5101:3-10-24 Speech generating devices (SGDs).

(A) Definition. For the purpose of this rule, all references to an assistive communication device (ACD) are being replaced with the term “speech generating device (SGD)”. An “SGD is defined as any electronic or nonelectronic aid or device that provides external assistance for communication and is an integral part of a speech-language pathology treatment plan for a person with a communication disability who is unable to communicate basic needs.

(B) Coverage criteria.

Only that SGD that is determined by the department to be necessary to meet the recipient’s basic communication needs is covered. “Basic communication needs” is defined as an individual’s ability to communicate needs and wants, transfer information, achieve social closeness, and demonstrate social etiquette. Authorization of reimbursement for an SGD is limited to medicaid recipients who meet the following criteria:

(1) Recipient is unable to communicate basic needs without the use of an SGD.

(2) Recipient’s communication needs and physical and language abilities, as documented in accordance with this rule, are commensurate with the prescribed AGD.

(C) Coverage of SGDs and related equipment.

Reimbursement for the purchase, rental, modification or major repair of an SGD or related equipment requires written authorization by the department. Authorization for reimbursement of other equipment may be considered if it is determined by the department to be necessary to meet a recipient’s basic communication needs in accordance with this rule. Covered SGD equipment includes the items listed in paragraphs (C)(1) to (C)(6) of this rule.

(1) SGDs (electronic or nonelectronic) including:

(a) Operational software;

(b) Speech synthesizer;

(c) Printer (if built in);

(d) Battery packs;

(e) Carrying case; and,

(f) Adapted access software and speech synthesizer, and any other accessories necessary to adapt a computer for use as an SGD, if the SGD is a computer-based system.

(2) Vocabulary application package.

(3) Overlay/multiple location configuration.

(4) Access device., including:

(a) Switch;

(b) Switch mount; and, (c) Scanning indicator, optical indicator, and head pointer, etc.

(5) Mounting device (e.g., wheelchair or desktop).

(6) Adapted access software and/or speech synthesizer, and any other accessories necessary to adapt a recipient-owned computer for use as a communication device.

(D) Limitations on coverage of SGDs. The following items are not medical in nature and are not covered by the medicaid program except as provided in paragraph (C) of this rule:

(1) Printers (unless a built-in component of an SGD as defined in this rule), printer paper, and printer cables.

(2) Environmental control devices.

(3) Personal computers and related hardware, unless components of a personal computer-based system that has been adapted for use as a communication device.

(E) Evaluation team. The evaluation must be made by a licensed speech-language pathologist and, when appropriate, other evaluation team members which may include an occupational therapist (OT), physical therapist (PT), psychologist, rehabilitation engineer, etc. “Licensed speech-language pathologist” means a person holding a valid license in speech-language pathology issued by a state licensing board of speech-language pathology and audiology and who has a certificate of clinical competence in speech-language pathology granted by the “American Speech-Language-Hearing Association (ASHA)” or has completed the academic program and is acquiring supervised work experience for the certificate.

(F) Documentation requirements for prior authorization requests. Prior authorization requests must be submitted to the department pursuant to rule 5101:3-10-06 of the Administrative Code. All prior authorization requests for SGDs and related equipment shall include a prior authorization form (JFS 03142) and the documentation referred to in paragraphs (G) to (Q) of this rule.

(1) Prior authorization form.

A completed prior authorization form (JFS 03142) must be submitted with all authorization requests for SGD rental, purchase, modification and major repair. When completing the prior authorization form, the provider must list only SGD equipment and accessories. When requesting rental for more than one SGD during a trial use period, a separate prior authorization form must be submitted with each SGD being requested. Providers must indicate on the prior authorization form when requesting authorization for payment for the modification (including upgrade), replacement, or repair of an SGD, and specify the serial number and funding source for the recipient’s SGD (e.g., Ohio medicaid, private insurance). Refer to paragraph (Q) of this rule for limitations on reimbursement for repair, modification, and replacement of SGDs.

(2) Required documentation.

In addition to the prior authorization form, the documentation listed in paragraphs (F)(2)(a) to (F)(2)(h) of this rule must also be submitted with all prior authorization requests for an SGD purchase when no trial use period is required, or for the rental of a device(s) during a trial use period. This list is only a summary; refer to paragraphs (G) to (N) of this rule for a description of the documentation required for each item. Requests that do not include complete documentation will be not approved and will be returned to the requesting provider.

(a) Physician prescription.

(b) Documentation of evaluating speech-language pathologist’s experience with SGD service delivery.

(c) Pertinent recipient background information.

(d) Occupational therapy and/or physical therapy assessment (if applicable).

(e) Cognitive status assessment.

(f) Sensory status assessment.

(g) Speech, language, and communication assessment.

(h) SGD assessment.

(G) Physician prescription. A physician’s prescription for an SGD must be submitted and shall be based on the evaluation of the recipient’s physical, language, and communication abilities and needs made by a licensed speech-language pathologist and, as determined appropriate by the speech-language pathologist, other evaluation team members which may include an OT, PT, psychologist, and rehabilitation engineer.

(H) Experience with SGD service delivery: evaluating speech-language pathologist. The evaluating speech-language pathologist’s experience with SGDs and other assistive technology must be documented separately from other components of the speech-language pathologist’s SGD evaluation. Documentation of experience may be submitted in letter, resume, and curriculum vitae format and should include documentation of relevant training and professional education and number of years experience with assistive technology.

(I) Pertinent recipient background information. must include the following:

(1) Name;

(2) Recipient billing number;

(3) Medical diagnoses;

(4) Significant medical information/medications; and,

(5) Medical prognosis.

(J) Occupational therapy and/or physical therapy assessment.

The assessment must be comprehensive and must be prepared and signed by a licensed OT and/or PT. The assessment must include, but is not limited to,: assessment of motor function (e.g., range of motion, tone, active motion), postural/positioning, mobility status, integration of mobility, and positioning with the SGD. The OT and/or PT assessment shall be prepared and signed by the evaluating therapist as a separate document, distinct from the documentation of other components (e.g., speech and language status, cognitive status) of the assessment. The evaluating therapist must include the OT’s and/or PT’s license number and the date of the assessment.

If the recipient has no motor barriers to accessing an SGD and the evaluation team determines that an OT/PT assessment is unwarranted, documentation must be provided explaining why this component of the assessment is nonapplicable.

(K) Cognitive status assessment(may include estimate of developmental and intellectual age or range).

The method (e.g., standardized testing, observation) of assessing cognitive status must be described.

The cognitive assessment completed by the speech-language pathologist may be included with the speech, language, and communication assessment.

Documentation of the recipient’s most recent cognitive assessment done by the speech-language pathologist must be included. If cognitive testing has not been conducted within a year prior to the date the recipient is evaluated for the SGD prescribed in accordance with this rule, the evaluating speech-language pathologist must document why a current assessment (i.e., assessment conducted within one year) is not required (e.g., recipient does not exhibit any behavior that would indicate a change in cognitive status since their last assessment). Include the licensed number of the evaluating team member, is available, and the date of the assessment.

(L) Sensory status (describe assessment methods).

(1) Visual abilities.

(2) Auditory abilities.

The sensory status assessment completed by the speech-language pathologist may be included with the speech, language, and communication assessment. Documentation of the recipient’s most recent visual and auditory assessment must be included. If visual and auditory ability testing has not been conducted within a year prior to the date the recipient is evaluated for the SGD prescribed in accordance with this rule, the evaluating speech-language pathologist must document why current assessments (i.e., assessments conducted within one year) are not required (e.g., recipient does not exhibit any behavior that would indicate a change in visual or auditory status since their last assessment). Include the license number of the evaluating team member and the date of the assessment.

(M) Speech, language, and communication assessment.

Prepared and signed by a licensed speech-language pathologist, the assessment must be dated and include the speech-language pathologist’s license number. The speech, language, and communication assessment may include cognitive and/or sensory status when assessed by the speech-language pathologist.

(1) Speech, language, and communication status.

(a) Specific description of communications disability, including speech diagnosis.

(b) Speech skills and prognosis.

(c) Language skills: expressive and receptive.

(d) Description of communication behaviors and interaction skills.

(e) Description of recipient’s use of current SGD, if recipient is currently using an SGD. Please include the date current SGD was acquired by the recipient.

(f) Emotional status as it relates to communication.

(2) Communication limitations and needs.

(a) Limitations of current communication behaviors. State why current communication behaviors prevent the client from communicating basic needs as defined in paragraph (B) of this rule.

(b) Identify communication partners (family members, caregivers, etc.) and any associated limitations and needs.

(c) Message needs (pragmatics).

(d) Vocabulary (semantics).

(e) Communication environments. Include description of vocational and education status.

(N) SGD assessment.

The SGD assessment must be jointly prepared and signed by the evaluating speech-language pathologist and other team members determined appropriate by the evaluating speech-language pathologist. The assessment must be dated and include all team member’s license numbers.

(1) SGD components and specifications: recipient needs assessment.

(a) Representational systems (symbol system).

(b) Vocabulary encoding (i.e., minspeak, levels plus location, traditional orthography, etc.).

(c) Vocabulary expandability and message generation (i.e., pre-programmed, fully programmable, combination of pre-programmed and programmable, additional memory, messages stored as letters, words, phrases, sentences, etc.).

(d) Rate enhancement techniques (i.e., – simple symbol selection, symbol sequencing, key linking, dynamic displays, abbreviation-expansion, word lists, word prediction, icon prediction, minserts, macros, etc.).

(e) Access techniques and strategies.

The assessment of the recipient’s ability to access an SGD and/or selection of the optimal SGD access technique must be conducted, in conjunction with the speech-language pathologist, by an OT or PT if an OT or PT assessment is required in accordance with paragraph (J) of this rule. When assessed jointly by the speech-language pathologist and OT and/or PT, documentation of the assessment may be included with the speech-language pathologist assessment; the OT or PT must also sign the speech-language report when access is jointly assessed.

(f) Overlay or keyboard organization and features (i.e., key size, keys per overlay, spacing between keys, overlay size, keyguard, multiple location overlay, etc.).

(g) Device output modes (i.e., – speech synthesis, printed output, display characteristics, auditory and visual prompting, auditory and visual feedback, etc.).

(h) Portability concerns.

(i) Integration with other technologies (i.e., calculator, clock, notepad, telephone, printer, computer, ECU, power wheelchair, FAX, modem, etc.) SGDs have the capability to be integrated with other equipment and technologies that are not eligible for reimbursement by medicaid. Refer to paragraphs (C) and

(D) of this rule for a listing of covered equipment and coverage limitations.

(2) Comparison of SGD specifications.

(a) List specifications for the SGD that most effectively and efficiently meets the recipient’s basic communication needs.

(b) Comparison of specifications.

Describe the SGDs considered for the recipient. Document why nonrequested comparable SGDs were considered to be inappropriate to meet the recipient’s basic communication needs and capabilities.

When requesting authorization for more than one SGD for a trial use period, list the pertinent specifications, in relation to recipient’s needs and capabilities, that will be evaluated for each rental device.

(3) SGD prescription.

Include the following documentation regarding the SGD prescribed for the recipient:

(a) Identify the requested SGD, including all required components, accessories, peripheral devices, supplies, and device vendor or vendors.

(b) Describe how the requested SGD will meet the recipient’s projected basic communication needs as described in paragraph (B) of this rule.

(4) The following items should be included in the recipient’s treatment plan and follow-up:

(a) Short and long-term communication goals.

(b) Individual speech-language pathologist and/or organization/facility responsible for SGD training.

(c) Necessary modification of SGD to suit the individual.

(d) Schedule for evaluating the outcome of the trial use period. Must be completed when requesting authorization for rental during a trial use period.

(O) Trial use period.

When recommended by the prescribing speech-language pathologist, a trial use period must be conducted before the department will consider authorizing the purchase of an SGD. Monthly rental payments, limited to the lower of the provider’s usual and customary monthly rental charge, six per cent of the medicaid maximum allowable for an SGD or ten per cent of the authorized purchase price of the prescribed SGD, will be paid during the trial use period. Payments authorized during the trial use period are generally limited to four monthly payments. Long-term rental may be considered for authorization. If long-term rental is required, documentation must support why it is necessary as an alternative to a trial use period and/or purchase. Rental payments require prior authorization which must include the documentation required in accordance with paragraphs (G) to (N) of this rule. Authorization for rental of SGDs for a trial use period or long-term rental will be limited to one device per month.

(P) Requesting purchase of an SGD at the end of a trial use period.

(1) When requesting purchase of an SGD at the end of a trial use period, the provider must submit:

(a) A completed “Prior Authorization” form (JFS 03142), and;

(b) Documentation of the effectiveness of the SGD/evaluation of the outcome of the trial use period,; and

(c) Certification, dated and signed by the evaluating speech-language pathologist, and other members of the evaluation team if applicable, that the SGD being requested appropriately meets the recipient’s needs, and there are no known factors which prevent the recipient’s successful utilization of the SGD.

If further evaluation is necessary at the end of a trial use period, the evaluating speech-language pathologist may submit a prior authorization request for the reimbursement of additional months of rental. Such a request must document the need for further evaluation.

(2) When requesting authorization for purchase subsequent to rental:

(a) The amount requested for payment should be the provider’s usual and customary charge for the SGD; and

(b) The amount of payment previously authorized for the rental, and the rental dates (“From” and “To”), should be listed on the prior authorization form.

When a rental device is the same make and model as the SGD that is subsequently authorized for purchase, all rental payments made by the department for that rental device will be deducted from the purchase payment authorized by the department.

(Q) Repair and replacement.

(1) Repair.

Medicaid reimbursement for repairs and modifications (including upgrades) is available for no more than one SGD per recipient. Reimbursement may be provided for repair or modification of an SGD not purchased by the department only if that SGD is determined by the department to be necessary to meet basic communication needs in accordance with this rule.

(See rule 5101:3-10-08 of the Administrative Code regarding reimbursement for the repair of equipment.) If requesting authorization for the repair (including battery pack replacement) of an SGD, the documentation listed in paragraphs (Q)(1)(a) to (Q)(1)(e) of this rule must be submitted. If requesting authorization for the modification (including software upgrade) of an SGD, the documentation listed in paragraphs (Q)(1)(a) to (Q)(1)(f) of this rule must be submitted.

(a) Prior authorization form (JFS 03142).

(b) Specify components to be repaired and/or replaced. If requesting a battery, include date of last battery replacement.

(c) SGD serial number and the date the SGD was purchased (specify funding source).

(d) Physician’s prescription (see paragraph (G) of this rule).

(e) For the repair (not including modification or upgrade) of an SGD not purchased by the department, a licensed speech-language pathologist must certify in writing that the recipient’s SGD is being used by the recipient to meet basic communication needs. The SGD provider may maintain such a certification on file for submission with any requests for repair (not including modification or upgrade). This certification must be updated annually.

(f) For a modification or upgrade, the evaluating licensed speech-language pathologist shall specify the component to be upgraded, describe how the current component does not meet the recipient’s basic communication needs, and describe how the SGD with the upgraded component will meet the recipient’s basic communication needs.

(2) Replacement of a recipient-owned SGD will be authorized only if it is determined by the department that the current SGD does not meet the recipient’s basic communication needs in accordance with this rule, regardless of the age of the current equipment, and the current SGD cannot be modified or repaired to meet basic communication needs. If the current SGD can be modified or repaired, replacement will only be considered when modification or repair of the current equipment is judged by the department to be more costly than replacement. A request for prior authorization for replacement of a recipient-owned SGD must meet all the requirements specified in paragraphs (G) to (N) of this rule. In general, reimbursement is limited to a maximum of one SGD in five years per recipient.

(3) A description, model number, and the condition of a recipient’s current equipment must be specified on a request for prior authorization of additional or replacement equipment. (See rule 5101:3-10-05 of the Administrative Code regarding duplicate and conflicting equipment.)

HISTORY: Eff 9-10-93; 12-10-93; 12-29-95 (Emer.); 3-21-96; 10-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.01, 5111.02

R.C. 119.032 review dates: 07/16/2004 and 10/01/2009