MASSACHUSETTS ADVOCATES for CHILDREN
MassHealth: NEW Coverage
Augmentative and Alternative Communication (AAC)
for Children with Disabilities, including Autism Spectrum Disorder
September 15, 2015
Files: AACMassHealthFactSheet9-16-15Final PDF
Update from MAC’s Autism Center and Massachusetts Law Reform Institute
A new state law requires MassHealth to cover medically necessary treatments for low-income children with autism spectrum disorder.
- In addition to insurance coverage for ABA services the new law expands MassHealth coverage for medically necessary Augmentative and Alternative Communication (AAC) devices. In the past, MassHealth covered AAC devices but did not cover electronic tablets, such as iPads, used for AAC.
MassHealth now covers electronic tablets dedicated to use as AAC, along with related software, when medically necessary for communication.
- Coverage of dedicated tablets is available now for children and youth under age 21 who require medically necessary AAC including children with autism.MassHealth is in the process of updating its regulations to provide coverage for adults, which will make the devices available to everyone for whom it is medicallynecessary.
Q. What is AAC – Augmentative and Alternative Communication?
Augmentative and Alternative Communication, also known as AAC, is a term used to describe various methods of communication that supplement or replace oral speech for people who are unable to use oral speech alone to communicate. Children with autism or any other type of disability that makes it difficult for them to communicate may benefit from AAC. Many different AAC methods are used by people of all ages with a range of disabilities.
MassHealth will cover electronic tablets that have been configured primarily for dedicated use as an AAC device, based on the recommendations of the speech pathologist and prescription. Use of the device to text and e-mail can be covered.
Q. What are the steps required to obtain an electronic tablet dedicated to AAC?
- An AAC device is considered Durable Medical Equipment. For members enrolled in a managed care entity (MCE), the tablet will be provided through the MCE based on the procedures of the MCE.
- For members enrolled in the Primary Care Clinician Plan or in MassHealth secondary to private insurance, it will be authorized directly by MassHealth.
The following steps are required by current MassHealth regulations. They require the patient’s primary care clinician, a speech and language pathologist, and a durable medical equipment supplier to work together, utilizing the same MassHealth process already established for covering other kinds of AAC devices.
- Get a referral from the patient’s primary care clinician for an evaluation by a licensed speech and language pathologist (SLP) who is a MassHealth provider.
- Obtain an evaluation by the speech and language pathologist. If AAC is needed, the SLP will recommend the AAC device and a treatment plan.
- Obtain a prescription for the recommended device and a diagnosis of a severe communication disorder from the primary care clinician (physician, physician assistant, or nurse practitioner).
- The speech and language pathologist will recommend a MassHealth approved durable medical equipment (DME) provider. The DME provider will request prior authorization from MassHealth and will provide the AAC device and software after MassHealth approves the request.
- If MassHealth denies the request, the patient will be notified and can appeal to an impartial hearing officer.
- All recommended configurations to the tablet will be made by the manufacturer and/or DME provider before the device is provided to the member.
- When the member or guardian (or the SLP) signs the delivery ticket for receipt of the tablet, they will confirm that the device will be used for communication only, and not, for example, for games or as a music player. Use of the device to text and email can be covered.
Q. What types of primary MassHealth insurance cover electronic tablets used for AAC?
Children under the age of 21 who are covered by MassHealth Standard and CommonHealth are entitled to medically necessary AAC devices, including electronic tablets dedicated to use for AAC.
Q. What is the process if I have MassHealth as secondary insurance?
If your private primary insurance provider covers electronic tablets used for AAC, you must first seek benefits under your primary plan. If you obtain a tablet through your primary insurance and have MassHealth as secondary insurance, MassHealth may cover the related co-pays and deductibles.
Q. What if my primary insurance does not cover electronic tablets used for AAC?
If a speech and language pathologist recommends an AAC device that your primary insurance does not cover and you have MassHealth as secondary insurance, you must meet MassHealth medical necessity, prior authorization, and other guidelines for MassHealth coverage of the device. See steps for MassHealth coverage above.
Q. Where can I get an electronic tablet approved by MassHealth?
Several of MassHealth’s current durable medical equipment providers can supply electronic tablets. Your speech and language pathologist will be able to connect you with a provider where you can obtain your device.
Q. Are speech applications (“apps”) or related software for electronic tablets covered?
Yes. MassHealth covers medically necessary AAC software, applications, and related equipment, as long as prior authorization is provided consistent with the steps for coverage outlined above.
Q. Who can I call for more information?
MassHealth Customer Service: (1-800-841-2900)
ADDITIONAL INFORMATION FOR PROVIDERS
Q. How is MassHealth going to determine “medical necessity” for coverage of electronic tablets used for AAC?
Recommendations for electronic tablets must meet the current medical necessity rules in the MassHealth regulations at 130 CMR § 409.428 and additional medical necessity guidelines specific to tablets, such as the requirement that the device be configured to limit the primary use to AAC.
Q. Are there new Prior Authorization procedures for providers?
No. The same procedures MassHealth now uses to authorize AAC devices will apply to electronic tablets configured as AAC devices. For members in the PCC plan or FFS (fee for service), the prescription, letter of medical necessity, and additional supporting clinical information will be submitted with the prior authorization request through the Provider Online Service Center (POSC) or by completing a MassHealth Prior Authorization Request form (PA-1) and attaching the documentation. Providers who work with MCEs will need to follow the MCE’s prior authorization process.
Q. Are there new codes for the DME providers of electronic tablets configured as AAC devices?
MassHealth codes for electronic tablets used for AAC are the same as current AAC codes, with modifiers.
Q. Who can I contact for more information?
MassHealth Customer Service: (1-800-841-2900) or firstname.lastname@example.org