Your client, who has stroke-induced aphasia, wants to use a computer tablet with a speech-generating application to communicate. Will insurance pay for it?
Speech-generating apps for laptops and computer tablets are increasingly available, and many patients with a variety of conditions are using them successfully to communicate. Most health plans, however, do not cover electronics that are not traditional speech-generating devices. They must be manufactured only to produce speech in medically necessary circumstances. For example, personal electronics used also to search the Internet or play music are not covered.
However, payers that will not cover a laptop or computer tablet—because it is used for purposes other than generating speech—may potentially cover speech-generating software or apps for that same electronic device.
Medicare covers software that allows a laptop, smartphone or computer tablet to function as an SGD. All of the four regional Durable Medical Equipment Medicare Administrative Contractors include this coverage in their Local Coverage Determinations for SGDs (see sidebar below).
A unique durable medical equipment code—E2511—in the Local Coverage Determination describes: "Speech generating software program, for personal computer or personal digital assistant." This coding system for durable medical equipment, prosthetics, orthotics and supplies is used by government as well as private payers.
Although Medicare policy seems to cover speech-generating apps, Medicare requires that durable medical equipment claims be submitted by a registered supplier, which must abide by comprehensive regulations that ensure customer support and service. Common computer tablet or smartphone apps that are downloaded directly through the device's operating system cannot meet these regulations and, therefore, cannot be handled by a registered supplier and are not eligible for reimbursement. ASHA staff are trying to determine if there are ways to submit an app claim to Medicare without a national rule change.
Medicare may cover speech-generating software for someone—whether or not the user has already received a dedicated SGD—if an SLP demonstrates that new software sold as a disk for a separately purchased multi-purpose device would serve the patient significantly better.
To obtain coverage, the SLP must submit to the patient's physician an evaluation and product recommendation that follow the Medicare criteria, focusing on a description of goals and the rationale for selection. If a durable medical equipment supplier is providing the software, the request to the supplier must include the physician's order and the SLP's evaluation.
Medicare does not list a price for the E2511 code because it is a "by report" code—that is, there is no standard fee posted for the product and the supplier must submit appropriate documentation indicating the cost, manufacturer and product number. Reimbursement for the supplier is typically 80 percent of the manufacturer's suggested retail price, leaving a 20 percent copayment for the beneficiary.
Many private insurers follow Medicare's lead on coverage policies. Private payers also may cover speech-generating software for people who have already received SGDs if an SLP demonstrates that an app installed in a separately purchased multi-purpose device would serve the patient significantly better.
To obtain coverage, most insurance plans require the SLP to submit to the patient's physician a request that follows the payer's requirements and focuses on a description of goals and the rationale for selection. Unlike Medicare, private insurers do not require the apps to be ordered through a registered Medicare durable medical equipment supplier. Private insurer payment policies vary significantly; patients or clinicians should contact the insurer for information about submitting claims and reimbursement.
As with all Medicaid policies, states vary in their coverage. ASHA interprets SGDs and speech-generating apps as included in the federal Medicaid regulation (42 CFR 440.110(c)) that requires coverage of "any necessary supplies and equipment" for individuals with speech, hearing and language disorders. This interpretation is based partly on the Medicare policy equating SGDs and speech-generating apps. If a state Medicaid agency is not covering speech-generating apps, SLPs should advocate to the agency regarding the federal requirement (contact Laurie Alban Havens, ASHA director of private health plans and Medicaid advocacy, firstname.lastname@example.org, for help).
Inevitable changes in health care delivery and payment—along with advances in technology—may open the door for public and private coverage for multi-use consumer devices that generate speech. Several factors are driving this change:
- Personal electronic devices and apps are significantly less expensive (by $3,000–$10,000) than dedicated SGDs.
- SLPs and clients report success using the apps to communicate.
- As public and private insurers realize that Internet access enhances communication, they may recognize that coverage of speech-generating tools should not be limited only to dedicated SGRs.
ASHA will continue to advocate with government and private payers regarding the practical and fiscally responsible use of personal laptops, tablets and apps for speech generation. For more information on SGDs, visit our Speech-Generating Devices resources page.