Speech therapists (SLPs) have questions about coverage for augmentative and alternative communication devices in nursing homes. There is a lot of confusion about who covers what and where it is covered. Let’s dive in.
How Do We Define Nursing Facilities?
These types of facilities may include skilled nursing facilities (SNFs), nursing facilities (NFs), or rehabilitation centers. The key is that they provide skilled nursing to people who need medical care, rehabilitation care, or long-term nursing care. They may stand along facilities or affiliated with a hospital. They provide treatment to people who are injured, ill, or have disabilities. We often call such places ‘nursing homes’ or ‘rehabilitation centers’. People who need the services of such facilities may be covered by some types of private insurance, or they may have Medicaid or Medicare. These two programs sound so much alike that it is worthwhile to define the differences between them.
Medicaid and Medicare: What is the Difference?
Medicaid is a federal and state program for people with limited income. If someone receives Supplemental Security Income (SSI), they will be covered by Medicaid. Medicaid will also cover people who receive waiver funding for home and community-based services (HCBS). HCBS has helped move people with disabilities out of institutional care and back into their communities.
Medicare is a federal program that covers people aged 65 and older or those with disabilities. If someone receives Social Security Disability Insurance (SSDI), they will be covered by Medicare. The individual must be unable to engage in “substantial gainful activity” long-term. The disabled adult children of someone on Medicare may also be covered. It is Medicare that gives us the definition of DME.
Both of Medicare and Medicaid cover the cost of medical equipment needed for daily life. Such devices are often called Durable Medical Equipment (DME). Some augmentative and alternative communication devices (AAC) may be classified as DME. So many acronyms!
What Counts as Durable Medical Equipment?
DME is defined as medical devices or equipment that meet the following criteria:
- Durable (can withstand repeated use)
- Used for a medical reason
- Not usually useful to someone who isn’t sick or injured
- Used in your home
- Generally has an expected lifetime of at least 3 years
Which AAC Devices are Considered DME?
AAC that counts as DME may include devices that use a recorded voice (digitized speech) or a computerized voice (synthesized speech). These devices may use different types of message formulation, i.e., text to speech, symbol-based communication, or both. This may include software on dedicated communication devices or software that can turn a computer into a speech-generating device. The key is that these devices be used for face to face communication.
Equipment that can provide functions other than speech is often not covered. In other words, devices that send emails, post to social media, or make phone calls, are not considered DME. A computer or tablet needs to be “locked down,” so the only function is speech generation. However, there is a way around this. People can talk to their device vendor. Once AAC is approved, you can often pay a fee to “unlock” it, i.e., connect the device to the internet.
You can learn about CMS coverage rules for AAC at the link below:
What Does Medicare cover?
Medicare does not cover many types of DME in nursing facilities. If it is labeled as DME, it will not be covered. Medicare rules state that DME is for use in a “patient’s home.” And Medicare does not consider a nursing facility to be a patient’s true home. This applies to SNFs and other facilities that provide skilled nursing care. However, the definition of “home” may include a custodial care facility or an intermediate care facility (ICF). The key is that the facility provides long-term care that is not medically-based.
What Does Medicaid Cover?
Too often, SLPs are told that AAC is not covered by Medicaid in nursing facilities. This is not true. Medicaid covers AAC devices in multiple settings, including nursing facilities (SNFs and NFs). The confusion may stem from the definition of DME, which does not crossover to apply to Medicaid. Medicaid coverage does contain language about medical equipment that falls under “home health benefits”. Home health benefits are not provided in nursing facilities.
However, AAC may indeed be covered in SNFs/NFs . Medicaid covers many types of equipment that are used in nursing facilities. This list may include wheelchairs, hospital beds, and even some AAC devices. The key is that such equipment is not classified as DME. Remember, we are talking about Medicaid.
Yes, this is a matter of semantics. A rose is a rose, but this technicality works in the patient’s favor. A device (a piece of “medical equipment”) must be provided if it is part of that patient’s “plan of care”. Medicaid regulations also require specialized rehabilitation services (OT, PT, and speech) and necessary supplies and equipment to be covered.
States determine how Medicaid services are disbursed. In Pennsylvania, you can always contact the Department of Human Services for Information:
For policy wonks who want to explore the intricacies of Medicaid and Medicare coverage of AAC, read the following article by Lewis Golinker:
Medicaid AAC Device Funding for Nursing Facility Residents
Getting AAC through Medicaid is not always easy. Money is always an issue. The daily rate that an SNF/NF receives for a patient may not be sufficient to cover a dedicated communication device. However, Pennsylvania is a state that allows billing for individual services (as an alternative to charging a daily rate).
Further Barriers to AAC Use in Nursing Facilities
Another potential barrier is a lack of knowledge among the speech pathologists working in these facilities. Graduate programs often do not center AAC and frequently do not offer robust coursework on the topic. An SLP may not feel qualified to make the determination or evaluate the patient for AAC. Fortunately, more and more resources are available online to help therapists improve their skills. Here at AAC Community, we have developed a series of modules for SLPs who want to learn about AAC:
Light Tech AAC
Not all AAC has to be high tech. For some patients, the right tool may be a pad of paper and a pencil. There are other light tech options to explore. The following resources may be helpful:
Covid 19 Core Communication Boards
Light tech eye gaze: https://aaccommunity.net/2019/04/light-tech-eye-gaze-a-place-to-start/
Patient-Provider Communication: https://www.patientprovidercommunication.org/tools-and-resources/
Consider the Tools You Already Have
Don’t forget to look at the technology a patient may already have. Do they own a smartphone? Or an iPad? Perhaps an iPad Pro? You might be able to use the accessibility settings on the device to support their communication needs. For instance, you can turn the Notes app on an iPhone into an on-the-spot text to speech device:
There may also be free apps that will cover some of the patient’s communication needs. SLPs may be able to get free copies of certain AAC apps to try with their patients:
Worth the Effort
The grand conclusion may be that this is complicated. You may need to fight to get communication into the hands of a patient in a nursing facility or SNF. It is a good fight and worth the effort. Communication is a Human Right.
The Communication Bill of rights
Brady, N. C., Bruce, S., Goldman, A., Erickson, K., Mineo, B., Ogletree, B. T., Paul, D., Romski, M. A., Sevcik, R., Siegel, E., Schoonover, J., Snell, M., Sylvester, L., & Wilkinson, K. (2016). Communication services and supports for individuals with severe disabilities: Guidance for assessment and intervention. American Journal on Intellectual and Developmental Disabilities, 121(2), 121-138. https://doi.org/10.1352/1944-7558-121.2.121
Burke, G., & Chen, D. (2018, May). Understanding Durable Medical Equipment. NCLER. https://ncler.acl.gov/pdf/Understanding%20DME%20Issue%20Brief.pdf
Golinker, L. (2003). Medicaid AAC device funding for nursing facility residents. Perspectives on Augmentative and Alternative Communication, 12(3), 29-33. https://doi.org/10.1044/aac12.3.29
Medicare Skilled Nursing Facility Manual. (2000, September 28). Centers for Medicare & Medicaid Services | CMS. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R367SNF.pdf
Medicare funding of AAC technology – Frequently asked questions and answers (FAQs):: AAC-RERC – Spread the word. (n.d.). AAC-RERC – Spread the Word. https://aac-rerc.psu.edu/index.php/pages/show/id/23#eligA
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