Current through Register Vol. 43, No. 02, November 27, 2024
(1) Coverage is provided for Augmentative
Communication Devices (ACD) for eligible individuals who meet criteria set out
herein. Prior authorization for the ACD service is required. Requests for prior
authorization must be made on the appropriate Alabama Prior Review and
Authorization Request Form. The request must include documentation regarding
the medical evaluation by the physician and speech language pathologist and
recipient information.
(2) ACDs are
defined as portable electronic or non-electronic aids, devices, or systems
determined to be necessary to assist a Medicaid-eligible recipient to overcome
or improve severe expressive speech-language impairments or limitations due to
medical conditions in which speech is not expected to be restored, and which
enable the recipient to communicate effectively. These impairments include but
are not limited to: apraxia of speech, dysarthria, and cognitive communication
disabilities. These devices are reusable equipment items which must be a
necessary part of the treatment plan consistent with the diagnosis, condition
or injury, and not furnished for the convenience of the recipient or his
family. ACD components or accessories prescribed or intended primarily for
vocational, social, or academic development or enhancement and which are not
necessary as described above will not be covered.
(3) The scope of services includes the
following elements:
(a) Screening and
evaluation,
(b) ACD, subject to
limitations, and
(c) Training on
use of equipment.
(4)
Candidates under the age of 21 must meet all of the following criteria:
(a) EPSDT referral by Medicaid-enrolled EPSDT
provider. Referral must be within one year of application for ACD. The EPSDT
provider must obtain a referral from the Patient 1st PMP (where
applicable);
(b) Medical condition
which impairs ability to communicate;
(c) Evaluation by required qualified,
experienced professionals; and
(d)
Physician prescription or order to be obtained after the evaluation and based
on documentation contained in the evaluation.
(5) Candidates over the age of 21 must meet
all of the following criteria:
(a) Referral
from a Patient 1st PMP (where applicable). Referral must be within one year of
application for ACD;
(b) Medical
condition which impairs ability to communicate;
(c) Evaluation required by qualified
experienced professionals; and
(d)
Physician prescription or order to be obtained after the evaluation and based
on documentation provided in the evaluation.
(6) The candidate must be evaluated by
qualified interdisciplinary professionals. Interdisciplinary professionals must
include all of the following:
(a)
Speech-Language Pathologist: This professional must meet all of the following
criteria:
1. Have a master's degree in
speech-language pathology from an accredited institution;
2. Have a Certificate of Clinical Competence
in Speech-Language Pathology from the American Speech, Language, Hearing
Association;
3. Have an Alabama
license in speech-language pathology;
4. Have no financial or other affiliation
with a vendor, manufacturer, or manufacturer's representative of
ACDs.
(b) Physician:
This professional must meet all of the following criteria:
1. Be a doctor of medicine or osteopathy
legally authorized to practice medicine and surgery by the state in which the
doctor performs such functions; and
2. Have no financial or other affiliation
with a vendor, manufacturer, or manufacturer's representative of ACDs.
Interdisciplinary professionals should also include, but may
not be limited to, the following:
(c) Physical Therapist: This professional
must meet all of the following criteria:
1.
Have a bachelor's degree in physical therapy from an accredited
institution;
2. Have an Alabama
license in physical therapy; and
3.
Have no financial or other affiliation with a vendor, manufacturer, or
manufacturer's representative of ACDs.
(d) Social Worker: This professional must
meet all of the following criteria:
1. Have a
bachelor's degree in social work from an accredited institution;
2. Have an Alabama license in social work;
and
3. Have no financial or other
affiliation with a vendor, manufacturer, or manufacturer's representative of
ACDs.
(e) Occupational
Therapist: This professional must meet all of the following criteria:
1. Have a bachelor's degree in occupational
therapy from an accredited institution;
2. Have an Alabama license in occupational
therapy; and
3. Have no financial
or other affiliation with a vendor, manufacturer, or manufacturer's
representative of ACDs.
(7) ACDs and services are only available
through the ALABAMA MEDICAID AGENCY prior authorization process. Requests for
authorization must be submitted to Medicaid for review. Documentation must
support that the client is mentally, physically, and emotionally capable of
operating and using an ACD. The request must include documentation regarding
the medical evaluation by the physician and recipient information:
(a) Medical Evaluation by Interdisciplinary
Professionals must meet all of the following criteria:
1. Medical examination by physician to assess
the need for an ACD to replace or support the recipient's capacity to
communicate;
2. Status of
respiration, hearing, vision, head control, trunk stability, arm movement,
ambulation, seating and positioning or ability to access the device;
and
3. Must have been conducted
within 90 days of request for ACD.
(b) Recipient Information must include all of
the following:
3. Date(s) of assessment;
4. Medical diagnoses (primary, secondary,
tertiary); and
5. Relevant medical
history.
(c) Sensory
Status (by physician) must include all of the following:
3. Description of how vision, hearing,
tactile, and/or receptive communication impairments affect expressive
communication (e.g., sensory integration, visual discrimination).
(d) Postural, Mobility, and Motor
Status must include all of the following:
3. Integration of
mobility with ACD; and
4.
Recipient's access methods (and options) for ACD.
(e) Developmental Status must include all of
the following:
1. Information on the
recipient's intellectual, cognitive, and developmental status; and
2. Determination of learning style (e.g.,
behavior, activity level).
(f) Family/Caregiver and Community Support
Systems must include all of the following:
1.
A detailed description identifying caregivers and support;
2. The extent of their participation in
assisting the recipient with use of the ACD; and
3. Their understanding of the use and their
expectations of the ACD.
(g) Current Speech, Language, and Expressive
Communication Status must include all of the following:
1. Identification and description of the
recipient's expressive or receptive (language comprehension) communication
impairment diagnosis;
2. Speech
skills and prognosis;
3.
Communication behaviors and interaction skills (i.e., styles and
patterns);
4. Description of
current communication strategies, including use of an ACD, if any;
and
5. Previous treatment of
communication problems.
(h) Communication Needs Inventory must
include all of the following:
1. Description
of recipient's current and projected (e.g., within five years) speech-language
needs;
2. Communication partners
and tasks, including partners' communication abilities and limitations, if any;
and
3. Communication environments
and constraints which affect ACD selection or features.
(i) Summary of Recipient Limitations which
must contain a description of the communication limitations.
(j) ACD Assessment Components must contain a
justification for and use to be made of each component and accessory
requested.
(k) Identification of at
least three ACDs considered for recipient to include all of the following:
1. Identification of the significant
characteristics and features of the ACDs considered for the
recipient;
2. Identification of the
cost of the ACDs considered for the recipient (including all required
components, accessories, peripherals, and supplies, as appropriate);
3. Identification of manufacturer;
4. Justification stating why a device is the
least costly, equally effective alternative form of treatment for the
recipient; and
5. Medical
justification of device preference, if any.
(l) Treatment Plan and Follow-Up must include
all of the following:
1. Description of
short-term and long-term therapy goals;
2. Assessment criteria to measure the
recipient's progress toward achieving short-term and long-term communication
goals;
3. Expected outcomes and
description of how device will contribute to these outcomes; and
4. Training plan to maximize use of
ACD.
(m) Documentation
of recipient's trial use of equipment must include all of the following:
3. Analysis of ability to use
equipment.
(n)
Documentation of qualifications of speech-language pathologists and other
professionals submitting portions of the evaluation must be present. Physicians
are exempt from this requirement.
(o) A signed statement by submitting
professionals that they have no financial or other affiliation with
manufacturer, vendor, or sales representative of ACDs must be present. One
statement signed by all professionals will suffice.
(8) Medicaid reserves the right to request
additional information or evaluations by appropriate professionals.
(9) ACDs are subject to the following
limitations. ACDs, including components and accessories, will be modified or
replaced only under the following circumstances:
(a) Medical Change: Upon the request of
recipient if a significant medical change occurs in the recipient's condition
which significantly alters the effectiveness of the device.
(b) Age of Equipment: ACDs outside the
manufacturer's or other applicable warranty which do not operate to capacity
will be repaired. At such time as repair is no longer cost-effective, upon
request by the recipient, replacement of identical or comparable component or
components will be made. Full documentation of the history of the service,
maintenance, and repair of the device must accompany such requests.
(c) Technological Advances: No replacements
or modifications will be approved based on technological advances unless the
new technology would meet a significant medical need of the recipient which is
currently unmet by the present device.
(10) All requests for replacement or
modification as outlined in A-C above will require a new evaluation and
complete documentation. If new equipment is approved, the old equipment must be
turned in.
(11) Invoice: The
manufacturer's invoice must be forwarded to the Medicaid Agency or its designee
before the prior authorization is approved.
(12) Trial Period: No communication
components will be approved unless the client has used the equipment and
demonstrated an ability to use the equipment. Prior authorization for rental
may be obtained for a trial period. This demonstrated ability can be documented
through periodic use of sample or demonstration equipment. Adequate supporting
documentation must accompany the request.
(13) Repair: Repairs are covered only to the
extent not covered by the manufacturer's warranty. Repairs must be prior
authorized. Battery replacement is not considered repair and does require prior
authorization.
(14) Loss or Damage:
Replacement of identical components due to loss or damage must be prior
authorized. These requests will be considered only if the loss or damage is not
the result of misuse, neglect, or malicious acts by the users.
(15) Component or Accessory Limits:
Components or accessories which are not medically required will not be
approved. Examples of non-covered items include, but are not limited to,
printers, modems, service contracts, office or /business software, software
intended for academic purposes, workstations, or any accessory that is not
medically required.
Author: Kelli Littlejohn Newman, PharmD,
Director, Clinical Services
Statutory Authority: State Plan;
42 CFR, Section
440.70; Title XIX, Social Security
Act.
