The Honorable Jan Brewer
Governor of Arizona
1700 West Washington
Phoenix, Arizona 85007

10 March, 2011
Re: Medicaid Benefits and State Flexibility

Dear Governor Brewer:

Last month you received two letters from Kathleen Sebelius, U.S. Secretary of Health and Human Services, addressing state Medicaid program savings. On February 3, 2011, she sent a letter regarding how her department can “…help…identify cost drivers in the Medicaid program and provide you with new tools and resources to achieve both short-term savings and longer-term sustainability while providing high-quality care to the citizens of your state.” Her subsequent letter of February 24, 2011, again emphasized how Medicaid is adaptable for our state but she did so without discussing the role of mandated services for children. The purpose of this letter is to ask that you ensure needed services remain available to Medicaid beneficiaries, both children and adults, in our state. While I sympathize with your need to make difficult decisions regarding Medicaid in our state, I also recognize the importance of preventing increased costs associated with lack of early-intervening services for our youth.

Secretary Sebelius specifically stated, “While some benefits, such as hospital and physician services, are required to be provided by state Medicaid programs, many services, such as prescription drugs, dental services, and speech therapy, are optional.” That is right; she specifically mentions “speech therapy” as a service that is optional. Secretary Sebelius neglects to mention that speech-language pathology and audiology services as well as speech-generating devices and hearing aids are covered under the mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for children. I realize that our state views speech, hearing, and language services as an integral part of the EPSDT program, but in light of Secretary Sebelius’s letter I wanted to be sure that nothing will change.

The February 3, 2011, letter includes an attachment entitled, “Medicaid Cost-Savings Opportunities” that includes a Medicaid benefits table on page 3. The EPSDT program is clearly part of the mandatory services while “speech, hearing and language disorder services” are listed under the optional services category.

Federal law (Title XIX of the Social Security Act) requires that children under the age of 21 be provided services including audiology and speech-language pathology on a comprehensive basis through EPSDT. EPSDT requires states to do more than merely offer to cover services. States are obligated to actively arrange for treatment, either by providing the service itself or through referral to appropriate agencies, organizations or individuals. 42 U.S.C. § 1396a(a)(43)(C). As part of the comprehensive developmental history, speech-language pathology and audiology services are included for:

       • identification of children with speech or language impairments
       • diagnosis and appraisal of specific speech or language impairments
       • referral for medical or other professional attention necessary for rehabilitation of speech or language impairment
       • provision of speech and language services
       • counseling and guidance for parents, children, and teachers

Additionally, EPSDT requires that any devices, such as hearing aids and augmentative and alternative communication devices, be covered when medically necessary. Federal Medicaid EPSDT specifically states that, at a minimum, the program include "diagnosis and treatment for defects of hearing, including hearing aids."

Speech-language pathology and audiology services require a very small budget investment for the states and the returns are great – a citizen who is more independent if not totally independent and, as a result, requires less services in the future. Communication is one of the most important qualities we possess. Having a communication disorder can impact functioning in everyday life, as well as affect job prospects. According to a U.S. Agency for Healthcare Research and Quality (AHRQ) report (2002), approximately 42 million people (i.e., 1 in 6) in the United States have some type of communication disorder. Of these, 28 million have communication disorders associated with hearing loss, and 14 million have disorders of speech, voice, and/or language not associated with hearing loss. The personal and societal costs of these disorders are high. On a personal level, such disorders may affect nearly every aspect of daily life. Annual societal cost estimates in the United States range from $30 billion to $154 billion in lost productivity, special education, and medical costs.

According to the Kaiser Family Foundation, 35 state Medicaid programs currently cover speech, language, and hearing disorders, although coverage limitations are often found. Our national organization, the American Speech-Language-Hearing Association, believes 35 states have already made a sound investment by covering speech-language services, and encourages states to retain or include this coverage. As the Arizona Speech-Language-Hearing Association we believe that Arizona has made the right choice in covering these services. This is the best choice for our children, our disabled citizens, and our state. I trust that you will continue to recognize the utter importance of maintaining coverage for speech, language, and hearing disorders under the Medicaid program.

I respectfully offer my services, as well as those of our association members, in furthering the efforts of your office and the AHCCCS program in providing for the immediate needs of Arizonans and protecting our future.

Sincerely,
Jeffrey C. Meeks, EdS CCC-SLP
State Association President
Arizona Speech-Language-Hearing Association

• Select Year (2011), State (any), Locality (any)
• Insert procedure code (31579 or 92511), Modifier (none)
• Click on “Search”
• 31579 or 92511 fee information appears
• Scroll down to “Indicators”
• See “Physician Supervision of Diagnostic Procedures”
• Click on question mark adjacent to “03” for a description of the 03 level of supervision: “Procedure must be performed under the personal supervision of a physician.” The regulatory definition of personal supervision is “in the room.”

1. Does the supervising physician need to be an otolaryngologist? No, but for hospital outpatients the physician must be able to perform the procedure (i.e., have the specific training). For non-hospital settings the Medicare requirement does not specify a specialist but states "physician."
2. There are times when the patient referred for the examination is not a patient of the otolaryngologists in our office. What is their responsibility? The fact that the patient is not being seen by a physician in the practice is not relevant to this issue. The same rules apply whether the patient was referred to the practice specifically for the procedure or is a patient under the care of physicians in the practice or hospital. See question #1.
3. Can the supervising physician be a resident?
4. No. According to the CMS Division of Practitioner Services a resident in a teaching setting under the Medicare program may not be a supervising physician. This applies to diagnostic tests as well as other services.
5. What documentation is necessary to indicate that a physician was present? CMS has not established documentation requirements.
6. I’m employed at a hospital. Who can provide guidance about complying with the new supervision requirements? Your hospital compliance officer should have guidance regarding Medicare physician supervision requirements.
7. How can I keep informed of the latest developments? We will use ASHA Headlines to notify members of new developments including assistance in advocacy, if needed. To subscribe to ASHA Headlines, go to ASHA’s Web site and insert "Headlines" in the search box. Follow the subscribe instructions listed.