Medicare Frequently Asked Questions And Answers (FAQs):

FAQ #2. How is Medicare Different than Medicaid?

Medicare and Medicaid are commonly confused. In a general sense, Medicare and Medicaid are most similar because of the complexity of their benefits programs, which have been described by judges as "unintelligible to the uninitiated." Many SLPs may find they agree with this description, particularly as they make their first inquiries about Medicare coverage of AAC assessment and AAC devices. Even so, these programs offer many essential services to individuals with severe communication disabilities, and SLPs are encouraged to proceed despite the initial, inevitable confusion. The characteristics of both programs are summarized in the following table:

FAQ #3. Who Is Eligible for Medicare?

Medicare provides coverage to approximately 40 million Americans. It covers all Americans age 65 and older, independent of health, income, or disability status.Medicare also covers three groups of individuals younger than age 65 who have been determined to be disabled under the Social Security Disability Insurance program rules. 1. Individuals who worked and paid the required contributions into the Social Security system while they were working. See Note 1 below. 2. Individuals with disabilities, including the children with disabilities of individuals who paid into the Social Security system, when the family member becomes disabled themselves, retires, or dies. 3. Individuals who have End Stage Renal Disease.Note 1: Typically, individuals with disabilities become eligible for Medicare benefits 24 months after they become disabled. However, at the end of 2000, Congress expanded eligibility for individuals diagnosed with ALS to waive the 24-month wait-period. This means that individuals with ALS will become eligible for Medicare sooner, and can obtain reimbursement for SLP services, AAC evaluations and AAC devices when they are needed. Dual Eligibility for Medicare and Medicaid: Some people who worked and who paid into the Social Security system had very low paying jobs, and sadly, many people age 65 and older are poor. Thus, individuals may qualify for Medicaid because of their income, and for Medicare because of their age or disability status. Thus, some individuals will be dually eligible for Medicare and Medicaid. For individuals with dual eligibility, rules are established to coordinate benefits between the two programs. This is discussed below in answer to Question __.

FAQ #4. Why Does Medicare Call AAC Devices "Speech Generating Devices?"

Medicare administrators proposed to change the name of AAC devices to "speech generating devices" or "SGD." The first time this name change appeared was in October 2000, when the DME Regional Carrier (DMERC) Medical Directors distributed the draft "Regional Medical Review Policy" or RMRP. The RMRP, however, was not accompanied by an explanatory text.
In mid-December, comments were submitted to the RMRP. These comments offered 3 alternatives for the DMERC medical directors to consider:

FAQ #5. What AAC Devices Are Covered by Medicare?

Medicare has established four "codes" for AAC devices, with each code
representing a group of devices with similar characteristics. The four codes
are described as follows:

Medicare guidance also provides some additional description of what these device codes mean:

Digitized speech (K0541, K0542), sometimes referred to as devices with "whole message" speech output, utilize words or phrases that have been recorded by an individual other than the SGD user for playback upon command of the SGD user. Synthesized speech (K0543, K0544), unlike the pre-recorded messages of digitized speech, is a technology that translates a user's input into device-generated speech using algorithms representing linguistic rules. Users of synthesized speech SGDs are not limited to pre-recorded messages but rather can independently create messages as their communication needs dictate.

In short, Medicare has included all AAC devices (Speech Generating Devices or SGDs) in these "codes."

Coding, however, does not automatically equal Medicare "coverage." As to coverage, Medicare will cover all the digitized speech output AAC devices that currently exist, and all the AAC devices that fit the characteristics of the K 0543 code.

For devices in the K 0544 code, by contrast, one coverage limitation or exception has been stated. Medicare will cover and provide reimbursement for AAC devices that are "dedicated" speech generating devices. Medicare's Regional Medical Review Policy (RMRP) states:

Laptop computers, desktop computers, PDAs [personal digital assistants] or other devices that are not dedicated SGDs are noncovered because they do not meet the definition of durable medical equipment (DME).

The AAC device manufacturers responded to Medicare's concerns: they modified existing multi-functional devices to meet the Medicare "dedicated device" limitation. As a result, a new group of AAC devices has been created and will soon be introduced into the marketplace. These devices are the "dedicated twins" of multi-functional, computer- and PDA-based AAC devices.

The devices that have modified include:

Prototypes of these devices were demonstrated to Medicare administrators in March and April, 2001, and were the catalyst for a policy clarification letter issued by Medicare on May 4. That letter states:

"Computer-based and PDA-based AAC devices/speech generating devices are covered when they have been modified to run only AAC software."

As a result of the manufacturers' quick response and Medicare's agreement that these devices meet the agency's expectations, these devices can be recommended for Medicare beneficiaries as soon as they are ready for distribution, and they will be eligible for Medicare reimbursement.

USSAAC members and others interested in more specifics about the features of these devices should contact the manufacturers. The manufacturers also should be contacted for information about the availability of these devices, for product literature and/or demonstrations. In addition, it is expected that all of these devices will be offered for a price that will permit the taking of "assignment" for these devices, which will maximize their access by Medicare beneficiaries. [See FAQ __ for more information about "taking assignment."]

Also, because almost no other funding programs have a position about "dedicated" devices comparable to that of Medicare, the AAC device manufacturers will continue to offer their multi-functional devices to individuals who need them.

FAQ#6. Why Aren't All AAC Devices Covered?

As explained in the answer to FAQ # 5, Medicare has defined 4 groups or "codes" of AAC devices, and has agreed to cover all existing AAC devices that fit into three of the four speech-generating device codes. All digitized speech output devices are covered (K 0541; K 0542), as are all synthesized speech output devices that require physical contact direct selection and message formulation by spelling. (K 0543). Among the devices that fit the fourth code: which produce synthesized speech and allow multiple methods of access and multiple methods of message formulation (K 0544), Medicare will cover all dedicated devices, and computer-based and PDA-based devices "that have been modified to run only AAC software. " (Letter dated May 4, 2001-- available for review and downloading ______________ ).

Medicare's coverage guidance on AAC devices/SGDs: the Regional Medical Review Policy (RMRP) and the National Coverage Decision on SGDs (# 60-23), both state that "multi-functional" AAC devices are not covered because Medicare believes they do not satisfy the Medicare definition of "durable medical equipment."

Two of the four criteria in Medicare's definition of durable medical equipment state that an item be "primarily and customarily used to serve a medical purpose;" and "generally not useful to an individual in the absence of illness or injury." Medicare views multi-functional, computer-based and PDA-based AAC devices as not meeting these criteria. This conclusion is obvious if these devices are viewed as computers and PDAs, as opposed to communication aids. In addition, Medicare has long-standing guidance that excludes equipment that for some individuals and in some circumstances can be of medical benefit, but which also has other, non-medical uses and benefits.

Although it is possible to argue with Medicare's conclusions and policy regarding multi-functional devices, leading AAC professionals and the AAC device manufacturers concluded it would be easier and faster, and thereby in the best interests of Medicare beneficiaries with current AAC needs to modify existing devices to meet Medicare's concerns. By doing so, some features of some AAC devices have been modified, but Medicare beneficiaries will have immediate access to the broadest range of devices that can help them meet their daily communication needs.

In addition, by making these modifications, the AAC device manufacturers recognize they now face an additional technical challenge: to adapt their AAC software to incorporate more features so that AAC device users have access to all the functions they require, and/or to otherwise make it possible for AAC device users to gain access to these functions. When modified computer-based and PDA-based devices are being considered, SLPs and beneficiaries should contact the manufacturers regarding these additional features, such as e-mail and text-processing, to see what options exist to make them available.

FAQ#7. Are AAC Assessments and Training -- SLP Services Covered?

Yes. AAC Assessments and Training Services are covered by Medicare as SLP services if the SLP works in a facility that is a Qualified Provider. Otherwise, SLP services are not covered. Briefly, the setting the SLP works in determines whether or not he/she is "Medicare Qualified" to be reimbursed for SLP Assessments and Training, including AAC services. Typically, SLPs know whether (or not) they can bill Medicare for SLP services. SLPs may be paid directly by Medicare only if they establish a rehabilitation agency; this agency may be limited to speech-language pathology services only. Practitioners billing through physicians' offices or medical clinics must be employees, not contractors.

FAQ#8. How Much Will Medicare Pay for AAC Assessments and Training -- SLP Services?

If an SLP works in a Medicare Qualified setting and thus is a "Qualified Provider," Medicare will pay for an AAC assessment and for AAC Training. The costs allowed are variable by State and are arrived at by a complicated formula. Current Medicare fees are posted on the ASHA website http://www.asha.org AAC Assessments and Training are now assigned G codes (which is a billing code). G codes represent "new billing codes." After awhile, AAC Assessments and Training will be assigned standard codes (or CPT codes).

FAQ#9. How Much Will Medicare Pay for AAC Devices?

Medicare regulations state that Medicare will pay 80% of the lesser of the following:

• The actual charge for the AAC device; or
• The fee schedule established for the AAC device.

Medicare has created four "codes" or categories of AAC devices, and has created a fee schedule for each code. The formula for calculating the reasonable charge is exceedingly complex, and cannot easily be re-stated here. The fee schedules for AAC devices with the following characteristics are as follows:

FAQ #10. How Much Must A Beneficiary Pay For An AAC Device?

Medicare requires beneficiaries to pay one of the following amounts for an AAC device:

FAQ #11. What Does "Accepting Assignment" Mean?

Medicare is a cost reimbursement program, like many insurance policies. This means that the beneficiary must incur a charge -- usually associated with having an examination or procedure performed, or purchasing an item of equipment -- before a claim can be submitted. After the charge is incurred, the claims procedure begins.
In Medicare, a claims procedure has evolved that is called "accepting assignment." Medicare has set a fee schedule for many covered procedures and devices, thus suppliers (manufacturers and their representatives) can develop a reasonable expectation of the amount they will be reimbursed. To make the service delivery and billing processes easier for their patients and customers, many manufacturers have agreed to follow a practice that is the equivalent to "billing Medicare first." Suppliers know Medicare will pay only 80% of the fee schedule or actual cost of the device, so the supplier charges 20% of this amount as a co-payment to be paid by the beneficiary at the time the device is delivered. When the co-payment and the other claims paperwork are received, the supplier submits the claim to Medicare and receives the balance from Medicare as reimbursement. Note: When a supplier accepts assignment, Medicare pays the supplier; if not, Medicare pays the beneficiary. The amount paid by Medicare, however, remains the same. The relationship between the fee schedule amount and the actual charge will lead AAC device suppliers to decide whether (or not) to "accept assignment." If the actual charge is below the fee schedule amount, suppliers will undoubtedly accept assignment. This makes their devices easier for beneficiaries to acquire, i.e., they need to pay only 20 % of the price to the supplier. By contrast, for devices that have selling prices (actual charges) above the fee schedule amount, the greater the difference, the greater the likelihood the supplier will not accept assignment. Suppliers' decisions whether to accept assignment are important from a business perspective. If a supplier agrees to accept assignment, it will receive from Medicare 80% of the fee schedule amount, or, 80% of the actual charge for the device, whichever is less. In addition, the supplier will receive 20 % as a co-payment from the beneficiary. When a supplier agrees to accept assignment, there can be no "balance billing" to the beneficiary. Thus, for a device with a selling price higher than the fee schedule amount, the supplier who accepts assignment will be agreeing to accept a reduced total payment for the device. When a supplier does not agree to accept assignment, the supplier can charge (and receive from) the beneficiary the full price of the device. The beneficiary will then be reimbursed 80% of the fee schedule amount. Accepting assignment is a very common billing/claims procedure among Medicare DME suppliers. As the cost of a device increases, the supplier's willingness to accept assignment can make the difference between whether or not the device will be available to the beneficiary. Because many AAC devices cost thousands of dollars, beneficiaries and their families often find it very difficult to pay the full price of a device, even though they must first do so in order to seek and receive Medicare reimbursement. In short, when a family cannot afford the AAC device, the potential Medicare reimbursement rates become meaningless. Most significantly, these beneficiaries will be unable to get or derive any benefit from the AAC device that is prescribed by the SLP and physician.From the supplier's perspective, when a device costs more than the fee schedule allows for a device category, when they "accept assignment", they are accepting a mandatory discount. However, if they do not accept assignment, they are most likely forgoing any sale at all so everyone loses. At present, our understanding is that all the devices in the K3 and K4 codes, i.e., all the synthesized speech output devices that we know to be covered, will have assignment taken. However, SLPs need to contact the suppliers to learn whether assignment will be taken for the device they are recommending.

FAQ #12. What if A Beneficiary Cannot Afford the Co-Payment? Can the Co-Payment be Waived? Must the Co-Payment be Paid in a Lump Sum?

Medicare requires durable medical equipment suppliers to collect the 20 % co-payment -- of either the actual charge for the device, or of the fee schedule amount -- from beneficiaries. However, as the cost of items increases, beneficiaries' ability to afford the co-payment amount can become a significant challenge. Medicare guidance acknowledges this potential difficulty, and has created an exception to this rule. A beneficiary may ask the AAC device manufacturer/supplier to waive the co-payment, because to pay it will create a special financial hardship. When such a request is received, the manufacturer/supplier should then determine, for this particular individual, whether collection of the co-payment should be waived. This exception must be based on a determination made by the manufacturer/supplier, and it must be made on a case-by-case basis. The beneficiary cannot self-certify that he/she is indigent, and manufacturers/suppliers cannot routinely waive the co-payment amount for all beneficiaries or any specific classes of beneficiaries. No definition or specific criteria have been found regarding what constitutes "special financial hardship," or to otherwise guide manufacturers/suppliers in this determination, but it is clear that Medicare expects it to be used rarely. Medicare guidance states clearly that the routine waiver of the co-payment amount is impermissible.Because SLPs will be discussing AAC device cost issues with most beneficiaries and their families as part of the device recommendation process, the SLP should be prepared to discuss the potential for a co-payment waiver. If the family believes they must pursue such a waiver, the SLP should provide information for the family to contact the manufacturer/supplier directly.Just as each manufacturer will be required to determine, on a case-by-case basis whether to waive the co-payment due to beneficiary indigence, each manufacturer also will have to determine whether it is willing to allow the family to divide the co-payment amount into multiple payments.

FAQ #13. What If the Beneficiary Cannot Afford to Purchase a Device When a Manufacturer/Supplier Will Not Accept Assignment?

Medicare coverage does not exist for all AAC devices, at present, and for some devices that are covered, the manufacturer/supplier may conclude that the applicable fee schedule amount is too low. In both of these circumstances, the manufacturer/supplier will not accept assignment for that particular device. As a result of that decision, the beneficiary will be required to pay the full catalogue or retail price for the device. Following the purchase of the device, a claim for Medicare reimbursement can then be made. However, both purchase of the device and the filing of the Medicare claim can occur only if the beneficiary can afford the initial purchase price of the device. If not, the beneficiary will not be able to obtain the device; there is no Medicare claim; there is no Medicare reimbursement; and the beneficiary will have no tangible benefits in functional communication ability.The dilemma posed by manufacturers/suppliers' refusal to accept assignment is a familiar one: it describes the principal barrier to AAC device access that existed up to the Medicare policy change on January 1, 2001. Because the "convenience item" guidance made reimbursement uncertain and in any event, delayed it for so long, AAC device manufacturers/suppliers were unable to accept assignment. But, very few Medicare beneficiaries were able to obtain AAC devices because they could not afford them.If the SLP proposes to recommend a device for which the manufacturer/supplier will not accept assignment, SLPs must: a) discuss with the beneficiary whether there are other possible sources to help pay for the device; or b) consider an alternative device and present it to the beneficiary to see it is affordable. In addition, SLPs should make it clear to the manufacturers/suppliers of these devices that their refusal to accept assignment is limiting beneficiaries' access to the most appropriate AAC devices that will meet their needs. Refusing to accept assignment defeats the potential benefits of the Medicare January 1, 2001 policy change to cover AAC devices.NOTE: Regardless whether the device is covered, if the device is purchased, the manufacturer/supplier is required to submit a Medicare claim. For devices that are covered, reimbursement (80% of the applicable fee schedule) will be paid directly to the beneficiary. For devices that are not covered, reimbursement still may be possible if appeals are followed to an administrative law judge hearing.

FAQ #14 Will Medicare provide reimbursement for the rental of an AAC device?

Medicare will provide reimbursement for the rental of AAC devices. Device rentals will be subject to the same documentation requirements as device purchases, meaning the SLP evaluation and report and physician's prescription must be completed.

Medicare will provide reimbursement for rental equipment based on the code in which the device "fits." Medicare's fee schedule for rental represents the full amount of Medicare reimbursement, either to the beneficiary if assignment is not accepted, or to the supplier/manufacturer, if assignment is taken. If assignment is taken, the beneficiary or supplemental insurance will have to meet the 20 % co-payment amount.

FAQ #15. What is the SLP's Role In Medicare Funding of AAC Devices?

The SLP is the key person in the Medicare claims process related to AAC devices. Medicare guidance related to AAC devices is unique among all items and medical services Medicare covers in that it designates a non-physician, the SLP, as the primary determiner of a beneficiary's medical need. For everything else Medicare covers, that the beneficiary's doctor holds responsibility.The assignment of this role to the SLP is based on the enormously positive impression made upon Medicare and DMERC staff by the SLPs who prepared the Formal Request and who thereafter responded patiently to questions raised about AAC intervention. The credibility they established in this process is priceless, and every SLP must approach each Medicare evaluation recognizing the importance of maintaining and reinforcing that trust. There are 4 specific steps the SLP must complete as part of the Medicare claims process:

FAQ #16. What is the Physician's Role in Medicare Funding of AAC Devices?

The physician is a necessary part of the Medicare claims process. No Medicare payment will be made for an AAC device, AAC software, or accessory without a physician's prescription. Medicare has not required that any particular physician prepare the prescription. Thus, Medicare beneficiaries with multiple physicians can have any one be the one to sign the prescription. The key will be the existence of a physician-patient relationship, but not particular training or expertise on the part of the doctor. It is expected that the doctor will base the prescription on the SLP report. Thus, the SLP report that is prepared following the evaluation should be submitted to the doctor for review. It is recommended that the doctor be asked to prepare the prescription with the following information included:

a) The physical and communication diagnosis;
b) That the doctor referred the pt for SLP evaluation (if that occurred)
c) That the doctor reviewed the SLP report;
d) That the doctor concurs in the recommendation of the SLP and prescribes EACH ITEM: device, switches, if any, software, if any and so on, that is recommended; and
e) That each of these items is reasonable and necessary for the treatment of the patient's expressive communication diagnosis (dysarthria, apraxia, aphasia, aphonia), and is necessary to achieve the functional communication goals stated for the patient in the SLP's treatment plan.

FAQ #17. What Is the Manufacturer/Supplier Role in Medicare Funding?

The AAC device manufacturer/supplier plays a critical role in the Medicare claims process. There are 6 specific steps that the manufacturer/supplier must do as part of the Medicare claims process:

FAQ #21. When Will the AAC Device Be Shipped to the Beneficiary?

The device (and/or software and accessories) will be shipped to the beneficiary when: a) payment is provided; or b) when all paperwork related to filing a Medicare claim has been received. The first alternative will likely occur for devices and other items that will not have assignment taken. In this circumstance, full payment of the catalogue or retail price is required. Thus, once payment is received, the manufacturer/supplier will have gotten all that it is entitled to, and it will then deliver the product. However, the manufacturer/supplier still is obligated to submit the Medicare claim, but it will be up to the beneficiary and his/her family to ensure all the necessary paperwork is submitted, and that the manufacturer/supplier then forwards it to Medicare. The second alternative will be followed for devices that will have assignment taken. For these devices, the manufacturer/supplier is unlikely to ship the device before all the necessary claims paperwork is submitted. The manufacturer/supplier will wait because it will be demanding from the beneficiary only 20% of either the actual charge for the device or of the applicable fee schedule, and will be relying on Medicare to provide reimbursement of the remaining 80%. Because the manufacturer/supplier is dependent on the approval of that claim to receive the bulk of its payment for the device, it has a much greater interest in ensuring that the documentation supporting the claim is complete.

FAQ #23 What AAC Device Accessories are Covered? What is the Claims Procedure and How are They Reimbursed? (more to be added)

Medicare has stated that AAC device software and AAC device accessories are covered, under code K0545, K0546, and K0547. These items will be reimbursed as "individual consideration" items. This means that no fee schedule for AAC software or the various types of accessories will be crafted. Instead, each of these items will be reimbursed at 80 % of its actual charge.

FAQ #24. Are AAC Device and Accessories Repairs Covered?

Yes. Medicare will cover AAC device and accessory repairs --both parts and labor -- for devices and accessories, which are beyond their warranty periods. During the warranty period, it is expected the supplier will be responsible for repairs. Beyond that time, Medicare will cover AAC device and accessory repairs as they do any other item of durable medical equipment.Individuals who require repairs on their AAC devices or accessories, whether within or beyond the repair period, should contact the supplier of the item in need of repair to inquire about the applicable repair procedure.Medicare also will repair AAC devices that were not purchased by Medicare, as long as the device is otherwise covered. When seeking repair for such a device, the manufacturer/supplier will ask who paid for the device (e.g., Medicaid, insurance, private purchase), but non-Medicare purchase of the device is not disqualifying. NOTE: Medicare assumes that durable medical equipment will have a useful life of 5 years. This means that Medicare will not replace items of durable medical equipment within a five-year span, except when a substitution request is based on change of beneficiary condition. The impacts of this practice are significant:

FAQ #25. Will Medicare Provide AAC Devices to Residents of Nursing Homes or other Types of Assisted Living Arrangements?

Medicare regulations state that Durable Medical Equipment will be provided if "the equipment is used in the patient's home or in an institution that is used as a home." In general, this is called a "place of service limitation." Because Medicare classifies AAC devices as DME, this limitation applies to AAC devices. Settings Considered "Home"Medicare considers the settings listed below to be a beneficiary's home, and thus, will provide reimbursement for DME to individuals who reside in:

• the beneficiary's home;
• a custodial care facility; and
• an intermediate care facility for the mentally retarded.

Individuals who live in any of these acceptable "home" settings are able to obtain Medicare reimbursement for AAC devices following a complete SLP evaluation and preparation of a complete report, and upon receipt of the physician's prescription for the device. Medicare guidance offers definitions for custodial care facility and intermediate care facility for the mentally retarded. These are:Custodial Care Facility: A facility which provides room, board and other personal assistance services generally on a long-term basis and which does not include a medical component.Intermediate Care Facility/Mentally Retarded: A facility, which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals, but does not provide the level of care or treatment available in a hospital or skilled nursing facility. [NOTE: Individuals eligible for DME must have a definition of mental retardation.]

Settings Not Considered "Home"
The phrase "an institution that is used as a home" is defined by Medicare regulations to exclude a hospital or a skilled nursing facility. Also excluded are hospice residences.Other Medicare guidance defines each of these settings as follows:Skilled Nursing Facility: A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, but does not provide the level of care or treatment available in a hospital;Nursing Facility: A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. Hospice: A facility other than a patient's home in which palliative and supportive care for terminally ill patients and their families are provided.NOTE: This FAQ applies to the availability of Medicare reimbursement for AAC devices. An SLP should make an independent inquiry regarding the availability of reimbursement for his or her services to a resident of any of these settings.