A Quiet Crisis: Quarter Two AAC Update- by the ArSHA AAC Committee

A Quiet Crisis: Quarter Two AAC Update- by the ArSHA AAC Committee

If you read the previous AAC Update from February, found here, then you know that just as the rest of the world was beginning to horde toilet paper and self-quarantine due to COVID-19, hundreds of special needs individuals and families in Arizona were simultaneously facing another, quieter crisis: the delay or denial of their or their children’s AAC devices, repairs, and training. Some individuals  have never been given a voice. Some wait for a repair; a broken button, a cracked screen. Many have been waiting for six months to a year for their voice. 

Let’s Review:

DDD’s Augmentative Communication (Aug Comm) Unit began undergoing the medical review process in the third quarter of 2019 when many requests for AAC evaluations were put on hold. Soon after, the nonprofit Arizona Center for Law in the Public Interest cited concerns about AAC related policy and procedure changes in accordance with State and Federal guidelines. By December of 2019, AHCCCS leadership was involved and a ‘comprehensive review’ of DDD’s Aug Comm unit policies began. In March, AHCCCS issued a ‘Notice to Cure’ with demands that DDD cease certain actions that were not in line with Federal and State coverage and authorization guidelines specific to AAC, and failure to comply with critical grievance and appeal systems. AHCCCS/DDD announced they would notify all affected individuals and families by the end of February whether or not their AAC device was approved.

Here’s What’s New:

In March, coincidentally just as the COVID-19 virus was peaking, DDD began processing the hundreds of evaluations, some backlogged as far back as June 2019. Hundreds of evaluation authorizations were released to the three provider agencies, who scrambled to meet AAC evaluation demands during the COVID pandemic. With no updated guidance or feedback from the Aug Comm Unit, the three evaluating agencies (Advanced Therapy Solutions, Northern Arizona University, and Therapy One) continued to follow original guidelines to document medical necessity and submit evaluations for approval. 

To further compound the issues, individuals and families whose children received a new AAC device cannot fully use them as they are still waiting for DDD to approve device implementation training. Under the new procedures, the evaluating agency is now required to submit a plan of care for AAC implementation training, which must be signed by the client’s referring physician and sent to DDD before training is authorized. Currently, 96 prior authorization requests for AAC implementation training have been submitted to DDD since January 2020.

Similarly, families whose devices need repair must now provide documentation proving the child still needs the AAC device, and that it is medically necessary before DDD will submit the broken device for repairs. This process of medically justifying need includes another prescription from the physician and a letter from the treating SLP. It is unknown at this time how many families are waiting for repairs statewide.

In April, medical reviews began. AHCCCS is overseeing the aug comm medical review process, and providing technical assistance and guidance to reviewers regarding the new prior authorization process and policy requirements. As part of the Notice to Cure, AHCCCS/DDD contracted with a neutral third party, Medical Review Institute of America, or MRIoA, hired to review the hundreds of previously denied AAC evaluations and trainings. AHCCCS took quality control samples of the medical reviews conducted. Anne Ronan, attorney for Arizona Center for Law in the Public Interest, stated recent data from AHCCCS reflects approximately 90% of evaluations sampled were deemed medically necessary. Most notably, AAC evaluators who spoke to independent  reviewers cited two common themes during these reviews: educating reviewers on AAC best practices (independent reviewers were mainly physicians and SLPs, none of whom were AAC specialists) and defending the cost of certain devices as medically necessary for clients.  

Throughout it all, many individuals and families continue to receive denial letters. Those who can appeal the decision gather evidence—school and medical records–to submit appeals, and file for extensions. They contact attorneys and ask for court hearings. They form a Facebook group to support and assist each other. 

In an effort to educate and update ArSHA members, the AAC Committee recently asked AHCCCS Deputy General Counsel Gina Relkin for a clarifying statement on the current state of AAC in Arizona. As of this publication date, we have not received a response. 

However,  a Status Report Summary for Augmentative and Alternative Communication, published by DES, revealed some powerful aggregate data from April 2019 through June 25, 2020. The data below reflects both initial determinations and appeals. MRIoA sends their review to DDD Per the Notice to Cure, since AHCCCS directed DDD to accept the MRIoA findings. Thus far, the state has seen a total of:

  • 629 device denials
  • 684 devices approved
  • 186 appeals
  • 25 State Fair Hearings requested

While the number of devices approved in this report is promising, many families continue to report they are still waiting and have not received any determination one way or the other.

There is also speculation that the lengthy red tape involved in filing multiple appeals, turning in grievances, and asking for Fair Hearings may be even more difficult for families of culturally and linguistically diverse populations to navigate, despite a brief multilingual statement at the top of every NOA letter in English/Spanish that lists a number individuals can call for help. One thing is certain: the appeals process is daunting enough, without adding a language or cultural barrier. 

Anne Ronan is an attorney for Arizona Center for Law in the Public Interest, one of the whistleblowing agencies that was instrumental in publishing public letters to bring the crisis to light when the story first broke in December of 2019.  She has been working behind the scenes with AHCCCS lawyers on a resolution and pushing for AHCCCS to release guidelines for the Medicaid funded AAC process in an effort to minimize denials. She continues to work with families directly, offering advice and support, as she negotiates with AHCCCS leadership on a possible new protocol in an attempt to resolve the situation without the need for formal litigation. 

Public Review 

On June 29, 2020, DDD proposed a significant shift in policy change for the administration of AAC related benefits serving ALTCS, or Arizona Long Term Care System, clients. For the past twenty plus years, DDD directly managed the Aug Comm unit, despite the statewide shift to managed care in recent years.

After October 1, 2020, Mercy Care and United Healthcare Community Plan will manage all DME, or durable medical equipment,  including AAC for ALTCS members.  According to  the proposed policy, “DDD has identified opportunities for improved member experience and access to this benefit by integrating responsibility for AAC into the Health Plans along with all other DME benefits.”  DDD’s Administration of AAC Benefits policy states it “is expected to result in a more efficient and timely process for the provision of these services and/or devices. The transfer of this benefit to the DDD Health Plans would include all aspects of the current AAC program – including service evaluation, prior authorization, medical necessity and cost effectiveness determinations, device acquisition, installation, training, modification, and repairs.” DDD is soliciting public comments on the new policy through 11:59 p.m. July 13th.

 Currently under direct DDD guidance, the Aug Comm Unit utilizes  an interdisciplinary evaluation model. Specialist teams consisting of a speech language pathologist  and  an occupational or  physical therapist to conduct evaluations.  One condition of DDD’s contract with the three provider agencies was that all AAC specialists must be vetted with at least 1,000 documented hours in AAC service delivery. This AAC specialist focus ensured evaluators have sufficient knowledge and experience with the range of devices on the market, and the complex minds and bodies that use them.

 It is unknown how the policy change will affect individuals receiving AAC benefits from Medicaid after October 1, 2020. Evaluators wonder whether or not clients will continue to receive the benefits of an interdisciplinary evaluation model. AAC provider agencies navigate the process of becoming a qualified provider agency with United Healthcare Community Plan and Mercy Care. Families and individuals wonder if they will receive the services they need. All involved wonder, will this policy shift be a change for the better?  

ArSHA strives to support its members with the professional knowledge and resources they need to service children and families with complex communication needs. Likewise, ArSHA supports AHCCCS and DES/DDD’s efforts to service individuals with disabilities. ArSHA will continue to work behind the scenes with all parties on behalf of children with complex communication needs, their families, and the SLPs who serve them.

 

What You Can Do: 

  1. Keep Referring.  Do NOT stop referring clients for AAC services simply because you’ve ‘heard’ they won’t get a device. You can find the referral packet here: https://des.az.gov/file/7951/download 
  2. Get informed. A link to the proposed policy changes regarding AAC services can be found here. https://des.az.gov/sites/default/files/media/Proposed_Changes_to_AAC_Services_Benefit_Administration.pdf?time=1593754653908 
  3. Comment. The proposed policy change is open for written public comment through 11:59 p.m. on July 13. 
  4. Encourage. Individuals and families who have received a denial should be encouraged to call their support coordinator for assistance with the appeals process. They should also reach out to the evaluation agency, as they may not be aware of the denial. Some resources are:
    Contact the Aug Comm Unit: DDDAugComms@azdes.gov
    DES DDD Customer Service Center DDDCustomerServiceCenter@azdes.gov
    Toll-FreeToll Free (844) 770-9500
    TTY/TDD 711
    Fax: (602) 542-6870
  5. Remind. If individuals and families wish to request an appeal on an adverse benefit determination (NOA) they must typically do so within 60 calendar days from the date of the adverse benefit determination letter. Remind them they should follow instructions found on their NOA paperwork. A link on adverse benefit determination and how to appeal it with DDD can be found here: https://des.az.gov/services/disabilities/developmental-disabilities/-individuals-and-families/request-an-appeal-on-an-adverse-benefit-determination
  6. Advocate. Under-represented populations such as low SES or CLD clients may have difficulty navigating the complex Medicaid system to file an appeal or request a fair hearing. Advocate for them to have the assistance they need to get through the process. Some resources you can share include:Arizona Center for Law in the Public Interest:
    514 West Roosevelt Street, Phoenix, AZ 85003
    Phone: 602-258-8850 Fax: 602-258-8757Arizona Center for Disability Law: center@azdisabilitylaw.org
    Tucson Location: 177 North Church Ave., Suite 800 Tucson, AZ 85701
    (520) 327-9547 (800) 922-1447 (Toll Free) Fax: (520) 884-0992

    Arizona Center for Disability Law:
    https://www.azdisabilitylaw.org/
    Phoenix Location: 514 West Roosevelt Street, Phoenix, AZ 85003
    Phone: 602-258-8850

For your convenience, previous entries from February 23 and March 20 are below in Arsha’s blog, linked with these dates:

February 23, 2020

March 12, 2020