Preschool/School Supportive Health
Services Program:
SSHSP – Medicaid in Education
NEW YORK STATE EDUCATION DEPARTMENT (NYSED)
Topics
 SSHSP Overview
 Program information resources
 Updates to the SSHSP Medicaid
claim requirements
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School Supportive Health
Services Program (SSHSP)
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SSHSP
 Medicaid reimbursement program available to
school districts and counties
 Services must be included in a student’s IEP
 Services have required Medicaid
documentation for medical necessity and
provider qualification
 NYS Department of Health – Medicaid Policy
and payment
 NYS Education Department – Special
Education policy and billing assistance
 Over $100 Million per year in fee for service
encounter claiming
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What is the Role of the CSE/CPSE?
The Committee on Special Education will always
develop and review the Individualized Education
Program, but may also perform SSHSP administrative
functions (just like CSE/CPSE chairs may perform
STAC functions). Examples:
 Secure parental consent authorizing district to
access Medicaid participation in funding
 Make referral for Psychological Counseling
Services, Psychological or Medical Evaluation
 Medicaid training- documentation, collection and
retention
 Monitor service delivery for compliance with
professional and SSHSP standards
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SSHSP
Policy and Guidance
Documents
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Policy, Guidance and Support Resources
Medicaid in Education Website
 Medicaid Handbook Update #8
 Posted Questions and Answers
 Medicaid Alerts
 Training Powerpoints
 Training Handouts
Regional Information Centers
 Medicaid 101 Training
 Documentation Training
 Direct support
Updates are available from LISTSERV
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Policy Resources
Special Education Policy – NYSED SEQA Regional Associate
Professional Scope of Practice – NYSED Office of the
Professions
Medicaid Policy – Regional Information Center, NYSED
Medicaid in Education Staff, NYS DOH Office of Health
Insurance Programs
Rules for each program area may vary; Medicaidbillable services comply with all three!
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Updates to Medicaid Claim
Requirements
What would you have heard about over the last
year by monitoring the SSHSP website, receiving
ListServ emails, attending SSHSP trainings
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Clarified Medicaid Policy
SSHSP - Same Day, Same CPT Code Billing for
Medicaid Reimbursement
Medicaid Alert #14-04 (Issued 8/15/2014) Clarification of Medicaid
Claim Form and Supporting Documentation Requirements: Billing PT
and OT Services (same day, same CPT code billing)
 When 2 SSHSP Medicaid are claimed (1 PT & 1 OT ) for the same CPT
code and service date. The 1st claim will be processed but the second
will be denied as a duplicate claim.
 Fix: see Alert #14-06, Starting in Cycle 1952, CNYRIC will add a
OT/PT/Speech (97000 code) modifier to all claims based on the
servicing profession’s code submitted in the claim.
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Clarified Medicaid Policy
SSHSP – Evaluation Clarification for Medicaid
Reimbursement
Medicaid Alert #14-08 (11/26/2014) Clarification on SSHSP Medicaid
Reimbursement for Evaluations
 Medicaid reimbursement is available for PT, OT, Speech and
Psychological evaluation ONLY when the IEP includes a
recommendation for ongoing services based on the this (or prior)
evaluation results.
 The evaluation must also have an written order or appropriate
referral dated prior to the evaluation (or an ongoing service
order/referral), be documented in a report and be completed by a
Medicaid qualified provider.
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Clarified Medicaid Policy
SSHSP – Clarification of Skilled Nursing Wording IEP
Location for Medicaid Reimbursement
Medicaid Alert #15-02_ (3/04/2015) Including Medicaidreimbursable Skilled Nursing Services in the Student’s IEP
Depending on the nature of the skilled nursing services, the
documentation in the student’s IEP could, as appropriate to the individual
student’s needs, be included as follows:
 The IEP may specify school health services or school nurse services as a
related service with further clarification under the column “Service
delivery recommendations” that such services are “skilled nursing
services.”
 Alternatively, as appropriate to the student’s need for certain skilled
nursing services, IEP recommendations for skilled nursing services could
be noted as supplementary aides and services
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Q & A’s
Response Revisions
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Clarified Medicaid Policy
SSHSP – Q & A’s , Claimable Age Limits
& NYS Medicaid Enrollment Requirement
NYSDOH Response to Question
#16:
In order for children to receive Medicaid reimbursable services
under SSHSP/PSSHSP, they must be Medicaid eligible, be between
the ages of 3 to 21 years , have been determined to have a
disability through the IEP process and have an IEP. Please note that
when a student turns 21 they are no longer reimbursable in the
SSHS Program.
In addition, the service must be ordered/referred by a NYS
Medicaid enrolled practitioner
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Clarified Medicaid Policy
SSHSP – Q & A’s, PT Provider Requirements
NYSDOH Response to Question
#24:
Effective July 24, 2013, all New York State licensed and currently
registered physical therapists are qualified physical therapy
providers under the New York State Medicaid program, including
SSHSP. Therefore, each school district/county must maintain
documentation of New York State licensure for their physical
therapist.
(Graduation from a CAPTE approved program is no longer a
requirement.)
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Clarified Medicaid Policy
SSHSP – Q & A’s, Written Orders/Referral Elements
NYSDOH Response to Question
#32:
The written order(/referral) must (now) include:
The frequency and duration of the ordered (referred) service
must either be specified on the order (referral) itself
OR
the order (referral) must explicitly adopt the frequency and
duration of the service in the IEP by reference (‘per the IEP’).
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Clarified Medicaid Policy
SSHSP – Q & A’s , Written Order/Referral Elements
NYSDOH Response to Question
#32 (continued):
 Stamped signatures are not allowable.
 The written order/referral must be in place prior to the initiation
of service prospectively, including evaluation.
 Referral for psychological evaluations and counseling service
may be made by ‘an appropriate school official or other
voluntary health or social agency’. School officials are not
allowed nor required to enroll as NYS Medicaid providers.
(November 24, 2014] therefore the SSHSP biller’s NPI would
need to be included on these claims.
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Clarified Medicaid Policy
SSHSP – Q & A’s, Special Transportation
Requirement Changes
NYSDOH Response to Question
#43:
 Medicaid reimbursement for special transportation is limited
to those situations where the child receives transportation
TO/FROM a provider in the community for the exclusive
purpose of accessing an SSHSP Medicaid covered service
OR
 Both the Medicaid covered service and how the transporting
vehicle is (specifically) modified to meet the needs of the
individual student are included in the student’s IEP.
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Clarified Medicaid Policy
SSHSP Special Transportation Criteria for Medicaid
Reimbursement
Two exceptions to the rule:
Special transportation is Medicaid reimbursable,
regardless of the type of vehicle used, under the
following special circumstances:
 A student resides in an area not having school bus
transportation, but has a medical need for that transportation and
is traveling to/from a Medicaid reimbursable service; or when
 A student is transported from school or home directly to and/or
from a provider in the community for the exclusive purpose of
accessing an SSHSP service.
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Clarified Medicaid Policy
SSHSP – Q & A’s, Evaluation SSHSP Reimbursable
Change
NYSDOH Response to Question
#57:
The evaluation would only be reimbursable under SSHSP if the
existing or new service is subsequently included as an ongoing
service in the student’s IEP. [November 24, 2014]
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Clarified Medicaid Policy
SSHSP – Q & A’s, Out of State Ordering Providers
Policy
NYSDOH Response to Question
#91:
In accordance with Article 31 section #6526 of the State
Education Law, the only out-of state practitioners that may
prescribe medically necessary care/treatment are physicians
licensed in a bordering state and who reside near the border of
this state. The border vicinity is usually defined as less than 25
miles.
In addition, the out-of-state ordering practitioner must be
enrolled in the NYS Medicaid program. [November 24, 2014]
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Clarified Medicaid Policy
SSHSP – Q & A’s, Medicaid does not have a ReEvaluation Requirement
NYSDOH Response to Question
#117:
Time frames pertaining to CSE/CPSE meeting for re-evaluation for
special education services are required by special education law
and regulation. There is no required re-evaluation schedule for
Medicaid covered SSHSP services.
To be Medicaid reimbursable an evaluation (or re-evaluation)
must be: Medically necessary, documented with a written
report, be included in the student’s IEP as an ongoing service and
is appropriately ordered/referred and delivered by a qualified
provider.
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Clarified Medicaid Policy
SSHSP – Q & A’s, Ordering/Referring NPI when
completed by an Appropriate School/County Official
NYSDOH Response to Question
#159:
Effective April 1, 2013, All SSHSP claims must contain the NPI of
the NYS Medicaid enrolled ordering referring provider.
The Psychological Evaluation or Counseling Service billing, the
school district’s or county’s NPI must be include on the claim in
place of a ‘referring school district or county official’s NPI’ since
enrollment by these individual is not required.
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Existing Medicaid Policy
Documentation Requirements Summary
Verification of current certification, licensure, and/or registration, as relevant,
of clinician providing the service must be available upon request.
Provider Agreement and Statement of Reassignment completed by outside
contractors, if applicable.
Written Orders/Referrals.
“Under the Direction of” or “Under the Supervision of” documentation, if
applicable. (FYI-the #1 reason for OMIG audit disallowance).
Documentation of each billable service:
• Evaluation report
• Session note
• Medication Administration Record (MAR)
• Special transportation logs
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Certified Public
Expenditures (CPEs)
Random Moment
Time Study (RMTS)
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Clarified Medicaid Policy
SSHSP – Certified Public Cost Amendments Have
Been Approved
Medicaid Alert #15-01 (1/16/2015) Medicaid State Plan
Amendments for Certified Public Expenditures have been Approved
 Districts will continue to submit Medicaid fee-for-service claims for each
encounter, providing interim reimbursement for SSHSP services.
 After the school year is over, the Certified Public Expenditure (CPE)
process will adjust that interim Federal Medicaid reimbursement to reflect
the district’s Medicaid allowable costs for providing SSHSP services.
 The calculation of those Medicaid allowable costs requires the district to
submit cost reports and participate in random moment time studies.
 Any district billing for the SSHSP services in 11-12 school year or
thereafter must complete this CPE cost settlement process
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Revised Medicaid RMTS Policy
Medicaid Alert 14-09 (12/23/2014) Random Moment Time
Study (RMTS) Moment Expiration Update
 Moments assigned to RMTS participants throughout the
January-March 2015 quarter are required to be submitted
within three (3) school days from the time of the moment.
 Effective April 1, 2015, moments assigned to RMTS
participants are required to be submitted within two (2)
school days from the time of the moment.
 In addition to the changes in the moment expiration
process, RMTS participants (and RMTS Coordinator) will no
longer be notified in advanced of a moment, but rather, will
receive notification at the exact time of their moment.
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SSHSP Billing/Claiming
Medicaid Alert # 14-02 (posted 5/1/14) International Classification
of Diseases, 10th revision, Clinical Modification (ICD-10-CM)
 ICD-9-CM will be replaced by ICD-10-CM (October 1, 2015)
 68,000 codes in ICD-10-CM (only 13,000 in ICD-9-CM)
 Free ICD-10-CM official guidelines and code sets online at:
http://cms.gov/Medicare/Coding/ICD10/index.html
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IDEA Parental Consent
Parental Consent Requirement for Release of Information
 One time consent with an annual notification is required to bill Medicaid for
SSHSP services. The written notice must explain all the of the protections
available to parents under Part B of IDEA to ensure parents are fully informed of
their rights.
 The written notice must be written in language understandable to the general
public and in the native language of the parent, unless it is clearly not feasible to
do so.
 The NYS Office of Special Education Services has issued guidance on the
implementation of these regulations:
http://www.p12.nysed.gov/specialed/publications/parentconsentpublicbenefits.htm
 The Federal Department of Education has also issued guidance:
http://www2.ed.gov/policy/speced/reg/idea/part-b/part-b-parental-consent.html
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Contact
Information and
Resources
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SSHSP Contacts
NYSED Medicaid Unit (Medicaid in Education)
SED: 518-474-7116, E-mail: medined@mail.nysed.gov
SED SSHSP Website: www.oms.nysed.gov/Medicaid
PCG, Random Moment Time Study (RMTS) and Annual Cost Reporting:
PCG Hotline: 866-912-2974,
E-mail: NYSSHSP@pcgus.com
SSHSP Medicaid Policy and Medicaid Claims:
NYSDOH: 518-473-2160
Computer Sciences Corporation (CSC):
1-800-343-9000, #1 (Billing), then #2 (CLINIC) or #2 (Enrollment), w/your NPI#
NERIC: Vernea Diehl, 518 862-5419, E-mail: Verbea.Diehl@neric.org
Heather Schubert, 518 862-5438, E-mail: Heather.Schubert@neric.org
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Additional Contacts
NYSED Office of Special Education
SED P-12 Website: http://www.p12.nysed.gov/specialed/
Regional Associates:
http://www.p12.nysed.gov/specialed/quality/regassoc.htm
NYS Office of the Medicaid Inspector General (OMIG)
http://www.omig.ny.gov/
NYSED Office of the Professions:
http://www.op.nysed.gov/
NYSED Office of Teaching Initiatives:
http://www.highered.nysed.gov/tcert/
NPI (Federal) Website: https://nppes.cms.hhs.gov/
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