The SGD Medicare Coverage Update
AAC technology changes fast. Medicare policy? Not so much.
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).
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.
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.
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.
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 wheelchair is not just a wheelchair. It's a part of me"
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:
Advocates believe that post election congress may move forward a larger Medicare bill--the mostly likely vehicle for this legislation.
- 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.
Learn more about CRT and the latest advocacy strategy at this NCART webpage.
List of national organizations supporting this legislation.
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 firstname.lastname@example.org or Weesie Walker at NRRTS at email@example.com.
Headed to ATIA 2015?
Register for EdcampAccess International--it's FREE!
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.
The Caribe Royale Hotel and Convention Center, Orlando FL
Saturday, January 31, 2015
12:30 PM - 4:30 PM
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