Public School Students: Who Can Pay for SGDs?
AAC-RERC Webcast Series
Slide 1:
       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 studentÕs individualized education program or IEP.   

       The information to be presented is intended for all the participants in a studentÕs IEP meeting.  This includes the schoolÕs instructional staff; speech-language pathologist; school administrators; the studentÕs 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 studentÕs 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.

Slide 2:
       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:
       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.  

       ÊSo, the schools always are a possibility, but to be clear: talking about the schools first is not intended to suggest that the schools:ÊAre required to pay for a needed SGD;ÊAre the most likely source of SGD funding; or ÊAre the best source of SGD funding.
Ê	
       Schools are a possible SGD funding source because all students with disabilities are entitled to a ÒFree Appropriate Public Education,Ó or F-A-P-E.  This ÒrightÓ 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 Ð to be performed or coordinated by the school in most cases Ð that need for an SGD will be identified and the decision made to incorporate it into the studentÕs educational program.  
       
       Once the decision is made to include the SGD in the studentÕs IEP, the last 2 steps of the procedural sequence, to ÒacquireÓ and ÒprovideÓ services and equipment items and to ÒintegrateÓ those things into the studentÕs IEP, also describe the schoolsÕ substantive duties. 

Slide 4:
       Schools are a possible SGD funding source because they are responsible to provide the services and supports identified on studentsÕ 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 studentsÕ 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 Òspecial education;Ó Òrelated services;Ó and Òsupplemental aidsÓ identified on studentsÕ 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 Òrelated services.Ó  

       Since 1990, SGDs also have been considered an Òassistive technology device.Ó  The 1990 Amendments to the IDEA added this phrase as well as assistive technology service.  In regard to SGD funding, the phrase Òassistive technology serviceÓ is important because it includes Òpurchasing, leasing, or otherwise providing for the acquisition of assistive technology devices by children with disabilities.Ó  As shown on Slide 4, both phrases have been directly linked by regulation to Òspecial education,Ó Òrelated services,Ó and Òsupplemental aids.Ó  
       Stated simply, the schoolsÕ duty to provide each student with a disability a F-A-P-E establishes the schools are a possible SGD funding source. 

Slide 5: 
       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 studentÕs IEP? The answer is No.  The IDEA regulations are absolutely clear on this point.  The schoolsÕ duty to ÒprovideÓ a F-A-P-E does not mean schools must pay for all the services and supports that are a part of the studentÕs 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 Òat public expenseÓ and Òwithout chargeÓ in the definition of F-A-P-E. They make clear that the these phrases and the overall concept of ÒFreeÓ in F-A-P-E are broad enough to allow the schools to search for, acquire, and use funds other than school budget dollars Ð consisting of its tax revenues, state aid and federal funds Ð 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 studentsÕ needs.  It states clearly that schools are authorized to use funding available from any other source: ÒEach state may use whatever state, local, federal and private sources of support are available in the state to meet the requirements of this part.Ó  [¤ 300.103(a)] 

Slide 6: 
       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 studentÕs needs.

Slide 7: 
       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 schoolsÕ 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. 
       
       YouÕll 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 studentÕs IEP.  In simpler terms, Medicaid cannot refuse to approve requested care by pointing to a studentÕs IEP and noting the same services are ÒeducationallyÓ and not Òmedically necessary,Ó based on their presence on the studentÕs 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.  
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Slide 8: 
       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 studentÕs 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.
       
       WeÕve 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 Òequipment distribution programsÓ 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 Ð health Ð vocational rehabilitation Ð 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 wonÕt 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.  

Slide 9: 
       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 Òspeech generating deviceÓ or even the name of the specific model of SGD considered or being recommended for the studentÕs use.  Avoid using ÒcategoryÓ labels to the extent possible, because this is where the vocabulary differs.  
       
       What is meant by Òcategory labels?Ó 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. Òassistive technology devicesÓ or Òrehabilitation technology devices.Ó  But, when writing or speaking to any health benefits program, SGDs should not be referred to as ÒassistiveÓ or ÒrehabilitationÓ 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:ÒSpecialized telephone communication equipmentÓ that will provide Òbasic accessÓ to the telephone network.

Slide 10: 
       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 Ð to which all students will be eligible Ð 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 Òcovered?Ó None of these programs covers everything, so it is necessary to establish that an item or service being requested, such as an SGD, ÒfitsÓ within the scope of at least one of the benefits categories that is ÒcoveredÓ Ð 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 Ð including the schools Ð offers benefits based on ÒI want.Ó Instead all programs provide benefits based on one concept or another of need. Because these are health benefits programs, the need must be Òmedical.Ó  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 ÒyesÓ for a health benefits program to provide SGD funding. 
       
       The next group of slides addresses the last 3 of these questions.  
       
       ÒGetting to yesÓ is the joint responsibility of the SLP, school, device supplier, and the clientÕs 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 SLPÕs 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 clientÕs physician, who must prescribe the recommended equipment.  Finally, the SLP transmits the evaluation report and doctorÕs prescription to the SGD manufacturer or supplier, who will send the paperwork to the funding source for review.

Slide 11: 
       ÒCoverageÓ 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 ÒfitÓ 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. 

Slide 12: 
       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 sourceÕs 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 nationÕs 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 Òthe evaluation conducted and this report followed the SGD coverage criteria.Ó  
       
       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 studentÕs 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 Òcertificate of coverage.Ó  For plans, it is called a Òsummary plan description.Ó  
       
       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 donÕt.  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 Òtreatment.Ó  To establish that an SGD serves a medical purpose the SLP report must say precisely that: It must identify the studentÕs 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 clientÕs communication impairment. For example, dysarthria, or apraxia. If there is evidence related to the clientÕs broader diagnosis, e.g., autism, this should be stated as well.  

       The criterion includes the phrase Òprimarily and customarily,Ó but for SGDs, the only purpose they serve is as treatment for severe communication impairment.   Remember: the need for or ÒpurposeÓ of the SGD is to serve as a supplement or substitute for the personÕs 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 Ð reflects only the studentÕs daily activities and communication partners.  It does not define the ÒneedÓ or ÒpurposeÓ 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 Ð the device is needed because of the studentÕs communication disability, not school enrollment.  

       The other criterion to address: ÒNot useful in the absence of illness or injury,Ó is not hard to establish, but again, care must be taken to avoid trouble.  For many SGDs, 2 versions are sold. One that is ÒdedicatedÓ and one that is ÒopenÓ or Òunlocked.Ó  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 ÒdedicatedÓ 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 ÒopenÓ 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 donÕt now have the capability to be made Òdedicated.Ó Although exceptions may occur, in general, these devices will not be covered by health benefits programs, so they wonÕt be covered. 

Slide 13: 
       This slide reviews the 3rd question: ÒIs 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 Òconditions in the person.Ó It refers to ÒconditionsÓ that Òcause acute suffering, endanger life, result in illness or infirmity, interfere with the personÕs capacity for normal activity, or threaten some significant handicap.Ó  It refers to Òcare, services and suppliesÓ that will Òprevent, diagnose, or correct or cure.Ó
       
       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 clientÕs severe communication impairment, which should be referred to by its communication impairment diagnosis Ð 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 Òmedical purposeÓ is not measured by where the device is going to be used, the concept of Òmedical needÓ 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 Òmedical speak.Ó  References to reporting health concerns or securing care can be referred to in reports as an example of the studentÕs 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 (doctorÕs 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 ÒformÓ or ÒtypeÓ 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.

Slide 14: 
       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.
       
Ê	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 ÒdedicatedÓ 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 Òexclusions and limitationsÓ 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 Òcomfort or convenience items.Ó   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 Òexperimental.Ó  
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       SLPs should search for and review exclusions carefully. If the wording is not precise the exclusion wonÕt apply. For example, a common phrasing of an exclusion is for Òdevices and computers to assist with communication and speech.Ó  In a recent case the wording was slightly different, Òdevices and computers to assist nonverbal communication.Ó  In that case we argued successfully that SGDs are not devices to assist with nonverbal communication. For this reason, the exclusion as written didnÕt apply to SGDs. The insurer agreed and an eye tracking system for a woman with ALS was approved.  
       
       ÊA 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.

Slide 15: 
       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: Ò 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 childÕs movement from school to post-school activitiesÉ.Ó ¤ 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 ÒcoordinatedÓ 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 Òrehabilitation technologyÓ device.  

       VRÕs 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 Ð 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 studentÕs 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 personÕs 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.

Slide 16: 
       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. TexasÕs 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 Òrelay operatorÓ 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 EDPsÕ focus. SGDs also are portable: they are not fixed objects that need to stay connected to a phone.  Even for phone use Ð 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 Ð children Ð 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 SLPÕs duty to determine the most appropriate SGD to meet the studentÕs needs.  
       
       The key finding that will make EDP funding possible is the identification in the evaluation report that phone use is among the studentÕs 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 EDPsÕ 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 donÕt 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 donÕt 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 studentÕs state and the student meets the programÕs 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 studentÕs IEP. 

Slide 17:
       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 studentÕs 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 studentÕs 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 ÒyesÓ 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 studentÕs 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 studentÕs as well as the schoolÕs best interests.  

       The familyÕs 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 hasnÕt yet applied for Ð such as vocational rehabilitation or the EDP Ð 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 studentÕs 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 studentÕs 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 schoolÕs 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. 

Slide 18: 
       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 studentÕs 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 studentÕs 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 donÕt use the same device or even if they donÕt 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 familyÕs 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 studentÕs 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? 

Slide 19: 
       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 ÒyesÓ 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 ÒyesÓ than a special education due process proceeding or the appeal processes of vocational rehabilitation.  The EDPs donÕt 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 Ð 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 ÒrehabilitativeÓ and ÒhabilitativeÓ purposes.  So, after 2014, it is possible that all students will have at least 1 other, meaning nonschool, SGD funding source Ð a health benefits program. 
Ê	
       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.