Medicare Rules Leave Patients Speechless Limits on what speech-generating devices Medicare will cover—and how it covers them—prevent users from communicating and, in some cases, from active life participation. On the Pulse
On the Pulse  |   August 01, 2014
Medicare Rules Leave Patients Speechless
Author Notes
  • Lisa G. Bardach, MS, CCC-SLP, is the owner of Communicating Solutions, a private practice in Ann Arbor, Mich., and also works for ALS of Michigan. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication.
    Lisa G. Bardach, MS, CCC-SLP, is the owner of Communicating Solutions, a private practice in Ann Arbor, Mich., and also works for ALS of Michigan. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication.×
Article Information
Augmentative & Alternative Communication / Practice Management / On the Pulse
On the Pulse   |   August 01, 2014
Medicare Rules Leave Patients Speechless
The ASHA Leader, August 2014, Vol. 19, 30-31. doi:10.1044/leader.OTP.19082014.30
The ASHA Leader, August 2014, Vol. 19, 30-31. doi:10.1044/leader.OTP.19082014.30
If a new SGD user wants to use her device to call her daughter on the phone—in addition to talking with her face-to-face—Medicare won’t pay for it. And if new SGD users need nursing home or hospice care, Medicare will suspend payments for the SGD—and the supplier could take the SGD back.
What can speech-language pathologists and their clients do about these counterproductive regulations?
Rent to own
I have a 45-year-old patient who was diagnosed with ALS in December 2013. Within two months, she was unable to express herself verbally. She is the primary breadwinner in the family, which includes a 7-year-old son. As the speech-language pathologist at ALS of Michigan, I scheduled her for a speech-generating device evaluation at a local ALS clinic in the first week of April. In the meantime, I provided her a loaner SGD, because the funding process for the device can take several months.
I received an e-mail from the husband: “Thank you. I hope [patient] will be well enough to use [SGD] during the coming weeks. Her condition is dire. Our son turns 8 tomorrow. She is composing a little birthday message for him. It will be the first thing she’s been able to tell him in a while. Our hearts have been so broken. There’s no way to thank you enough for getting this device to us.”
By the April evaluation, she couldn’t move her arms or legs. The evaluating SLP recommended a device and initiated the funding process. But the patient enrolled in hospice barely a month later for needed care—and was no longer eligible under Medicare for an SGD. Fortunately, she still has the loaner, which she continues to use daily; her husband reports that every morning, she writes messages to her son before he heads out to school.
Why didn’t we move faster to get this patient her SGD before she signed on to hospice—so it would have been hers to take with her? Until April 1, 2014, that would have been possible. But a Medicare Part B policy change moved SGDs from a routinely purchased item—paid in one lump sum by Medicare to the distributor—to capped rental. Under capped rental, Medicare amortizes the payment to the distributor over 13 months, at which point the patient own the device.
If the patient is admitted to hospice (at home or in a facility) or nursing facility during those 13 months, Medicare Part B stops paying for capped rental equipment. The supplier has the right to take the device back—although none of them is interested in doing so. If the patient wants to keep the SGD, the only recourse is to pay the supplier the outstanding balance. For example, if the patient has had the SGD for 10 months, the supplier may allow the patient to pay the last three months’ rental—either over three months or in one lump sum—at which time the patient would own the device.
Dedicated device
To complicate SGD issues even further, Medicare also issued a Coverage Reminder on Feb. 27, 2014, reiterating the “dedicated” device rule: Medicare does not cover SGDs that could operate as a computer.
SGDs became a “covered benefit” in 2001, a landmark decision that allowed patients who lost their speech due to ALS, traumatic brain injury, aphasia, Parkinson’s disease, multiple sclerosis or other conditions to acquire devices that allowed them to communicate independently. With technological advances, even the most physically challenged individuals can use an SGD to communicate with the smallest of movements, even eye gaze.
Of course, there were restrictions, most notably that if the SGD could perform as a computer (for example, Internet connectivity, e-mail), it was not covered. To comply with the restrictions, manufacturers created “dedicated” SGDs with those features locked out. However, once the patient owned the device, he or she could “unlock” the device—and the additional features—with a code purchased from the manufacturer.
The coverage reminder broadens the restrictions. Two changes are most significant: any non-speech feature (such as the ability to control a telephone) will disqualify an SGD for Medicare coverage, and SGDs that can be unlocked at any time during the life of the device also are disqualified from coverage.
Some people with complex communication needs use their SGDs not only for face-to-face communication, but also for other forms of communication—e-mail, chat rooms, Internet, phone, texting—and for general Internet use, accessing media, reading electronic media, controlling their environments (lights, television, fans). But for devices purchased as of March 1, 2014, Medicare says patients can never use their devices in that manner.
Life limits
These new Medicare SGD restrictions seem to have been issued without consideration of their effects on the lives of people with complex communication needs. Imagine all the things you can’t do: You can’t text your spouse to let her know she doesn’t need to come home and check up on you during her lunch break. You can’t call your son, or talk to your grandkids, because you can’t dial the phone without infrared or Bluetooth capability. You can’t travel to your daughter’s graduation, but now you also can’t see it on Skype or FaceTime. You can’t view your latest lab results because your doctor puts them on the patient portal, and you don’t have access to the Internet. You can’t research your disease or treatments on the Internet.
It should be pointed out that this policy saves Medicare no money: The patient—not Medicare—incurs the additional costs of the features that all them to perform these tasks.
Patient advocacy
What can SLPs do about these problematic rules? Here are some suggestions:
  • Be aware of the new restrictions and educate patients about what they will and won’t be able to do with an SGD. Let them know that devices funded by Medicare after March 1 can never be modified and discuss whether they might want to pay for equipment out of pocket.

  • Have patients who have been affected by these changes lodge a complaint with the Medicare hotline, 1-800-MEDICARE.

  • The Centers for Medicare and Medicaid Services has not responded to fact-based challenges to the policy. Advocates in a variety of arenas suggest that change may come through Congressional pressure. Please consider contacting your senators and representative (locate them at I’d be happy to provide talking points and sample letters.

  • Have patients contact their legislators as well. Personal stories can make a difference.

And the hospice patient? I recently stopped by her home to exchange some equipment and see how she is doing. Her son came out to meet me, and then disappeared. He returned five minutes later with a stack of paper—every one of the notes his mom has written to him since getting the loaner device.
August 1, 2014
Andrea Townsend
What the heck were they thinking?
I'm trying to picture the "big enchiladas" at Medicare sitting around the conference table saying, "now what next can we do to screw the consumer?" And then they decided to take away peoples' chances for independence, dignity and communication. IT SAVES MEDICARE NO MONEY TO BAN THE USE OF A DEVICE FOR USE OTHER THAN DIRECT COMMUNICATION! We need to use the media to get the word out and apply public pressure to get this changed. Let's work quickly. Quality of life is at stake!
August 18, 2014
Shirley Morganstein
The fight for Quality of Life
While people all over the world embrace the World Health Organization's view of Life Participation as a human goal, the US consistently moves further away from the quality of life issues that define wellness. It is inconceivable that medical necessity should exclude the human right to communication. To deny not only the device but the ability to modify it post purchase at no cost to the third party payer is purely Machiavellian. Fortunately, technology brings us closer every day to access of more affordable equipment and software that will make private purchase more affordable for some, but for many, such a thing is not vaguely possible. It's appalling.
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August 2014
Volume 19, Issue 8