130 CMR, § 409.428

Current through Register 1538, January 3, 2025

Section 409.428 - Augmentative and Alternative Communication Devices and Speech Generation Devices (AAC)

(A)Covered Services. AAC devices are defined in 130 CMR 409.402. An AAC device must be a dedicated speech device, used solely by the member who has severe expressive communication impairment. Examples of AAC devices are

(1) communication boards or books;

(2) electro larynxes;

(3) speech/voice amplifiers;

(4) electronic devices that produce speech or written output; and

(5) communication software and applications.

(B)Requirements for Coverage. MassHealth covers AAC devices when

(1) The device or software is recommended by the member's multidisciplinary team, following a formal face-to-face evaluation and assessment by a licensed, certified, speech and language pathologist meeting nationally accepted knowledge and skill qualifications for AAC delivery, within six months prior to the date of the written prior authorization request. The speech-language pathologist must not be affiliated with the AAC provider. An ordering practitioner must prescribe the device or software, in accordance with the requirements in 130 CMR 409.416.

Information from other professionals may be included as needed for demonstrating motor or other needs, such as physical access to the device;

(2) The member has the cognitive, visual, language, and physical abilities to effectively use, or to learn how to effectively use, an AAC;

(3) The member meets all clinical coverage criteria in the Guidelines for Medical Necessity Determination for Augmentative and Alternative Communication Devices; and

(4) The provider has obtained prior authorization from the MassHealth agency for the AAC device. The request for a prior authorization request must include the MassHealth Prescription and Medical Necessity Review Form for DME, and documentation in accordance with 130 CMR 409.418 and documentation demonstrating that the conditions in in the clinical coverage criteria have been met, including a copy of the member's treatment plan.

(C)Trial Period.

(1) A trial-use period of not more than two months may be authorized by the MassHealth agency to determine if the device requested is appropriate for the member.

(2) The provider must submit the following documentation in order to receive a trial period with an AAC device:

(a) a prescription or letter of medical necessity pursuant to 130 CMR 409.416;

(b) a prior-authorization request pursuant to 130 CMR 409.418;

(c) an explanation of the type of AAC device to be used by the member, including all necessary components;

(d) identification of the clinicians or therapists who will assess the trial period; and

(e) the evaluation criteria specific to the member that will be used by the clinician or therapist to determine the success or failure of the trial period.

(3) Success of the trial period will be determined by a current evaluation of the therapeutic benefit of the AAC device completed by a licensed speech/language pathologist experienced in the assessment of AAC services.

(4) After evaluating all appropriate documentation, the MassHealth agency will decide whether to purchase the equipment or to continue renting up to the purchase price of the device.

(D)Reasons for Non-coverage. The MassHealth agency will deny coverage of an AAC device or software for reasons including, but not limited to, the following:

(1) the criteria set forth in 130 CMR 409.428(B) have not been met;

(2) after a trial period, the member has failed to demonstrate to the MassHealth agency's satisfaction that the device is medically necessary;

(3) the requested device is not a dedicated speech device; and

(4) the member does not meet the clinical criteria in MassHealth's Guidelines for Medical Necessity for Augmentative and Alternative Communication Devices.

(E)Coverage of AAC Devices Not Eligible for Federal Financial Participation. Coverage of AAC devices pursuant to M.G.L. c. 118E, § 10H must be in accordance with policies set by EOHHS for augmentative and alternative communication devices not eligible for Federal Financial Participation, in particular for augmentative and alternative communication devices not primarily and customarily used to serve a medical purpose.