold the 3nd annual National CRT Leadership and Advocacy Conference. The conference brings CRT stakeholders together in one place for high value education, networking, and advocacy.

Program details and registration options will be announced in the coming months, so for now SAVE THE DATE in your calendar and share this information with others who are invested in the future of CRT. For additional information contact Don Clayback at NCART at dclayback@ncart.us or Weesie Walker at NRRTS at wwalker@nrrts.org

Headed to ATIA 2015?
Register for EdcampAccess International--it's FREE!

edcamp logo with apple as flame
EdcampAccess is an unconference devoted to K-12 special education with a focus on teaching all struggling learners and the use of assistive technology. The event is not limited to special educators. All are welcome to attend and share your expertise!

The Edcamp tradition calls for each Edcamp agenda to be created by participants for the benefit of participants. 

"Built on principles of connected and participatory learning, Edcamp strives to bring teachers together to talk about the things that matter most to them: their interests, passions, and questions."
--the Edcamp Foundation

Attendees may choose to facilitate a session, lead discussions or attend sessions of interest to further their professional learning.

Where:
The Caribe Royale Hotel and Convention Center, Orlando FL

When:
Saturday, January 31, 2015

Time:
12:30 PM - 4:30 PM

Tentative Schedule:
12:30-12:50: Intro / Welcome / Build the session board
1:00-1:50: Session 1
2:00-2:50: Session 2
3:00-3:50: Session 3
4:00-4:30: Wrap up / Group Sharing-App Smackdown / Prizes

Register and learn more

PARCC Accessibility Update


New guidelines suggest students may use their own AT for assessments, but alarming policy gaps remain


The Partnership for Assessment of Readiness for College and Careers (PARCC) is creating scholastic assessments based on the new Common Core State Standards for its consortium of states. AT Program News reported extensively on advocacy efforts to improve accessibility of the new digital assessments in our last newsletter. Below is an update reflecting the latest edition of PARCC's Accessibility and Accommodations Manual. 

"It does not appear that PARCC has improved much in this version of their accommodations manual," ATAP's Diane Cordry Golden reported to the statewide AT Act programs in a recent email. "Many people were hopeful after the NFB suit that things would be changed significantly."

One key frustration, however, does show signs of progress. In this 3rd edition of the manual, PARCC has included language suggesting intent to allow the use of a student's own AT: 
 
"Students may use a range of assistive technologies on the PARCC asessments, including devices that are compatible with the PARCC online testing platform, and those that are used externally (i.e on a separate computer)."

Additionally, it suggests further guidance will be forthcoming: "For information on how to test assistive technology devices and software for use on the PARCC assessments with the TestNav 8 platform via an "Infrastructure Trail," refer to the Assistive Technology Guidelines available at 
www.parcconline.org/
parcc-accessibility-features-and-accommodations-manual." (The website indicates the AT Guidelines be released in late November).

"Of course the devil is in those details," Golden reminds ATPN (in a phone interview). "What is required to use a student's AT? Who will make it happen? How will it work?"

Indeed, one of the areas that continues to stymie many is the bureaucratic burden that assessing, documenting, and uploading individual assessment needs for each student will require for PARCC's Personal Needs Profile (PNP). In addition to the IEP/504 plan, every student will have a PNP to record preferences as well as accommodations (including those without IEPs if they make use of embedded Universal Design tools available for activating).

 
Also concerning are the ways PARCC continues to convey a lack of knowledge about how students with disabilities use assistive technology tools. There continues to be no acknowledgment of graphic organizers, the single most commonly used writing tool by students with disabilities. And while text-to-speech (TTS) is permitted for students who document a need, use of this built-in feature on the ELA portion of the PARCC assessment will generate the notation: "no claims should be inferred regarding the student's ability to demonstration foundational reading skills (i.e., decoding and fluency)." More alarming, TTS is neither available nor recognized as a tool students commonly use for proof reading their own writing; it continues to be restricted for use by students with print disabilities only, rather than allowed for use by all students with disabilities as a reading support to increase reading speed, fluency, and comprehension.

"Yet in some places you can really see where the test developers are trying," Golden acknowledges, "just without sufficient disability expertise!" New to this edition, she highlights, is an accommodation for students to manually sign responses to a scribe using American Sign Language. But the transcription guidelines fall short. "Student's responses," the manual asserts, "must be transcribed exactly as dictated/signed (e.g., the human scribe/signer may not change, embellish, or interpret a student's responses when transcribing."

"You cannot do a verbatim translation of ASL to English," she notes. (ASL is not English and has its own unique grammar.)

On the positive side, Golden notes the separation of Screen Reader Guidelines from TTS. "We assume the difference is that the screen reader access includes audio navigation where the TTS access does not. This suggests PARCC now understands the non-visual navigation needs of students who are blind."

See below for the official PARCC summary of changes.
In an email to colleagues, Tamara Reavis, PARCC Senior Adviser on Accessibility and Equity, reports the following changes in the 3rd Edition of the PARCC Accessibility and Accommodations Manual:

1. New and revised language added on the Personal Needs Profile (p.19-20)
 
2. Clarified information on the accessibility features available to all students (p.22-26):

o   Added a low contrast option for “color contrast (background/font color)”

o   Added browser magnification limits for “magnification/ enlargement device”
 
o   Noted that spell check is available through an external device.
 
o   Provided all available modes for text-to-speech for mathematics (including text-to-speech, human reader, or human signer).

3. Combined Sections three and four to streamline the document, and added/clarified a number of accommodations (p. 27-48)

o   Presentation accommodations for students with disabilities:
  • Added a link to where the Assistive Technology Guidelines will be posted on PARCConline.org in mid-November.
     
  • Split out the following accommodations into separate categories: refreshable braille display with screen reader version for ELA/literacy; hard copy braille edition; tactile graphics.
     
  • Included large print edition and paper-based edition accommodations, and referred readers to Appendix A for additional guidance.
     
  • Provided all available modes for text-to-speech for ELA/literacy (including text-to-speech, screen reader only, ASL video, human reader, or human signer).
     
  • Clarified language for text-to-speech accommodation for ELA/literacy.
     
  • Included a human signer for test directions.
     
  • Added the following accommodation: student reads assessment aloud to themselves.
o   Response accommodations for students with disabilities:
  • See assistive technology note above.
     
  • Added a braille writer accommodation.
     
  • Added a calculator accommodation for the calculator sections of the mathematics assessments.
     
  • Revised calculator accommodation for the non-calculator sections of the mathematics assessments based on PARCC blueprints.
     
  • Provided all available modes for scribing for each content area (including speech-to-text, human scribe, human signer, and external assistive technology device).
     
  • Clarified that word prediction will be done via an external device.
  Accommodations for English learners:
  • Provided all available modes for speech-to-text for mathematics (speech-to-text or human scribe).
     
  • Added ten highest incidence languages across PARCC states for translation of general test administrator directions.
     
  • Added online, paper-based, and large print translation of the mathematics assessments as an accommodation (at state discretion, approved by the Governing Board in 2013).
     
  • Added text-to-speech and/or human reader in Spanish or other languages as needed for the mathematics assessments (at state discretion, approved by the Governing Board in 2013)
Streamlined the final section (originally Section 5 and now Section 4) for clarity (p. 49-67).

Generation Tech: Your Student Here!


Headed to ATIA 2015 this January? Join ATPN's Editor-in-Chief Eliza Anderson, special educator Melissa Bugaj and author/AT guru Christopher Bugaj for Generation Tech! Empower students
with an authentic writing/publishing opportunity


Learn how student's who love their technology are published in AT Program News!

Where? Caribbean IV (at the Caribe Royale Hotel and Convention Center in Orlando Florida!)
When? Thursday, January 29th
Time? 8:00 AM!
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