Public School Students – Who Can Pay for SGDs? – Lew Golinker

Public School Students – Who Can Pay for SGDs? –  Lew Golinker


I am Lewis Golinker. This webcast will last
one hour. It will review speech generating device or SGD funding sources for children
with severe communication impairments. The context or setting of this presentation will
be a meeting in a public school to develop or revise the student’s individualized education
program or IEP. The information to be presented is intended for all the participants in a
student’s IEP meeting. This includes the school’s instructional staff; speech-language
pathologist; school administrators; the student’s parents; and advocates. Four key questions
will be addressed. First, are the schools an SGD funding source? If so, must the schools
pay for an SGD identified on a student’s IEP as needed? If not, who else can pay? And
finally What criteria should guide the decision about who pays? It is my hope this information
will help participants at the IEP meeting achieve 3 goals: To secure an essential tool
for the student; To conserve scarce school financial resources; and Finally to protect
or strengthen the family-school relationship. Maybe even reduce the stress commonly associated
with a decision to recommend an SGD. Throughout this webcast, I will use acronyms and abbreviations.
The SGD funding programs to be reviewed are filled with them. Slide 2 lists those that
will be used most often. Also, on several of the slides are numbers in brackets. These
refer to sections of the federal special education regulations, which can be found at Title 34
Code of Federal Regulations, or C.F.R., Part 300. The full text of federal regulations
can be found on-line. Enter 34 C-F-R and the number listed on the slide as a Google search.
Slide 3 answers the first of the key questions to be addressed in this presentation: Are
schools an SGD funding source? This is the easiest question of the four. The answer is
Yes, of course schools are an SGD funding source. Before explaining this answer, it
may be helpful to explain why this is the first question. Why are schools being discussed
first? The reason is that for some children, the only source of available SGD funding will
be the schools. The IDEA was originally called the Education for All Handicapped Children
Act. No other program we will talk about covers everyone. So, the schools always are a possibility,
but to be clear: talking about the schools first is not intended to suggest that the
schools: Are required to pay for a needed SGD; Are the most likely source of SGD funding;
or Are the best source of SGD funding. Schools are a possible SGD funding source because
all students with disabilities are entitled to a “Free Appropriate Public Education,”
or F-A-P-E. This “right” is guaranteed by the Individuals with Disabilities Education
Act, or IDEA, enacted in 1975. The scope of this right is explained in greater detail
in regulations adopted by the U.S. Department of Education. The IDEA describes a F-A-P-E
in both procedural and substantive terms. Slide 3 lists the procedures or tasks that
are part of the special education process. They represent a sequence of steps: To identify
students with disabilities and refer them for evaluation; To evaluate them to determine
their abilities and needs; and To plan the educational services and supports they need.
It is through these steps – to be performed or coordinated by the school in most cases
– that need for an SGD will be identified and the decision made to incorporate it into
the student’s educational program. Once the decision is made to include the SGD in
the student’s IEP, the last 2 steps of the procedural sequence, to “acquire” and
“provide” services and equipment items and to “integrate” those things into the
student’s IEP, also describe the schools’ substantive duties. Schools are a possible
SGD funding source because they are responsible to provide the services and supports identified
on students’ IEPs. As a practical matter, schools spend tremendous sums to hire specially
trained staff; make adaptations to buildings and vehicles; and acquire many different items
to accommodate students’ needs. The IDEA provides some funds for this purpose and schools
also spend funds raised locally and through state aid. These outlays are made to provide
the “special education;” “related services;” and “supplemental aids” identified on
students’ IEPs. And, some of these outlays have been to pay for SGDs. Schools have paid
for communication devices throughout the history of the special education law. SGDs are most
commonly considered “related services.” Since 1990, SGDs also have been considered
an “assistive technology device.” The 1990 Amendments to the IDEA added this phrase
as well as assistive technology service. In regard to SGD funding, the phrase “assistive
technology service” is important because it includes “purchasing, leasing, or otherwise
providing for the acquisition of assistive technology devices by children with disabilities.”
As shown on Slide 4, both phrases have been directly linked by regulation to “special
education,” “related services,” and “supplemental aids.” Stated simply, the
schools’ duty to provide each student with a disability a F-A-P-E establishes the schools
are a possible SGD funding source. Slides 5, 6 and 7 answer the second key question:
If schools are a possible funding source, must the schools pay for an SGD identified
on a student’s IEP? The answer is No. The IDEA regulations are absolutely clear on this
point. The schools’ duty to “provide” a F-A-P-E does not mean schools must pay for
all the services and supports that are a part of the student’s educational program. Slides
5, 6, and 7 contain excerpts from the IDEA and its regulations that do 3 things: they
speak directly to the authority of schools to look to other possible funding sources;
they name several of these sources; and they speak directly to the other sources to limit
their ability to refuse to cooperate with the schools. These regulations all interpret
the phrases “at public expense” and “without charge” in the definition of F-A-P-E. They
make clear that the these phrases and the overall concept of “Free” in F-A-P-E are
broad enough to allow the schools to search for, acquire, and use funds other than school
budget dollars – consisting of its tax revenues, state aid and federal funds – to pay for
needed services. The first regulation printed on slide 5 is the most general, expressly
answering the question whether schools can use other funding to meet students’ needs.
It states clearly that schools are authorized to use funding available from any other source:
“Each state may use whatever state, local, federal and private sources of support are
available in the state to meet the requirements of this part.” [§ 300.103(a)] The regulations
referenced on Slide 6 are more specific. They speak directly to the schools and mention
Medicaid, other public benefits programs, and private health insurance by name as possible
funding sources to meet student’s needs. The text on Slide 7 is pretty crowded, These
4 references are reprinted together because they all are directed to Medicaid and other
public benefits programs and to private health insurers, in contrast to the regulations on
Slides 5 and 6 that focused on the schools’ powers. The first 2 regulations on Slide 7
state that Medicaid and other public benefits programs may not alter their scope of coverage
or their eligibility criteria in a way that reduces the benefits available to students
with disabilities. In other words, Medicaid and other programs cannot say that because
the recipient is of school age the school must provide and pay for the item or service
that is requested. You’ll note in the second regulation there is a reference to title 19
of the Social Security Act. Medicaid is the common program name for Title 19. The 3rd
reference on Slide 7 is taken from a section of the Medicaid Act, added in 1989. It states
that Medicaid cannot refuse to provide services otherwise covered by Medicaid because the
services are stated in the student’s IEP. In simpler terms, Medicaid cannot refuse to
approve requested care by pointing to a student’s IEP and noting the same services are “educationally”
and not “medically necessary,” based on their presence on the student’s IEP. Finally,
the fourth reference is directed to private health insurance and states the IDEA does
not by itself provide any basis for an insurer to refuse to provide any care otherwise covered
by the policy or plan. Having made clear that schools can use other funding sources, Slide
8 answers the 3rd key question of this presentation: Who else can pay for a student’s SGD? Slide
8 presents a list of the 4 types of public and private benefits programs that can be
considered as possible funding sources for SGDs: Public Schools; Health Benefits Programs,
including: Medicaid, Insurance, Medicare, and Tricare; Vocational Rehabilitation; and
Telecommunications Equipment Distribution Programs. We’ve already identified the schools
as a potential funding source; and the IDEA and its regulations specifically name Medicaid
and health insurance. Those regulations also state they apply to other public benefits
or insurance programs, which include 2 health benefits programs: Medicare and Tricare. Although
Medicare is most often thought of as a program for persons older than 65, children with disabilities
can be eligible for Medicare. Tricare is a health benefits program offered by the Department
of Defense to the dependents, including the children, of active duty military personnel
and of military retirees. In addition, beyond health care are federally supported programs
that provide vocational rehabilitation services. Clearly, an effective and efficient means
of communication is needed to hold a job, to live independently, and to participate
in community based activities. All of these are outcomes supported by VR services. Yet
another possible SGD funding source is state-law based. These programs, known as “equipment
distribution programs” or EDPs, provide equipment needed by people with disabilities
to use phone. EDPs are SGD funding sources because many types of SGDs will enable telephone
communication. Once an SGD is provided by an EDP, it can be used in any other settings
in which it will be of value. Although the purpose of each of these programs is unique:
education – health – vocational rehabilitation – telephone access, common among all of
them is that each will pay for SGDs. As a result, each of these programs is appropriately
considered as a possible SGD funding source for a student with a severe communication
disability. Having identified these possible SGD funding programs, in an actual IEP meeting,
the next step will be to identify the specific programs, if any, that the student is eligible
for. We won’t discuss eligibility here. Instead, in this presentation, we will review
each type of program and the criteria used to cover and pay for an SGD. As we begin to
consider other funding programs, it is important to remember that although each program can
be seen as an SGD funding source, each has distinct goals and purposes, and uses distinct
vocabulary. School-based SLPs can do evaluations and can write reports to support an SGD funding
request to any of these programs. The purpose of slide 9 is to remind SLPs to be careful
to use only the correct program-specific vocabulary. To be safe the SLP should write or speak about
an SGD using the phrase “speech generating device” or even the name of the specific
model of SGD considered or being recommended for the student’s use. Avoid using “category”
labels to the extent possible, because this is where the vocabulary differs. What is meant
by “category labels?” As noted on Slide 9, when writing or speaking to either the
schools or vocational rehabilitation, SGDs can be referred to in terms of a category.
“assistive technology devices” or “rehabilitation technology devices.” But, when writing or
speaking to any health benefits program, SGDs should not be referred to as “assistive”
or “rehabilitation” technology. These programs have their own category labels. SGDs
should be called: An item of durable medical equipment – DME; or A prosthetic device. When
writing or speaking to any of the telecommunications equipment distribution programs, neither the
assistive technology phrases nor medical phrases should be used, instead refer to SGDs as:“Specialized
telephone communication equipment” that will provide “basic access” to the telephone
network. As noted on slide 10, the first of the other funding sources we will consider
are those that provide health benefits. A rational reason to discuss these sources first
is that after the schools themselves – to which all students will be eligible – the
greatest number of students will be eligible for one or more of these health benefits programs.
Slide 8 listed the 4 different programs that provide these benefits: Medicaid; Private
health insurance policies and health benefits plans; Medicare and Tricare Although there
are many differences among these programs, common among them is the procedure used to
determine whether they are required to pay for requested care. All four use the 4 question
test that is stated on Slide 10. The first question asks: Is the person eligible? None
of these programs is open to everyone, so the first question to ask is whether the student
is a recipient, participant, or beneficiary of any of these programs? Next, Is the item
or service “covered?” None of these programs covers everything, so it is necessary to establish
that an item or service being requested, such as an SGD, “fits” within the scope of
at least one of the benefits categories that is “covered” – that is a part of the
program. If the person is eligible and the item is covered, the third question is whether
it is needed. No program – including the schools – offers benefits based on “I
want.” Instead all programs provide benefits based on one concept or another of need. Because
these are health benefits programs, the need must be “medical.” Thus, the question
is Is the item or service medically necessary? Finally, the last question addressed asks
whether the request satisfies any special rules or limitations that may relate to this
request. For example, most health benefits programs require specific evaluations and
reports to support an SGD funding request; some insurance policies and plans exclude
SGDs; some limit the types of SGDs that will be covered. As stated on Slide 10, all of
these questions must be answered “yes” for a health benefits program to provide SGD
funding. The next group of slides addresses the last 3 of these questions. “Getting
to yes” is the joint responsibility of the SLP, school, device supplier, and the client’s
family. When appeals are needed, advocates will have an important role as well. Among
everyone who will be involved, SLPs most often will be the key person. The SLP’s tasks,
particularly at the first step of the funding process, include: Investigating each funding
program to learn whether it has SGD coverage criteria. These guidelines will set out a
specific format for the SLP evaluation and report. More than half of all Medicaid programs;
many insurers; Medicare and Tricare all have coverage criteria. When there are none, it
is recommended that SLPs follow the Medicare criteria to ensure a complete evaluation and
report are produced. The Medicare criteria are reprinted at www.aac-rerc.com. SLPs also
conduct the evaluation that will determine SGD need, and need for any mounts and accessories.
The conclusion of the evaluation will be a recommendation for a specific SGD model. Then,
consistent with either program-specific guidelines, or the Medicare guidelines, the SLP must prepare
a report explaining the evaluation findings and recommendations. When dealing with health
benefits programs, the SLP must then transmit the report to the client’s physician, who
must prescribe the recommended equipment. Finally, the SLP transmits the evaluation
report and doctor’s prescription to the SGD manufacturer or supplier, who will send
the paperwork to the funding source for review. “Coverage” is a key question, because
no health benefits program covers everything. Happily, whether SGDs are covered already
has been answered for the 3 public health benefits programs (Medicaid; Medicare; and
Tricare) all acknowledge that SGDs are covered. So, too, have many insurers. Coverage is still
an open question only for a subset of private health insurers and health plans. Where SGD
coverage already is accepted, the programs agree that communication devices “fit”
within the scope of benefits the programs offer. Because our focus is SGDs, the programs
accepted SGDs fit in at least one of the benefits categories related to equipment. Durable medical
equipment, or DME, is a covered benefit category in all the public health benefits programs,
and in almost all insurance policies and health plans. DME also is the most common benefit
category in which SGDs are covered by health benefits programs. The second most common
coverage category for SGDs is prosthetic devices. When seeking an SGD from any funding source
that accepts SGDs as covered the SLP report does not have to address SGD coverage. However,
private health insurance policies and plans still require consideration of SGD coverage.
Although many more than 1,000 health insurers and health benefits plans have covered SGDs,
not all do. When exploring SGD funding from private health insurers and health plans,
SLPs should first check to see if the insurer or plan already accepts SGDs as covered. To
learn this, look for SGD coverage criteria. These may be posted at the funding source’s
web page, but SLPs also can ask any SGD manufacturer if it knows whether the insurer has coverage
criteria. If the answer is yes, SLPs can assume there is SGD coverage. Many of the nation’s
largest insurers have SGD coverage criteria. This includes Aetna; more than half of all
Blue Cross Blue Shield associations; CIGNA; and since February 2011, United Healthcare.
Many smaller insurers and plans also have SGD coverage criteria. The SLP should note
the existence of these criteria because they also will include an outline of the data points
to be reported. The SLP report also should say “the evaluation conducted and this report
followed the SGD coverage criteria.” If an insurer or plan has no SGD coverage criteria,
as a matter of procedure, it is recommended that SLPs follow the evaluation and report
outline stated in the Medicare SGD coverage criteria. These criteria and supporting materials
are both posted at www.aac-rerc.com. When there are no guidelines the task of establishing
SGD coverage falls to the SLP. SLPs should look for a definition of DME in the benefits
booklet for the policy or plan. The student’s family should have a copy of this document,
or be able to access it on-line. For insurance policies, the document will be called a “certificate
of coverage.” For plans, it is called a “summary plan description.” Unfortunately,
there is no uniform definition of DME in all policies and plans. As a general matter, every
policy or plan can have unique benefits definitions, but in practice, they don’t. Instead, most
insurers copy the Medicare DME definition for their own use. It is reprinted on this
slide. Of these 4 criteria, only 2 require much attention: the middle 2 that relate to
medical purpose and usefulness in the absence of illness or injury. Medical purpose means
“treatment.” To establish that an SGD serves a medical purpose the SLP report must
say precisely that: It must identify the student’s communication diagnosis; state it requires
speech-language pathology treatment; and that SGD use is a recognized form of SLP treatment
for individuals with severe communication impairment when they unable to meet daily
communication needs using natural communication methods. In addition, the SLP report should
state that SGD use is recognized as an effective treatment method for the client’s communication
impairment. For example, dysarthria, or apraxia. If there is evidence related to the client’s
broader diagnosis, e.g., autism, this should be stated as well. The criterion includes
the phrase “primarily and customarily,” but for SGDs, the only purpose they serve
is as treatment for severe communication impairment. Remember: the need for or “purpose” of
the SGD is to serve as a supplement or substitute for the person’s inability to speak or use
other means of expression. That the student plans to use the device in school or other
particular settings; with peers, teachers or school personnel; or to talk about school
topics – reflects only the student’s daily activities and communication partners. It
does not define the “need” or “purpose” for the device. The easiest way to address
this point is to note that the student will need the device even if the client did not
attend school – the device is needed because of the student’s communication disability,
not school enrollment. The other criterion to address: “Not useful in the absence of
illness or injury,” is not hard to establish, but again, care must be taken to avoid trouble.
For many SGDs, 2 versions are sold. One that is “dedicated” and one that is “open”
or “unlocked.” Dedicated SGDs only work as SGDs. Open or unlocked SGDs will provide
access to SGD functions and other functions of the device, such as internet access; or
access to other programs, such as word processing. SLPs always should recommend the “dedicated”
model of any SGD, and clearly state this in the report. The report should state clearly
that the device recommended only serves as a communication device and is useful only
to a person with severe communication disability, like the student. Dedicated devices will not
be of use to a person without severe communication impairment. No one who can speak will want
to use one of these devices. That these devices still offer several miscellaneous features,
such as calculator or TV remote control or phone is not relevant: no one will pay thousands
of dollars for devices with these features when other devices offering the same features
can be had for less than $ 100. Recommending dedicated devices is wholly consistent with
the outlines of the SLP report stated in funding program SGD coverage criteria. None asks any
questions about need for or use of the device for anything other than communication purposes.
No SLP report ever should mention that a client needs any of these features; intends to use
any of these features; or will benefit from any of these features. Remember: the task
being undertaken is preparation of a report to support a funding request, hopefully a
funding approval. A funding report is not the same as a set of clinical notes. Uses
of an SGD beyond speech generation for face to face communication is just not relevant
to the funding question at hand. In addition, for any SGD with two models, dedicated-open
twin models, it is possible to unlock the device after is obtained to allow the client
to access all of its features and functions. But this needs to be done after the funding
decisions have been made. The point here is that being careful to what is written in the
SLP report and what device is recommended, the SLP will be helping to get the device
approved faster and still enable the student to access any device function that will be
of value. One final comment, these criteria will most likely preclude health program coverage
and payment for I-Platform devices, such as i-Pods, i-Phones, and i-Pads and other similar
“open” computer- or PDA-based devices. All of these platforms are common consumer
electronics items and remain so even when used as an SGD. The I-platform and similar
devices don’t now have the capability to be made “dedicated.” Although exceptions
may occur, in general, these devices will not be covered by health benefits programs,
so they won’t be covered. This slide reviews the 3rd question: “Is the SGD medically
necessary? Medical need is a requirement for all health benefits programs. Although all
use the same standard, there is no universal medical need definition. What is common among
the definitions are the following elements: There must be a condition: an illness, injury
or disability. It must cause adverse health effect, such as a functional limitation related
to speaking, writing, or using sign language. There must be a treatment for that condition
that is recognized as effective and non-experimental. And, the treatment must represent the least
costly equally effective alternative for the condition. This slide reprints the New York
Medicaid definition of medical need. It references the first 3 of these 4 elements. It refers
to “conditions in the person.” It refers to “conditions” that “cause acute suffering,
endanger life, result in illness or infirmity, interfere with the person’s capacity for
normal activity, or threaten some significant handicap.” It refers to “care, services
and supplies” that will “prevent, diagnose, or correct or cure.” This definition does
not expressly mention least costly, but it important to remember that it always is a
requirement for health benefits programs, whether stated directly in the definition
or not. Consideration of alternatives first for appropriateness first and then for cost
is a required element of all SLP evaluation and reporting guidelines. Generally speaking,
the same facts that establish an SGD serves a medical purpose related to coverage will
also establish when it is medically necessary. The SLP must state in the report that the
SGD is treatment for the client’s severe communication impairment, which should be
referred to by its communication impairment diagnosis – e.g., dysarthria; apraxia. The
report should state there is no form of SLP treatment that will enable the client to meet
daily communication needs using natural communication methods. This finding led to consideration
of AAC intervention and to the conclusion that an SGD is the most appropriate form of
AAC treatment that will enable the client to meet daily communication needs. Then the
report has to explain why the particular SGD was selected and recommended. A few miscellaneous
points: school-based SLPs were once viewed by health based funding sources as inappropriate
sources of evaluations and reports to support health based funding requests. They were viewed
as justifying educational need, not medical need. This is no longer a concern. School
based SLPs can conduct evaluations and prepare reports to support SGD funding by any health
benefits program. Reports can be submitted on school letterhead and the SLP can identify
his or her position as a school based SLP. Another point to note in report writing is
that just as the concept of “medical purpose” is not measured by where the device is going
to be used, the concept of “medical need” is not measured solely or primarily by whether
the student will use the SGD in order to get medical care. Medical need does not equal
“medical speak.” References to reporting health concerns or securing care can be referred
to in reports as an example of the student’s medical need, but not as the reason the SGD
is medically necessary. Always keep in mind that SGD use is part of speech-language pathology.
SLP interventions are not directed to enable speech with particular people (e.g., medical
professionals or care givers); about specific topics (symptoms; medical care needs); or
in specific settings (doctor’s offices; other care settings). SLP treatment is provided
to clients who cannot meet daily communication needs due to speech impairment. The same standard
applies to when an SGD is needed. An SGD is just a different “form” or “type”
of SLP treatment, but the same rules for determining need apply. A last point about medical need
is that whenever appropriate SLP reports should note that the student has higher receptive
language abilities than expressive language abilities. Professional literature supports
this expressive/receptive gap as a medical need marker for AAC intervention, which includes
SGD use. This slide addresses the fourth question applicable to health benefits program SGD
coverage: does the request satisfy any special rules that apply? Special rules fall into
2 categories: those related to documentation, and those related to coverage. Special rules
related to documentation are the less severe of the 2. They are most commonly imposed by
Medicaid programs. They focus on what information must be provided to support an SGD funding
request. The most common of these already was discussed: The existence of SGD coverage
criteria. In addition, SLPs should be alert for requirements beyond the evaluation report.
For example, some funding programs require: an additional report of a trial use period;
or a video showing the device being used by the student. Special rules related to coverage
are different. Some focus on which types of SGDs will be covered. Already discussed has
been rules that limit SGD coverage only to “dedicated” models. A second type of coverage
rule is an exclusion, which are found in only a small number of insurance policies and health
plans. Exclusions can block coverage of all SGDs or for people with particular diagnoses.
If an exclusion exists, it can be found in 3 possible places: Certificates of coverage
and summary plan descriptions will have an “exclusions and limitations” section.
SGDs may be among the list of things that are excluded; or they may be listed as an
example of a broader category of care that is excluded. The most common category is the
exclusion for “comfort or convenience items.” To be clear, if an SGD is excluded, the exclusion
must clearly identify SGDs. SGDs must be named as an excluded item. The second place an SGD
exclusion or limitation may be found is as part of the definition of covered benefits
such as DME or prosthetic devices. Or, they may be stated in SGD coverage criteria. An
example is CIGNA, which currently excludes SGDs for use by people with autism, claiming
this use is “experimental.” SLPs should search for and review exclusions carefully.
If the wording is not precise the exclusion won’t apply. For example, a common phrasing
of an exclusion is for “devices and computers to assist with communication and speech.”
In a recent case the wording was slightly different, “devices and computers to assist
nonverbal communication.” In that case we argued successfully that SGDs are not devices
to assist with nonverbal communication. For this reason, the exclusion as written didn’t
apply to SGDs. The insurer agreed and an eye tracking system for a woman with ALS was approved.
A few closing comments about health benefits programs as SGD funding sources are these:
* health benefits programs are the largest source of SGD funding among all funding programs,
both for children and adults. * They will approve SGDs for students in school. * They
will approve funding requests at the initial level of decision making. * They will approve
funding requests when they are supported by SLP reports that are prepared by school based
SLPs. * Whenever a student is eligible for a health benefits program, it should be pursued
as a possible SGD funding source. This slide discusses another SGD funding program: vocational
rehabilitation. For students age 14 and older, schools are required to plan for, and no later
than age 16, begin to provide services for transition to adult life. The IDEA regulations
define Transition services as: “ a coordinated set of activities for a child with a disability
that is designed to be within a results oriented process, that is focused on improving the
academic and functional achievement of the child with a disability to facilitate the
child’s movement from school to post-school activities….” § 300.43(a). Post school
activities can be: post-secondary education; vocational education; employment; adult education;
adult services; independent living and community participation. Transition services consist
of 2 related parts: one is a planning component and the second is a services component. The
IDEA regulations make clear that the scope of the services supporting transition can
include special education and related services, and also include assistive technology devices
and services. In regard to our focus on SGDs, it is hard to imagine a person successfully
engaging in any adult activity without an effective means of expressive communication.
Transition services give school-based SLPs a specific opportunity to ensure that no student
with severe communication disability will exit from the public schools without the skills
and tools to communicate effectively. That outcome can be accomplished by making transition
planning and services delivery a truly “coordinated” activity. Specifically, school staff should
coordinate both planning and services delivery with their state vocational rehabilitation
program. The IDEA regulations make several references to the schools and VR working together
and the VR statute and regulations make several references to transition. In other words,
there is an expectation stated in the regulations of both programs that VR and the schools will
work together during the transition period. VR is a program designed to aid individuals
with disabilities to prepare for, to secure, to retain or regain employment. Its staff
has skills to help students to: explore goals for adult life; identify needed services to
achieve those goals; help find jobs; provide work-related and independent living supports;
and provide funding for needed services and equipment. This last point, to provide funding
for needed equipment and services, is clearly a way for a student with severe communication
disability to obtain funding for an SGD. The VR jargon an SGD is a “rehabilitation technology”
device. VR’s ability to pay for SGDs has 2 applications: First, VR can buy an SGD for
the student to use while in the last years of his or her school program. This ability
is particularly valuable for students nearing the age of school exit – during this period,
schools will see providing devices with their own funds as a poor investment. So if VR will
purchase the device, schools can direct their resources to the training and support the
student will need to be a competent communicator. Second, VR can buy a school-purchased SGD
from the school at the point of the student’s school exit, whether at graduation or aging-out.
This option benefits the student because it allows for continued use of a device the student
is familiar with. It also eliminates any risk of delay in seeking funding for and then in
ordering, delivery, and set-up of a new device. It can benefit the schools when the device
the student is using is unlikely to be of benefit to anyone else in the district. It
also benefit the VR program because it enables the student to obtain a device recognized
as needed, at a discounted price. VR has its own eligibility requirements, and it is recommended
that students be directed to the VR office to apply for services at the outset of the
transition process. VR has no age-threshold for receipt of its services. However, VR staff
may tell students to return when they are closer to school exit. This advice should
be rejected: students should insist on completing the application process. If necessary, school
staff should go with the student to the VR office for this purpose. Just as schools rely
on the IEP to outline a program of services, VR programs will develop an individualized
plan for employment, or IPE for its clients. The IPE will identify the person’s vocational
goals and all the services and supports required to achieve those goals. For a student in transition,
the IEP and IPE should have very similar content. This slide focuses on a fourth nonschool SGD
funding source, telecommunication equipment distribution programs or EDPs. EDPs are programs
created by state law. They operate in about 40 states and they provide equipment to enable
people with disabilities to use the phone. They were created to help people with disabilities
overcome the cost barriers to obtaining the specialized equipment they need to use the
telephone. People who are deaf or hard of hearing are the primary beneficiaries of the
EDPs but in almost all states also include people with speech disabilities among those
eligible for EDP services. About 1-2 dozen of the EDPs already cover SGDs; the others
are likely never to have been asked to do so. Texas’s program, known as S-T-A-P is
the largest to cover SGDs. In Texas, it is a significant source of SGD funding. EDPs
raise their funds through a sur-tax on phone bills. Most of those funds are used to pay
for the state “relay operator” system, needed by people who use TTY or TDD devices
to communicate. A small portion of the taxes are directed to the EDPs. But because of the
explosion of phones in the past decade, the EDPs in many states have more money than they
can spend. Using them to pay for SGDs, rather than other programs that are cash-strapped,
such as the schools and Medicaid programs, seems to be an efficient use of scarce public
financial resources. EDPs can be of benefit to students needing SGDs because SGDs can
enable their users to use the phone. That SGDs also support face-to-face communication
is an added benefit, but not part of the EDPs’ focus. SGDs also are portable: they are not
fixed objects that need to stay connected to a phone. Even for phone use – many SGDs
can connect to any phone, in any setting, making them even more valuable to their users.
There is no absolute age threshold for phone use. Obviously, students in school – children
– use the phone. Even very young children, even those too young to place a call on their
own, can and do communicate by telephone. Only a few years later, young children will
have the skills to place as well as receive calls. Children with speech disabilities should
have the same opportunities. The EDPs can make this possible. The EDPs tend to operate
very informally. They may not even require an evaluation; instead they may only require
certification of: speech disability; of a barrier to telephone communication using standard
equipment; and the identification of a device that will enable the person to overcome that
barrier and have basic telephone access. Even if only certification is required, it is recommended
that in all cases an SLP evaluation be conducted that follows the Medicare protocol. The administrative
simplicity of the EDP should be viewed as independent of the SLP’s duty to determine
the most appropriate SGD to meet the student’s needs. The key finding that will make EDP
funding possible is the identification in the evaluation report that phone use is among
the student’s daily communication needs. It will be likely this is a need that cannot
now be met because the student lacks an effective means of expression. But with a communication
device, this barrier can be overcome. SGDs are covered and should be covered by EDPs
because they meet all the EDPs’ interests. Some communication devices have phones built
in; others can support plug-in cards that allow them to operate as cell phones; others
can connect to the phone through a wired connection; others can connect wirelessly through an intermediate
device that will connect to the phone. In all of these examples, the SGD enables the
messages created by the device to travel electronically through the phone network and be received
as a speech by the communication partner. Yet, another possible way for SGDs connect
to the phone network is to work with a speaker-phone. In this example, the device produces a voice
message that is transmitted as speech through the phone network to the other party. EDPs
can be a valuable source of SGD funding, but there are some limitations to consider: they
don’t operate in every state. To find out if there is an EDP in your state, check the
list posted at www.tedpa.org. Some EDPs don’t admit to SGD coverage at present; some EDPs
have financial eligibility criteria. Some of these criteria mirror Medicaid eligibility,
but others are more generous. This will limit who may be eligible for an EDP funded a communication
device. And, some EDPs provide only partial funding for covered devices. This may mean
the EDPs can be a funding partner for a device, rather than provide full funding. Of these
limitations, an additional comment is warranted. If an EDP reports SGDs are not covered, SLPs
should submit a report anyway and if the device is denied the request should be forwarded
to an advocate for review. If an EDP exists in the student’s state and the student meets
the program’s eligibility criteria, the EDP should be seriously considered. Their
informal administration leads to a very quick decision making process from start to finish.
And, as stated, once the SGD is provided, it can be used anywhere, including in school
to support a student’s IEP. The last group of slides answer the last of the key questions:
What criteria guide the decision about who pays? Before answering this question we must
answer another: who is the decision maker regarding SGD funding? The setting for this
presentation is an IEP meeting following the report by an SLP that the student needs a
communication device. Around the table are school staff and administrators, an SLP, and
the student’s parents. SGD need has just been laid on the table, and the question is:
who is going to pay for it? There are 2 primary decision makers: the school and the student’s
family. If the school just accepts the SLP report, writes the SGD into the IEP and agrees
to pay for the SGD, then the school clearly is the decision maker. Likewise, if the family
just pursues another funding source, then the decision is theirs. But it also is important
for the school to be prepared for the family to not say “yes” when asked. Schools may
have to persuade the family to agree, and to negotiate in order to secure that agreement.
The reason why persuasion and negotiation may be necessary is that the student’s family
has veto power over use of any non-school SGD funding source. The family can require
the schools to pay by not allowing any other source to be considered. Thus, the schools
may have to persuade the family that consideration of another SGD funding source is in the student’s
as well as the school’s best interests. The family’s veto power is based on the
requirement in several IDEA regulations and administrative and court decisions that require
the family to give consent before any other funding source is considered. This extends
to programs the student may be eligible for but hasn’t yet applied for – such as vocational
rehabilitation or the EDP – and programs such as health benefits programs for which
eligibility is likely to already exist. Families might refuse to give consent if they become
convinced that the school must pay for anything written on the student’s IEP. Some people
hold to this view, although as we have seen, it clearly is not legally accurate. A second
reason a family might refuse to give consent is as payback or revenge for past disputes
about other aspects of the student’s F-A-P-E. If there is a poor relationship between the
school and family, the parents may try to get even by refusing to allow any other SGD
funding source to be considered. Or, parents can refuse to allow an existing SGD obtained
from some other source to come with the student to school, in effect, forcing the school to
purchase a second SGD. Schools cannot force a student to bring a student-owned device
to school or refuse to provide one because of the existence of one available at home.
There are lots of possible reasons why a school-family relationship can deteriorate to this point.
Whatever the cause or causes, this outcome is not required. It clearly does not benefit
the student or the school. In circumstances like this, but really in all cases, putting
an SGD on the table will test the school’s seriousness of purpose and skills at negotiation.
Schools should use the need to talk about who pays for the SGD as an opportunity to
build a good foundation for a good family-school relationship, rather than a source of poison
for a toxic one. This slide lists some of the ways schools can negotiate to get parental
consent. First, they should recognize the full costs of laying an SGD on the table at
an IEP meeting: There are the direct costs of acquiring the SGD. There are direct costs
of training or hiring skilled staff to integrate the SGD into the student’s program. And
there also are potential costs of due process proceedings if there is a refusal to add the
SGD to the IEP or to properly integrate it. Knowing this, schools can make several offers
that keep the focus on the student rather than on the funding decision. For example:
At the very outset of the process, the school can offer to do the SGD evaluation, if the
school has staff trained to do so; Or, the school can offer to pay for an independent
SGD evaluation if it does not have the staff trained to do one. Schools can offer to pay
for a short-term rental of the device for a trial use period to produce data to support
a funding request or an appeal. Schools can offer to put funds aside for the training
of all the staff who will interact with the student so they know the best way to improve
the student’s communication. The schools obviously must have trained staff in sufficient
numbers to educate all its students, but money can only be spent only once. Spending on training
will benefit this student, and can also benefit others even if they don’t use the same device
or even if they don’t use any device. But spending on an SGD will benefit this one student
and maybe no other, ever. Schools can extend the training offer to the family. The schools
obviously have a duty to provide such training as an assistive technology service, but volunteering
these services will go a long way to persuade the family that educating their son or daughter
is going to be a team effort, with the family as a valued part of the team. Close and ongoing
home-school communication is extraordinarily important to parents, and particularly for
parents of kids who use SGDs. Schools can offer to provide access to an extended school
year. Again, this is a duty the schools already may have, but volunteering these services
will show good faith on the part of the schools to spend school funds for the benefit of this
student, if the family will contribute its access to other funding programs for the purchase
of the device. If needed, the school can offer to pay the family’s co-payment or other
out-of-pocket charges associated with the device purchase. These outlays are permitted
by the IDEA regulations. Most health insurance and Medicare offer only partial payment for
covered care. The EDP also may contribute an amount that covers only part of the costs
of the device. This offer is directed to the equipment rather than to school services,
but it is a lot less costly to pay 20 % of the cost of a device than paying for the device
in full. And, the school can remind the family that the device will be theirs. This means
there will be no issue, ever, about the student’s access to the device. The device can come
and go with the student, and be with the student on vacations, if the family moves, and when
the student exits school. If it needs to be replaced, the family can secure a new one
without having to go back through the IEP process. These are
just some of the offers schools can make to
persuade the family to give its consent to have another funding program to pay for the
SGD. In the end, these offers will lead to the type of relationship that will be in the
best interests of the student and the best interests of the schools. Once consent is
granted, all the participants at the IEP meeting should turn to this last key question: Which
program should be asked to pay and why? In general 3 criteria should guide this process.
* Which program has the most straightforward path to yes? * Which program will make its
decision fastest? And, * Which program will offer the most funding? This slide addresses
this last group of questions. Most often the answer to these questions will point to health
benefits programs to pay for SGDs when they are available. Health benefits programs have
lots of experience covering and providing SGD funding; many have established procedures
and guidelines to govern the funding process; and the majority of their decisions are “yes”
at the first level of review. And if an appeal is needed, these can be described as easier
and faster and more likely to lead to “yes” than a special education due process proceeding
or the appeal processes of vocational rehabilitation. The EDPs don’t even have appeal procedures.
Even among the small percentage of students who have no health benefits now, things may
change. In 2014, assuming the health care reform legislation goes into effect, almost
all of these students will have access to SGD funding – either because they will become
eligible for Medicaid, or based on the requirement that everyone else obtain health insurance.
The Affordable Care Act expands Medicaid it also requires everyone else to have insurance.
The law also describes the minimum benefits package that an insurance policy must have
to satisfy this requirement. They have to include: Rehabilitative and habilitative services
and devices. SGDs clearly serve “rehabilitative” and “habilitative” purposes. So, after
2014, it is possible that all students will have at least 1 other, meaning nonschool,
SGD funding source – a health benefits program. In closing, this presentation explained that
schools can be an SGD funding source, but they can seek and use funding available from
any other sources to obtain an SGD. The only limitations are the existence of another funding
source, and parental consent to use that source. If schools are careful to develop and maintain
a positive relationship with the family, and make clear that the interests of the student
are being put first, schools may never have to buy an SGD. Instead, health benefits programs,
primarily Medicaid and insurance, or vocational rehabilitation programs or telecommunications
equipment distribution programs can provide the funds needed to obtain an SGD for a student
with severe communication disability. Thank you.

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