Before setting out to write a report for a speech generating device (SGD) for your client, you must identify the funding source or sources that your client is eligible for, as well as the corresponding SGD policy guidelines for each funding source. These SGD policy guidelines are essentially the directions for what must be contained in your evaluation. They will tell you what you need to document in your report and can be thought of as the rules you must follow in order to get an SGD funded. We will look at the various SGD funding options and where to look for the policy guidelines specific to each source.
A review of the various funding sources of SGDs and their definitions (keep in mind your client may have a combination of funding sources):
Once you know the client’s funding source or sources, where do you start looking for SGD policy guidelines?
Medicare is the gold standard, and Medicare guidelines are the most commonly adopted guidelines for other funding sources and are most likely to cover the bases needed. Many insurer clinical guidelines are based on Medicare guidelines. Two Medicare guidelines that govern AAC device coverage are:
If you are in doubt about the guidelines to follow, or if you can’t find funding guidelines for a different funding source, follow Medicare guidelines. Tricare, is an example of a funding source that follows Medicare guidelines.
To locate the SGD policy guidelines if your client has Medicaid:
Each state Medicaid program must follow Federal CMS guidelines (the CMS LCD and NCD guidelines linked above), but they can pass their own laws and put guidelines in place for how their individual Medicaid program will be run. As mentioned above, there are two different types of Medicaid programs that you may encounter:
If your client has straight Medicaid, to locate the SGD policy guidelines:
As previously discussed, Medicaid MCO is a hybrid of state Medicaid and a private insurance company. Therefore, it is important to keep in mind that an MCO will contain all that straight Medicaid requires and also, most importantly, it will contain MORE than what straight Medicaid requires. It all depends on the state and how much latitude the state gives the MCO in administering the program. To be thorough, if your client has Medicaid MCO, you need to reference several policy guidelines, including, the Federal CMS (Medicare) guidelines, the insurance company’s guidelines, AND the state Medicaid guidelines.
If your client has private insurance, you can check the provider section of the insurer website for SGD policy guidelines to see if they have the policy posted. Even though many insurers post their clinical guidelines, some may not have a clinical policy or guidelines specifically for SGDs. Some insurers may not have a separate SGD policy but instead will include it in their DME policy, so you should look at the boarder DME policy if a specific SGD policy is not available.
Finally, it is important to keep in mind that all of the funding sources mentioned may review, update, and make changes to their guidelines (some do this yearly and some do it even more often). For example, Medicare publishes updates quarterly. Even if you have recently had an SGD approved through a certain funding source, checking to see if there have been any updates to their policy guidelines since you last submitted could save you time in responding to a denial or deferral for not including necessary information required in the policy guidelines.