Medicare has covered SGDs since as early as 1981.  Over the years, Medicare SGD coverage has progressed through three distinct periods.  The first period extended from 1981 to the late 1980’s.  Medicare coverage of SGDs was characterized then by ad hoc decision making.  Each Medicare recipient had to establish that an SGD “fit” within one or more Medicare covered benefits categories, e.g., durable medical equipment (DME) or prosthetic devices, and was “reasonable and necessary,” Medicare’s phrasing of “medical necessity.”  During this period, two SGD funding approvals have been identified.  The earliest decision, In re: Michael W. (1981) approved the requested SGD as a “speech prosthesis.”  The second decision, In re: Kim D. (1986), approved the requested SGD as an item of durable medical equipment.  There are no statistics reporting how many other Medicare SGD approvals were issued during this period.

The second period of Medicare SGD coverage extended from an unknown date in the late 1980’s to January 1, 2001.  This period of Medicare SGD coverage was characterized by the existence of a National Coverage Determination, § 60-9 which came to be known as the “convenience item NCD.”  It stated SGDs were “convenience items,” “not medical in nature,” and therefore, not consistent with Medicare coverage of items of durable medical equipment, § 1861(n) of the Act, 42 U.S.C. § 1395x(n). 

The first coverage period has no official end date, and the second has no official start date because Medicare officials have reported they have no records regarding the development and issuance of this NCD.  Freedom of Information Act Requests Reveal No Basis Exists for Convenience Item National Coverage Determination; Letter dated July 8, 1998 to Elizabeth Carder, from Philip Brown, Director, Division of Information and Privacy, Health Care Financing Administration; Letter dated August 24, 1999 to Lewis Golinker from Philip Brown, Director, Division of Information and Privacy, Health Care Financing Administration. 

During this period, few SGDs were sold to Medicare recipients.  The convenience item NCD deterred suppliers from accepting assignment for SGDs.  This industry-wide decision forced Medicare recipients to pay in full for their SGDs before filing a Medicare claim for reimbursement.  In all but a very few cases, the pre-requisite of purchase at full price was beyond recipients’ financial means.  Also, the convenience item NCD forced everyone seeking Medicare SGD funding to pursue multiple levels of Medicare administrative appeals. Although Medicare never informed recipients, this National Coverage Determination was binding only at the first 3 levels of Medicare decision making. Medicare administrative law judges, the 4^th step on the decision making ladder, were not obligated to follow this guidance.  Instead, ALJs were able to look at all the information about SGDs and make their own decisions whether SGDs are appropriately covered as items of DME or as a prosthetic device.  See ATLC & Neighborhood Legal Services, “Medicare& AAC Devices: Funding AAC Devices Through Medicare – The Decision Making & Appeals Process for Non-HMO Participants” (April 1999); Neighborhood Legal Services & ATLC, “Medicare, Managed Care & AAC Devices: Funding AAC Devices Through Medicare – The Decision Making & Appeals Process for HMO & Other Medicare + Choice Participants” (December  1999)

Notwithstanding these barriers, approximately two-dozen Medicare recipients were able to get Medicare funding in the period between 1993 to January 1, 2001 when the current Medicare coverage guidance went into effect.  These decisions represent 100 percent of the appeals that were pursued.  In other words, the convenience item NCD could have been rendered irrelevant.  The key challenges were confidence, patience, and economics.  Medicare recipients, SGD manufacturers and suppliers, and SLPs needed sufficient information to be persuaded that Medicare funding was available.  Medicare recipients had to be willing to continue to appeal despite multiple denials; and the SGD manufacturers and suppliers had to be willing to wait approximately 24-36 months for Medicare payment, which was the average time needed to obtain an ALJ decision. Unfortunately, these 3 challenges were not met often.  As a result, only these few Medicare recipients received payment for their SGD purchases. 

The Table: Individual Appeals Awarding Medicare Funding & Evading “Convenience Item” NCD provides links to copies of these decisions.  For some of these appeals, access also is available to the appeal memoranda and other documents that support the required legal conclusions: (1) that SGDs meet the Medicare definition of durable medical equipment or prosthetic devices; (2) that SGDs are “reasonable and necessary;” (3) that the need for and purposes for an SGD make it clear that they are not “convenience items;” and (4) that the original NCD was not binding on all Medicare decision makers. 

As these appeals were being pursued, advocates began to chafe at the one-by-one-by-one pace and impact of this process.  From an advocacy standpoint, the main challenge was to develop a workable strategy to get past the convenience item NCD.  Once that was accomplished, the rote application of that strategy was liberating to individual Medicare recipients, but it was having no effect on increasing Medicare SGD funding to levels that match its status as the nation’s largest health benefits program.  For Medicare to make such a transformation, the “convenience item” NCD had to be eliminated.

Beginning in 1996, litigation options began to be explored. See Medicare Funding for Augmentative & Alternative Communication (AAC) Devices; Assistive Technology Law Center Memorandum re: Medicare AAC Device Funding (May 15, 1997).  In support of those early efforts, discussion also began among the nation’s leading AAC researchers, educators and clinicians to develop the factual and scientific foundation for a challenge to the “convenience item” guidance.  The first meeting of AAC professionals was on the eve of the November 1997 ASHA conference in Boston.  Those in attendance later formed the Medicare Implementation Team (MIT), the work-group that advised Medicare as it developed its current SGD coverage guidance.

In the Spring of 1998, a complete course reversal occurred in planning for Medicare SGD coverage policy reform.  The catalyst for that change was the purchase of Dynavox Systems, now Dynavox Technologies, by Sunrise Medical.  Sunrise brought extraordinary resources to aid the Medicare SGD coverage policy reform effort.  In particular, Sunrise had staff with extensive contacts and experience working with Medicare, the DMERC medical directors, and members of Congress.  Sunrise staff and consultants argued persuasively the most efficient and effective way to achieve desired Medicare SGD coverage policy reform was through a voluntary administrative decision to replace the “convenience item” guidance.   

To accomplish this goal, a 3-pronged strategy was devised.  First, inquiries were made to confirm that Medicare had no specific reason to not cover and provide SGDs.  Two types of inquiries were pursued.  Freedom of Information Act requests were sent to Medicare seeking documents related to the convenience item NCD.  In response, Medicare reported no documents existed.  Medicare could not explain why SGDs ever came to notice; who was involved with the development of the guidance; what was reviewed; or even the specific date when it was issued. Freedom of Information Act Requests Reveal No Basis Exists for Convenience Item National Coverage Determination; Letter dated July 8, 1998 to Elizabeth Carder, from Philip Brown, Director, Division of Information and Privacy, Health Care Financing Administration; Letter dated August 24, 1999 to Lewis Golinker from Philip Brown, Director, Division of Information and Privacy, Health Care Financing Administration. 

In addition, inquiries were made to the Medical Directors of each of the four DMERCs.  In-person meetings were held with each to describe SGDs and to ask whether the Medical Directors had any specific objections to Medicare coverage. 8-)See ATLC Materials Provided to DMERC Medical Directors.  The uniform response was that none had objections, but all felt boxed in by the “convenience item” NCD.  Eliminate that, and SGD coverage can follow.

The second prong of the strategy was to get Medicare to again take notice of SGDs. This was not an easy task. No matter how important SGDs might be to the Medicare recipients who need them, to SLPs, and to SGD manufacturers and suppliers, they are such a low-incidence item, Medicare staff will always have more important and costly issues to confront.  A way had to be found to promote SGDs so they will end up on the Medicare policy agenda.

This goal was accomplished through letters from influential Members of Congress and from disability organizations.  Each requested that Medicare re-examine the NCD.  Similar requests were directed to the White House.

Congressional Letters supporting HCFA Re-review of non-coverage NCD

• Letter dated January 28, 1999 from Rep. William Coyne

• Letter dated January 29, 1999 from Rep. Randy “Duke” Cunningham and Ron Packard

• Letter dated February 3, 1999 from Sen. Rick Santorum

• Letter dated March 13, 1999 from Rep. Roger Wicker

• Letter dated April 21, 1999 from Rep. Sam Johnson

• Letter dated June 22, 1999 from Sen. Max Baucus

• Letter dated July 19, 1999 from Rep. Jerrold Nadler

Disability Organization Letters

• Letter dated February 26, 1999 from the Coalition for Citizens with Disabilities Health Task Force

• Letter dated March 1, 1999 from the Amyotrophic Lateral Sclerosis Association.

Other letters

• Letter dated December 18, 1998 to Jonathan Young, Associate Director for Disability Outreach, Office of Public Liaison, The White House, from Steven Jaye, Senior Vice President and General Counsel, Sunrise Medical.

• Letter dated April 30, 1999 to Hon. Donna Shalala, Secretary of Health & Human Services, from Richard H. Chandler, Chairman and President, Sunrise Medical.

Merely asking Medicare to re-examine the NCD was necessary, but not sufficient.  At the time, Medicare had no formal procedures governing how, when or why National Coverage Determinations will be issued for any type of device, procedure, or service.  Also missing was any standard for Medicare to re-examine existing NCDs. In other words, Medicare had no existing process or procedure to offer in response to these Congressional and other letters.

Coincidence then intervened.  The letters attempting to put SGD coverage policy reform before Medicare decision makers never addressed how Medicare was to re-evaluate the convenience item NCD, they just asked that it be re-examined.  But, at the same time, other parties interested in Medicare coverage policies were pressuring Medicare to focus on how these guidelines were developed.  In response to this broader expression of interest and concern, Medicare announced procedures for requesting, developing and issuing new NCDs, as well as procedures applicable to the re-review of existing NCDs.  64 Federal Register 22,619-22,629 (April 27, 1999). 

Developing New (Current) Medicare SGD Coverage Policy

These procedures enabled Medicare to announce it was going to re-examine the convenience item NCD.  In June 1999, Henry Claypool, then the disability policy advisor to the Administrator of the Health Care Financing Administration, Nancy Ann Min DeParle, contacted the ATLC.  He asked the ATLC to provide Medicare staff with a Formal Request for Medicare to re-examine the convenience item NCD. See Letter dated July 23, 1999 to Rep. Ron Packard from Michael Hash, Deputy Administrator, Health Care Financing Administration.  A Formal Request is the central element of the procedure Medicare outlined for re-examination of existing NCDs.  It describes the professional literature related to a device, procedure or service, and therefore, provides the foundation for Medicare coverage.

Medicare’s invitation to submit a Formal Request was the catalyst to begin the third prong of the overall strategy: to enable the nation’s leading AAC professionals to educate Medicare staff as new coverage policy was being developed.  Beginning in July 1999, after an in-person meeting with Medicare staff to discuss what it expected in the Formal Request, the ATLC assembled a work group of the nation’s leading AAC researchers, educators and clinicians.  This work-group was responsible for writing the Formal Request.  Its members included: (Also participating in this work group were Steven Jaye and Rita Hostak, General Counsel and VP of Government Relations, respectively, of Sunrise Medical, and Marcia Nusgart, of Nusgart Consulting.)

The Formal Request for National Coverage Decision for Augmentative & Alternative Communication Devices was completed in five months.  It was submitted to Medicare on December 30, 1999.  Letter dated December 30, 1999 to Jeffrey Kang, M.D., Director, Office of Clinical Standards & Quality, Health Care Financing Administration, from Lewis Golinker, Director, Assistive Technology Law Center.   The Formal Request was submitted on behalf of 13 organizations representing all parties interested in Medicare SGD policy reform (Medicare recipients; assessment and treatment professionals; advocates; manufacturers; and suppliers).  The participating organizations included:

The Formal Request also included proposed coding and coverage criteria.  The proposed codes allowed for Medicare coverage of all SGD models and the proposed coverage criteria described Medicare SGD funding without limitation. 

The procedures Medicare adopted for re-examination of NCDs stated that filing a Formal Request starts a 90day review period.  Letter dated January 6, 2000 to Lewis Golinker, Esq., Director, Assistive Technology Law Center from Hugh Hill, M.D., Acting Director, Coverage & Analysis Group, Office of Clinical Standards and Quality, Health Care Financing Administration.  During this period, a wide range of additional efforts were made to persuade Medicare staff to adopt the recommendations of the Formal Request as a whole, including the proposed coding and coverage criteria.  These efforts included:

• conducting an in-person presentation about SGDs to Medicare staff;

• obtaining additional Congressional support letters, see Joint Letter dated January 11, 2000 from Hawaii Congressional Delegation; Letter dated January 11, 2000 from Rep. Jerrold Nadler; Letter dated March 20, 2000 from Rep. Sam Johnson;.

• obtaining a letter in support of Medicare SGD coverage from Stephen Hawking, Ph.D. see Letter dated February 24, 2000 to President Bill Clinton, from Stephen Hawking.

• obtaining letters in support of Medicare SGD coverage from approximately 3 dozen individual physicians who treat Medicare recipients with severe communication impairments;

• obtaining letters in support of Medicare SGD coverage from the American Medical Association; American Academy of Neurology; and the American Academy of Physical Medicine and Rehabilitation.  Ultimately, the American Academy of Neurology submitted 3 letters to support Medicare SGD coverage. American Academy of Neurology, March 22, 2000; American Academy of Neurology, April 25, 2000; American Academy of Neurology, October 23, 2000;

• obtaining letters in support of Medicare SGD coverage from the UCP Research and Educational Foundation and the American Speech-Language-Hearing Association

The letters to Medicare from the AMA, the American Academy of Neurology and the American Academy of Physical Medicine & Rehabilitation support the medical need and effectiveness of AAC interventions and SGD use for individuals with the types of conditions listed in the Formal Request.  These letters also support the treatment goal to be achieved through use of an SGD: to enable an individual to meet the communication needs arising out of all daily activities. 

Although Medicare created a 90-day review period for formal requests, it announced it would need more time to complete its review of the Formal Request related to SGD coverage.  That review was completed on April 26, 2000.  On that date Medicare announced it was able to make a partial decision related to Medicare SGD coverage.  Memorandum dated April 26, 2000 from Hugh Hill, M.D., Acting Director, Coverage & Analysis Group, re: CAG 00055, Augmentative & Alternative Communication Devices. Of greatest importance, it announced it was withdrawing the “convenience item NCD” and with it, the conclusion that SGDs are not medical in nature and not items of durable medical equipment.  Effective January 1, 2001, Medicare will recognize SGDs as items of DME, and will provide coverage.  In addition, Medicare staff identified another communication impairment: Aphonia, which it believed AAC interventions and SGD use was appropriate and effective treatment, along with dysarthria, apraxia, and aphasia.

Medicare explained the long lead time between this announcement and the effective date of this new coverage status was needed because its staff had numerous questions about how SGDs should be covered.  Medicare stated it was not prepared at that time to issue new coverage guidance for SGDs and would use this period to continue to develop them.

Because Medicare staff identified specific questions related to SGD coverage, efforts then began to develop responses.  These responses included:

• arranging a meeting between Medicare staff and Michael Weinrich, M.D., Director, Center for Medical Rehabilitation Research, National Institute of Child Health & Human Development.  Dr. Weinrich has conducted research related to the effectiveness of AAC interventions for persons with aphasia;

• securing confirmation from ASHA that aphonia is a severe communication impairment for which AAC interventions and SGD use are recognized as medically necessary and appropriate.  Memorandum dated June 27, 2000 to Lewis Golinker from Steven White, Ph.D., American Speech-Language Hearing Association;

• obtaining Memorandum dated June 27, 2000 to Lewis Golinker from David Beukelman, Ph.D., describing study outcome regarding use of SGDs by individuals with aphasia;

• preparing Memorandum dated June 29, 2000 to Madeline Ulrich, M.D., from Lewis Golinker responding to 12 Medicare staff questions posed in the April 26, 2000 decision memorandum.

• Arranging for Medicare staff to meet with members of the AAC professionals work group that prepared the Formal Request, and to attend the August 2000 ISAAC conference, in Washington, D.C.;

• Producing Letter dated August 31, 2000 to Madeline Ulrich, M.D., from Marcia Nusgart, reporting on the results of outcomes studies related to SGD need, use and benefit;

• Producing Memorandum  dated September 8, 2000 to Madeline Ulrich, M.D., from Lewis Golinker, reporting supplemental responses to the April 26, 2000 Medicare staff questions regarding SGD coverage.  This memorandum also provided a detailed report about existing outcomes studies related to SGD use and benefit.  Also reported were the results of a consumer effectiveness survey conducted in 1997 of 45 SGD users, and a 2000 follow up study of more than 200 SGD users. 

On October 24, 2000, Medicare, through the medical directors of the 4 DMERCs, issued the first guidelines to replace the convenience item NCD.  On that date the DMERCs issued a draft Regional Medical Review Policy for Speech Generating Devices.  Letter dated October 24, 2000 to Lewis Golinker from Paul Hughes, M.D., Medical Director, DMERC Region A; Adrien Oleck, M.D., Medical Director, DMERC Region B; Paul Metzger, M.D., Medical Director, DMERC Region C; and Robert Hoover, Jr., M.D., Medical Director DMERC Region D. 

The RMRP for SGDs – even in draft -- is an extraordinary document.  It describes the clinical assessment and report Medicare will require SLPs to complete to support an SGD funding request.  The elements of that assessment and report were taken from the input provided by the AAC professional work-group.  The RMRP adopts the key standard of care that the goal of providing an SGD is to enable an individual to meet all daily communication needs.  It also makes clear that Medicare funding for SGDs will be based primarily on the SLP’s professional judgment.  It is structured so that the SLP makes the substantive determination that a Medicare recipient has a medical need for an SGD, making SGDs the only Medicare covered benefit for which the determination of medical need is the responsibility of a non-physician. For SGDs, a physician’s prescription is required, but in practice, the physician is expected to adopt the SLP’s recommendations.  The RMRP also does not restrict SGD coverage by specific neurologic diagnosis, consistent with input provided by the SLP work-group. 

The RMRP also is significant as the source of the phrase “speech generating devices” or SGDs.  Previously, the term used was “augmentative and alternative communication (AAC) devices. 

The DMERC medical directors offered approximately 60 days for public comment to the draft RMRP, which led to submission of Letter dated December 19, 2000 to Dr. Robert Hoover, Jr., M.D., from Lewis Golinker.  This letter synthesized comments received from the AAC community regarding the draft RMRP.  The final RMRP for SGDs, which remains in effect, was issued in March 2001. 

Issuance of the draft RMRP by the DMERCs was followed by Medicare’s issuance of a new National Coverage Determination for Speech Generating Devices (November 30, 2000), effective, January 1, 2001. This NCD is the formal replacement of the convenience item NCD.  It defines speech generating devices and divides them into four codes: 2 for digitized speech output devices, and 2 for synthesized speech output devices.  This division is substantively identical to the proposed codes stated in the Formal Request.  The Digitized speech output device codes are distinguished by the amount of available recording time: less than or equal to 8 minutes; or greater than 8 minutes.  The two synthesized speech output device codes are distinguished by the manner in which the user accesses the device and produces messages.  One synthesized speech output device code requires message formulation by spelling and access by physical contact with the device. The other synthesized speech output device code permits multiple methods of message assembly (rather than just by spelling), and multiple methods of access (instead of just by direct physical contact). 

January 1, 2001 marked the beginning of the third phase of Medicare SGD coverage.  It is characterized by routine acceptance of SGDs, based on the NCD for SGDs and the RMRP for SGDs.  These two Medicare SGD guidelines establish that Medicare will cover SGDs without limitation.  Any Medicare recipient – regardless of age; neurologic diagnosis or communication diagnosis – is eligible for any SGD recommended by an SLP, as long as the SLP completes the required assessment and prepares the required report.  These Medicare guidelines also represent the complete reversal of prior Medicare policy.  Medicare had declared SGDs were outside the scope of Medicare – they were convenience items, not medical in nature, and not DME.  Now, Medicare is declaring SGDs are DME, are not convenience items, are medical in nature, are medically necessary, and are covered for anyone who needs one. 

These two Medicare SGD coverage guidelines remain in effect.  They have had two subsequent amendments: the original 4 SGD codes have been expanded to 6 (4 digitized speech output device codes, still based on total recording time; plus 2 synthesized speech output device codes); and, clarification has been issued to address Medicare coverage of computer and PDA based SGDs.

Medicare Coverage of Computer & PDA Based SGDs

The NCD for SGDs stated one limitation regarding the scope of SGD models that Medicare will cover.  It states:   

Laptop computers, desktop computers, or PDAs which may be programmed to perform the same function as a speech generating device, are non-covered since they are not primarily medical in nature and do not meet the definition of DME.  For this reason, they cannot be considered speech generating devices for Medicare coverage purposes.

This limitation caused concern among the SGD manufacturers and suppliers of computer-based and PDA based devices.  The Formal Request had proposed that these devices, like all other SGD models, be covered, and information was provided to Medicare staff regarding how these models were covered by other health based funding programs, such as Medicaid.  Nonetheless, the NCD proposed to exclude them.

The exclusion of these devices presented 3 options for SLPs, SGD manufacturers, and advocates:

• the NCD could be challenged in court;

• Congressional intervention could be sought; or,

• the computer- and PDA-based devices could be altered to meet the requirements of the NCD. 

Within a matter of weeks, general agreement was reached that the third option – alter the devices -- offered the most cost-effective and efficient way to respond.  The manufacturers reported they would be able to alter their software such that the devices ran only AAC software, and the only way to exit the software is to turn the device off.  By making these changes – by locking out the other non-AAC functions – these devices were indistinguishable from so-called “dedicated devices.” 

A few weeks then passed to enable the manufacturers to develop prototypes of the new models. Medicare was informed that new models were being developed to comply with the NCD and that an opportunity was sought to show them to Medicare staff.  Letter dated February 16, 2001 to Robert Berenson, M.D., Acting Administrator, Health Care Financing Administration.

Demonstrations of these new models were made to Dr. Hoover, the DMERC Region D medical director, and then to Thomas Hoyer and other Medicare staff.  Letter dated April 2, 2001 to Thomas Hoyer, Health Care Financing Administration, from Lewis Golinker.  On May 4, 2001, Medicare agreed that “dedicated, computer and PDA-based devices” satisfy the requirements of the NCD, and therefore, will be covered by Medicare.  Medicare stated:

Computer-based and PDA-based AAC devices/speech generating devices are covered when they have been modified to run only AAC software.

Letter dated May 4, 2001 to Lewis Golinker from Thomas Hoyer, Director, Chronic Care Policy Group, Center for Health Plans and Providers, Health Care Financing Administration.

SLP Tools to Complete Medicare Assessment and Report

The Medicare Implementation Team quickly recognized both the great opportunity and great burden presented by the new Medicare SGD coverage guidance.  The opportunities were obvious:  Medicare is the largest health benefits program in the nation, with more than 40 million recipients.  The number of Medicare recipients who need SGDs will be very large.  In addition, because adults – the primary population served by Medicare – are not as well served by other systems of health benefits as are children, the percentage of adults with SGD needs who are not served was estimated to be very high.  In addition, the Medicare SGD coverage guidance made funding for SGDs recommended by SLPs almost automatic. 

The ease of access to Medicare funding based on SLP recommendation also was immediately seen as an enormous responsibility.  The NCD for SGDs and RMRP for SGDs reflected Medicare staff’s trust in SLPs’ skill, experience and professionalism.  SLPs had been given the authority to determine medical need for an SGD: SGDs are the only Medicare covered item or service for which this role is not assigned to a physician.  The MIT recognized that SLP assessments and reports on behalf of Medicare recipients had to reflect that trust – every time.  If not, SLPs risk jeopardizing ongoing access to Medicare SGD coverage and funding. 

To ensure SLPs conducted complete assessments and prepared complete reports, the MIT planned nation-wide training and the development of additional materials.  Throughout 2001 and 2002, MIT members delivered trainings as often as possible about the new Medicare SGD coverage guidance.  The MIT also began to develop additional written materials, in particular, a detailed outline of the SLP tasks required to complete each sub-part of the assessment and report as stated in the RMRP.   What emerged from this effort is the SGD Assessment Protocol, or simply, the Protocol.  The Protocol addresses each section of the SLP assessment, and explains the information to be obtained, suggests tests or other ways to gather the information, and includes sample reports.  The Protocol also offers SLPs an opportunity for SLPs to receive individualized assistance from MIT members. It is posted for review at www.aac-rerc.com. 

To complement the Protocol, an additional tool has been developed to aid SLPs in the process of preparing their report.  The AAC Report Coach was developed by Pamela Mathy, Ph.D., Clinical Director, Arizona State University, a member of the MIT.  The AAC Report Coach is a template that will help SLPs to quickly organize their assessment data into a report that meets Medicare’s and other funding programs’ expectations.  The AAC Report Coach is designed to allow an SLP to prepare a complete report within 30 minutes. 

Implementation of the New SGD Coverage Guidance: Medicare SGD Purchases Since January 1, 2001

In contrast to the second period of Medicare SGD coverage, where only approximately 2 dozen Medicare recipients were able to obtain Medicare SGD funding, the NCD for SGDs and the RMRP for SGDs allowed Medicare to become the single largest funding source for SGDs, even in their first year of operation.  Medicare also has maintained its status as the leading SGD funding source in each succeeding year. Memorandum describing Medicare SGD purchases, 2001-2003; see also Frequently Asked Question # 32. 

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