October 27, 2014
Members of the Medicaid Reform Advisory Group:
Re: Alaska Medicaid Coverage for Physical, Occupational, and Speech Therapy: Background
Information and Recommendations for Possible Utilization Limits.
The purpose of this letter is to provide legislators, the Medicaid Advisory Group, and
constituents with additional information regarding the medical necessity and community
based need for outpatient speech-language pathology services
Issue: The proposed Alaska Medicaid changes for speech-language therapy services would
ultimately propound disadvantageous client-centered outcomes and effect a reduced
health-related quality of life and well-being. Therefore, The Alaska Medicaid Advisory
Group should address the following concerns that are part of Alaska Medicaid
Proposal/Innovations:
 The distinction between school based educational speech-language pathology services,
other health professions, and outpatient medically necessary speech-language therapy
services;
 The potential disruptions in continuity of care and collaboration between the Medicaid
recipient’s multidisciplinary team of Medicaid eligible individuals;
 The lack of evidence to support the proposed Alaska Medicaid changes;
 The additional non-value added services;
Outpatient speech-language pathology services are required services under Medicaid for
children under 21 years of age. Under the Early Periodic Screening Diagnostic Treatment
(EPSDT) provisions of the Social Security Act, states are required to provide
comprehensive services and furnish all eligible Medicaid recipients (i.e., individuals birth to
21-years of age) with services that are medically necessary to correct and ameliorate
health conditions identified through screening and diagnostic services. These medically
necessary services include habilitative speech-language pathology services and devices.
The evidence presented by the Advisory group is lacking and does not represent the entire
scope of the profession. The restricted evidence only accounts for individuals with “certain
speech impediments.” Within the scope of speech-language pathology speecharticulation
only represents a portion of the communication disorders addressed as a part of outpatient
speech-language pathology.
Additionally, the evidence regarding client-outcomes has been grossly misinterpreted and
inappropriately generalized. The foundation of effective and ethical client-centered care
relies on caregiver education that is provided in collaboration under the supervision of a
licensed and insured speech-language pathologist. The appropriate and safe management
of individuals with speech, language, and/or swallowing disorders should be
multidisciplinary. Therefore, the individual’s directed care should involve the individual’s
caregivers and other members that may include a team of professionals from diverse
disciplines to provide comprehensive medical management, including speech-language
pathologists.
Correspondingly, the EPSDT guidelines stipulate that individuals are eligible for outpatient
speech-language services that require direct intervention from a specialist. Within the
scope of outpatient speech-language pathology, the following communication and
swallowing disorders require specialized treatment:
 neonatal problems (e.g., prematurity, low birth weight, substance exposure);
 developmental disabilities (e.g., specific language impairment, autism spectrum
disorder, dyslexia, learning disabilities, attention deficit disorder);
 auditory problems (e.g., hearing loss or deafness);
 oral anomalies (e.g., cleft lip/palate, dental malocclusion, macroglossia, oral-motor
dysfunction);
 respiratory compromise (e.g., bronchopulmonary dysplasia, chronic obstructive
pulmonary disease);
 pharyngeal anomalies (e.g., upper airway obstruction, velopharyngeal
insufficiency/incompetence);
 laryngeal anomalies (e.g., vocal fold pathology, tracheal stenosis, tracheostomy);
 neurological disease/dysfunction (e.g., traumatic brain injury, cerebral palsy, cerebral
vascular accident, dementia, Parkinson's disease, amyotrophic lateral sclerosis);
 psychiatric disorder (e.g., psychosis, schizophrenia);
 genetic disorders (e.g., Down syndrome, fragile X syndrome, Rett syndrome,
velocardiofacial syndrome).
 Feeding and swallowing disorders (e.g. failure to thrive, aspiration, gastrostomy tube
fed, sensory based feeding disorders, dysphagia).
According to the American Speech-Language Hearing Association, the National Outcomes
Measurement System, which is a collection of evidenced based client-outcome data for the
entire scope of served communication and swallowing disorders for the infant through
Adult population, the expected client outcome and related health-related quality of life, as a
function of speech-language intervention cannot empirically be compared. Therefore, the
determination of services should not be confined to predetermined prescription of care
with misinterpreted information gleaned from a single study.
In addition, requiring reauthorization every 3-weeks, which in most cases would be the
proposed 6-session maximum, would construct a governmental regulatory overburden.
Whereby both the state and the speech-language pathologist would endure increased nonvalue added administrative duties to an unrealistic and potentially cost prohibitive level.
Undoubtedly this would contradict the anticipated 2% savings. This would also directly
affect the quality of care for clients and caregivers who are expected to gain skills and
competency from the multidisciplinary expertise that would otherwise have been provided
through collaboration with a speech-language pathologists.
Therefore, the Advisory groups globally assumed premise that a caregiver could remediate
their child’s speech, language, and/or swallowing disorder after a short period of treatment
is unfounded, significantly flawed, unsafe and warrants mandate. The proposed Alaska
Medicaid changes would function to disrupt the collaborative therapeutic relationship
established and provided by outpatient speech-language pathologists, and expeditiously
effect an overburdening amount of non-value added services for the state, healthcare
providers, including speech-language pathologists and physicians. Whereby, an unrelated
and untrained discipline specific party, Xerox, would authorize services on a grossly limited
basis without sufficient knowledge of the individual’s complex case and needs.
We appreciate your consideration regarding the needs of children and adults who
experience significant communication disabilities. As you can see this issue addresses
needs that are significantly more complex than remediating a simple speech impedimant.
The scope of our practice and experitese warrants more consideration in your decision
making on an issue that would significantly impact the quality of life of the people we serve.
We are happy to engage in further discussions to answer any questions or address any of
the issues presented above.
Sincerely,
The Alaska Speech and Hearing Association
Amy Russell, President