Ala. Admin. Code r. 560-X-13-.14

Current through Register Vol. 42, No. 12, September 30, 2024

Section 560-X-13-.14 - Augmentative Communication Devices

(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:

1. Name;

2. Medicaid number;

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:

1. Vision status;

2. Hearing status; and

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:

1. Motor status;

2. Optimal positioning;

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:

1. Amount of time;

2. Location; and

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.

Ala. Admin. Code r. 560-X-13-.14

New Rule: Filed March 22, 1999; effective April 26, 1999. Amended: Filed October 12, 2001; effective November 16, 2001. Amended: Filed December 30, 2008; effective February 3, 2009.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016.

Author: Kelli Littlejohn Newman, PharmD, Director, Clinical Services

Statutory Authority: State Plan; 42 CFR, Section 440.70 ; Title XIX, Social Security Act.