Appeals Process for the Denial of
Medicaid Funding for Augmentative and Alternative Communication Services
Date: April 10, 1996
Prepared by: S.J. Landaas
Medical Assistance Administration (MAA), which reviews all requests for funding
for augmentative and alternative communication services (AAC), will occasionally
deny your initial request for funding either because the service is not
"medically necessary" or because it is not covered for some other reason. This
document will explain the process for appealing this denial of Medicaid funding,
and your rights and responsibilities as the appellant.
Notification Requirements:
MAA must approve or deny all requests for medical services within 15 days of the
receipt of the request. When MAA denies a request for medical services,
including all or part of a requested service, it must give the client and the
provider written notice of the denial within five working days of the decision.
Such notice from MAA must include:
- The Washington Administrative Code (WAC) references used as a basis for
the decision;
- A summary statement of the specific facts the department relied upon for
the decision;
- An explanation of the reasons for the denial, including the reasons why
the specific facts relied on did not meet the requirements for approval. [WAC
388.501.0165(6)]
Request for Additional Information:
MAA may request additional information from the requesting provider within 15
days of receiving your initial application. If MAA does not receive additional
information within 30 days of the date requested, it can deny the original
request within five days after the 30-day period on the basis of insufficient
justification of medical necessity.
Notification Problems:
In some instances MAA will not deny your request for funding of AAC equipment
and services, but will instead place your application on a pending status. As a
result you may not receive notification in a timely manner.
Request for a Fair Hearing:
If you receive a letter denying your request for AAC equipment and services, you
have 90 days to submit a written request for a fair hearing.
Preparation for the Hearing:
Once the hearing has been scheduled, the next step is to prepare your case. You
will need to present documentation from your physician or health care provider
along with a copy of the original evaluation and recommendations of the speech
pathologist. If necessary, a second evaluation should be performed by a second
speech pathologist. Copies of the second evaluation need to be included in the
presentation.
Right to Counsel:
As in any legal proceeding, you have the right to retain council to assist you
with your appeal at the fair hearing. A Fair Hearings Coordinator will represent
MAA at the hearing. Additional MAA staff may provide testimony if necessary.
Pre-hearing Conference:
The purpose of a pre-hearing conference is to clarify issues and to set the
agenda for the fair hearing. Pre-hearing conferences may be held by telephone
conference call or at a time and place specified by the Administrative Law Judge
(ALJ).
Pre-Hearing Settlement:
After the MAA has had a chance to review your application and any additional
information, they may reverse their initial decision and approve your request
prior to the hearing.
The Fair Hearing:
Fair hearings are informal and are held either at the local Department of Social
and Health Services (DSHS) office or by phone. The hearing will be conducted by
an ALJ. After all parties have been sworn in, the Medical Coordinator will
present the Medical Assistance Administration's reasons for denying the funding
request for AAC equipment and services. MAA may argue that the AAC equipment and
services requested are not "medically necessary" because the medical
justification presented by the physician did not adequately address the issue.
MAA must present specific detailed reasons for their denial. Their conclusion
must be based on sound medical practice and supported by the objective medical
information in your file. After the MAA has presented its case, you then present
your case.
Offensive Strategies:
The ALJ assigned to your case serves as a neutral third party. Your goal at the
fair hearing is to persuade the ALJ that the AAC equipment and services you
requested are "medically necessary" and that the MAA was wrong to deny your
application. Points that may be helpful to your case include:
- The MAA failed to notify you of their decision denying the funding request
in a timely manner as required in WAC 388.501.0165(5)(a).
- The AAC equipment and services requested are "medically necessary."
- Speech pathology and audiology services cover the "treating and
ameliorating of disorders of human communication." It clearly includes the
providing and use of an augmentative and alternative communication device.
Although the word "speech" might make people think this field is limited to
spoken language, it actually extends to restoring functions in written
language as well. So, computer-based devices to aid in writing can come within
"speech pathology" as well.
- According to state law [WAC 388.86.098], MAA must pay for speech therapy
services for conditions which are the result of medically recognized diseases
and defects. To be covered, the services must be provided by a speech
pathologist or audiologist who has been granted a certificate of clinical
competence by the American Speech, Hearing and Language Association.
Children's services:
MAA may not deny Medicaid funding for AAC equipment and services for children
who are enrolled in the early and periodic screening, diagnostic, and treatment
program under the Social Security Act 42 USC 1396d(a)(4)(B). Medicaid must also
provide funds for AAC equipment and services for any child under the age of 21
if the client's physician considers such services to be "medically necessary"
for treatment.
Medically Necessary:
Another issue you could raise is the issue of medical necessity. You might argue
that the AAC equipment and services requested are "medically necessary" for the
following reasons.
Emergency Services:
Effective communication is essential, especially in an emergency. The AAC
equipment and services requested are medically necessary for your safety,
especially if you are unable to communicate in any other way. Get a doctor's
statement describing your communication needs and how the AAC equipment and/or
service would provide the assistance needed in an emergency.
Mental Health:
The need to communicate is basic to good mental health. In some cases the AAC
equipment and services requested may provide the only means by which you would
be able to communicate with others. Present a written statement from your
physician or mental health specialist explaining why the AAC equipment or
services requested are "medically necessary."
Conclusion:
If MAA presents an argument which requires additional information from the
equipment provider, physician or speech pathologist, you may ask the ALJ for
more time. Copies of the additional information requested must be sent to the
ALJ and the Fair Hearings Coordinator.
Decision:
The ALJ will review all the testimony presented and render a decision. A written
decision will be sent to all parties in about three weeks. If either you or MAA
is dissatisfied with the ALJs' decision, you have 21 days to submit a written
request for a petition for review. If after having reviewed the ALJ's decision
and the issues still have not been resolved to the satisfaction of either party,
then either you or MAA can appeal to Superior Court.
This publication is an information service of the Washington Protection &
Advocacy System (WPAS). It provides general information only and should not be
used as legal advice for any specific situation. If you would like more
information about this topic, call us and ask for a Resource Advocate.
To receive this document in an alternative format,
such as large print or Braille, please call Washington Protection & Advocacy
System (WPAS) at 1-800-562-2702.
WPAS is a member of the National Disability Rights
Network
A substantial portion
of the WPAS budget is federally funded.
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