Once You Know One Medicaid Program……….
You Know One Medicaid Program


State by State Commonality = Federal Regulations and Guidance

1988; Congress amended the Social Security Act to allow Local Education Agencies (LEA) to access Medicaid federal
funds for some “health related services”

Services that are reimbursed by Medicaid must be listed in the Medicaid statute (section 1905(a) of the Social
Security Act) and must be included in the state plan

Schools can receive Medicaid payment for medical services provided to children under Individuals with Disabilities
Education Act (IDEA) through a child’s Individualized Education Plan (IEP).

Federal guidance: Health related services included in an Individual Education Plan (IEP) can be reimbursable if all
state and federal statutory and regulatory requirements are met, the services are identified in the state plan, and the
services are medically necessary

To receive federal matching dollars for medical services the state must have a federally approved state plan

There is no benefit category in the Medicaid statute or state plan titled “school health services”; services, regardless
of location, must be identified in the state plan

State plan includes:

Eligibility groups and standards

Services provided

Service requirements

Payment rates

Amount

Duration

Scope

*Resources for this information can be found in the *CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997) Link can be
found at www.sbs.dhw.idaho.gov

How We Got Here

The school-based committee spent several years collaborating to identify Medicaid reimbursed services in
the school that meet the needs of the children on IEP’s in Idaho. The following is a condensed list of
collaborative activities regarding school-based services (SBS) and rules:
Date
Target Group
Activity
August, 2010
School-based Medicaid Committee
Discussed the impact to school-based services due to children’s system redesign
School districts/Special Education Directors
Webinar posted on how children’s system redesign impacts to schools
January, 2011
School-based Medicaid Committee
February, 2011
School-based Medicaid Workgroup
Identified SBS workgroup members to work on changes to services/IDAPA
Began workgroup to develop proposal for Centers for Medicare and Medicaid Services
(CMS). The workgroup met 6 full days
School-based Medicaid Committee
School-based Medicaid Committee
March, 2012
April, 2012
June, 2012
January, 2013
SBS workgroup presented the draft proposal, Received feedback from the committee
Committee approved SBS proposal/Submitted SBS proposal to CMS
School-based Medicaid Committee
Discuss CMS feedback and service options to the committee
School-based Medicaid Committee
Shared research from other states
School-based Medicaid Committee
Discuss new service options and timelines based on CMS feedback
School-based Medicaid Workgroup
Developed behavioral intervention/consultation services
School-based Medicaid Committee
Workgroup presented recommendations for intervention/consultation to the committee
Families, providers, and community
Negotiated Rulemaking Meeting: School-based replacement services
Idaho Association of Special Education
Administrators (IASEA)
Presentation of the proposed school-based service rules at the annual IASEA conference
Legislature/Public
Idaho Administrative Code proposed changes presented by Medicaid: State
Department Of Education spoke in support of proposed rules
Federal and State
Rule Compliance

 Idaho Medicaid encourages public and charter schools to
become Medicaid providers so that they can receive
Medicaid reimbursement for health related services they
are providing to children who are eligible
 Idaho Medicaid also wants to assure that schools who are
receiving reimbursement for health related services are in
compliance with federal and state regulations
WHY…………..?
Federal Concerns over
School-based Services

 US Department of Health and Human Services’ concern of schoolbased services billings On March 9, 2011, Inspector General
testified before a US Senate subcommittee that series of audits over
past decade identified improper federal Medicaid payments for
school-based health services.
 FFY 2013 Work Plan - will review Medicaid payments for schoolbased services in selected states to determine whether costs
claimed for services are reasonable and properly allocated.
 Idaho’s CMS Regional Auditor identified school-based services as
a priority

Special Study: School-based Services Overview: Medicaid Program Integrity March 5, 2013
Office of Inspector
General Audit Reports

 Maine (4/2013)
 Recommended Repayment of $667,569
 Claims were not in accordance with Federal & State
Requirements
 Lack of adequate documentation to support services provided
 Unqualified providers
 New Hampshire (10/2012)
 Recommended Repayment of $2,700,000
 Transportation services
* Resources for OIG Reports can be found at: www.oig.hhs.gov
Office of Inspector
General Audit Reports

 Colorado (4/2012)
 Recommend Repayment of $871,246
 Claims were not reasonable, allowable and/or adequately
supported.
 New Hampshire (1/2012)
 Recommended Repayment of $494,738
 Providing Health services that were not reimbursable
 Overbilling for services
 Lack of adequate documentation to support services provided
* Resources for OIG Reports can be found at: www.oig.hhs.gov
Office of Inspector
General Audit Reports

 New Jersey (4/2010)
 Recommended Repayment of $8,079,312
 Lack of documentation to support services provided
 Lack of referral or prescription for services
 Unqualified Providers
 Services provided not documented in IEP
 Arizona (3/2010)
 Recommended Repayment of $21,288,312
 Overbilling
 Lack of documentation
 Unqualified Providers
 Unallowable Transportation
 Lack of referral for services
 Eligibility not met
* Resources for OIG Reports can be found at: www.oig.hhs.gov
Medicaid Reimbursable Services
Provided in Schools by State
Services Provided
OT
PT
SLP
Idaho
Kansas
Oregon
Colorado
Washington
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Montana
Iowa
Utah
Nevada
Wyoming
Alaska
Texas
Kentucky
Maryland
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Audiology
X
Personal Care
X
Nursing
X
X
X
X
Transportation
X
X
X
X
Interpretive Services
X
Medical Equipment
X
X
Behavioral
Therapy/Intervention
X
X
Behavioral Health
Services
X
X
X
X
X
X
X
X
X
X
X
X
Psychological/
Counseling
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Physician Services
X
Orientation and
Mobility Services
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Other Services:
X
X
X
Targeted Case
Management
EPSDT
X

X
X
X
XX
X
X
X
X
X
X
X
X
X
SBS Medicaid State Comparison
2010-2011
Approximate annual cost of
School Based Services

Approximate number of
students
Approximate annual cost
per student
4,500
$8,000
Iowa
$36,000,000
Rhode Island
$22,000,000
9,500
$2,315
Idaho
$26,400,000
13,231
$1,993
Kansas
$24,500,000
12,500
$1,960
Oregon
$5,800,000
7,000
$828
New York
$44,000,000
75,000
$587
Arizona
$22,500,000
39,000
California
$124,000,000
225,000
$577
$551
New Jersey
$21,500,000
43,000
$500
Colorado
$5,600,000
11,310
$494
Indiana
$2,900,000
8,000
$363
Washington
$5,500,000
18,031
$303
Nevada
$1,050,000
3,998
$263
Montana
$2,600,000
13,500
$193
Virginia
$8,200,000
120,000
$68
Annual Average Cost Per Student
2010-2011

Iowa
Rhode Island
By Comparison, Idaho ranked 3rd out
of 15 states for the highest annual
average cost per student
Idaho
Kansas
Oregon
New York
Arizona
California
New Jersey
Colorado
Indiana
Washington
Nevada
Montana
Virginia
$0
$500
$1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 $4,500 $5,000 $5,500 $6,000 $6,500 $7,000 $7,500 $8,000 $8,500
2011-2012 State Comparison

Approximate annual cost
of School Based Services
Approximate number
of students
Approximate annual
cost per student
Idaho
$23,303,109
13,676
$1,704
Colorado
$8,105,642
12,328
$658
Washington
$8,119,192
17,765
$457
Federal Regulations for Services
FEDERAL
CITATION
SERVICE
DESCRIPTION
42 CFR 440.50
physicians’ services
and medical and
surgical services of a
dentist
“services furnished by a physician (or a doctor of dental medicine or surgery for a dentist) within the
scope of practice of medicine or osteopathy as defined by state law and by or under the personal
supervision of an individual licensed under state law to practice medicine or osteopathy”
42 CFR 440.60
medical or other
remedial care provided
by licensed
practitioners
“any medical or remedial care or services provided by licensed practitioners within the scope of
practice under state law.” This category is used by states to cover such services as psychologist services
and nursing services other than those nursing services specifically identified in the Medicaid statute
and regulations (such as private duty nursing, home health nurses or nurse practitioners).
42 CFR 440.90
clinic services
“preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished by a facility
that is not a part of a hospital but is organized and operated to provide medical care to outpatients.”
The services must be furnished under the supervision of a physician or dentist, in a facility which meets
the state’s definition of a clinic.”
42 CFR 440.100
dental services
“diagnostic, preventive or corrective procedures provided by or under the supervision of a dentist in
the practice of his or her profession.”
42 CFR 440.110
physical therapy,
occupational therapy,
and services for
individuals with
speech, hearing and
language disorders.
“Physical and occupational therapy services must be prescribed by a physician or other licensed
practitioner of the healing arts within the scope of practice under the state’s law and must be provided
by or under the direction of a qualified licensed physical therapist or occupational therapist. Services
for individuals with speech, hearing or language disorders means diagnostic, screening, preventive or
corrective services provided by or under the direction of a speech pathologist or audiologist, for which
the patient is referred by a physician or other licensed practitioner of the healing arts. It includes any
necessary supplies or equipment.”
42 CFR
440.130(a)
diagnostic services
“any medical procedures or supplies recommended by a physician or other licensed practitioner of the
healing arts, within the scope of practice under state law, to enable him or her to identify the existence,
nature or extent of illness, injury or other health deviation in a recipient.”
42 CFR
440.130(c)
preventive services
“provided by a physician or other licensed practitioner of the healing arts within the scope of practice
under state law to prevent disease, disability, and other health conditions or their progression; to
prolong life and promote physical and mental health and efficiency.”

*This chart is not necessarily all-inclusive, and while it indicates the general Federal Medicaid regulatory requirements, schools should
check with their state Medicaid agency to determine any additional or specific state requirements.
*Resources for this information can be found in the CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)
Federal Regulations for Services
FEDERAL
CITATION
SERVICE
DESCRIPTION
42 CFR 440.130(d)
rehabilitative
services
“any medical or remedial services recommended by a physician or other licensed practitioner of the
healing arts, within the scope of practice under state law, for maximum reduction of physical or mental
disability and restoration of a recipient to his or her best possible functional level.” This optional benefit
category is used to cover both mental health and substance abuse services and may include assessments,
individual, group and family counseling, therapies, psychosocial rehabilitation services, living skills
training, drug abuse treatment, medication monitoring and crisis intervention.”
42 CFR 440.170(a)
transportation
services
(Please see the Transportation section of the guide for more specific information on transportation and
school-based services).
42 CFR 440.166
nurse practitioner
services
“furnished by a registered professional nurse who meets the state’s advanced educational and clinical
requirements, if any, beyond the 2 to 4 years of basic nursing education required.”
42 CFR 440.166
Private duty nursing
services
“for recipients who require more individual and continuous care than is available from a visiting nurse or
routinely provided by the nursing staff of a hospital or skilled nursing facility.” These services are
provided by a registered nurse or licensed practical nurse under the direction of a physician, usually in the
beneficiary’s home. However, the nurse is permitted to be taken into the community (such as when the
child attends school) with the beneficiary if his or her normal life activities take the beneficiary out of the
home and the services have been prescribed by the physician for primary use in the home.”
Section
1905(a)(24) of the
Act (soon to be
published ate 42
CFR 440.167)
personal care
services
“These services are authorized for an individual by a physician in accordance with a plan of treatment or
otherwise authorized by the state in accordance with a service plan approved by the state, and may be
provided in a home or other location (however, not in a Medicaid-funded inpatient facility) by an
individual qualified to provide such services, who is not a member of the individual’s family.”
Section 1905(a)(4)
(c) of the Act and
42 CFR 441.20
family planning
services
“supplies for children who are of childbearing age, including minors who can be considered to be sexually
active and desire such services and supplies. These include services to aid those who voluntarily choose
not to risk an individual pregnancy or who wish to control family size. Federal Medicaid law limits
coverage of abortion. In general, family planning services are matched at a higher FFP rate of 90%.”

*This chart is not necessarily all-inclusive, and while it indicates the general Federal Medicaid regulatory requirements, schools should
check with their state Medicaid agency to determine any additional or specific state requirements.
*Resources for this information can be found in the CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)
Medicaid Reimbursed
School Based Services
Managed/ Oversight
ALL services are managed
by Licensing Rules
Physician
Recommendation
No
Yes
Managed Care: Minimum of 10 school-based Medicaid program
reviews annually. Schools must submit the following annually: All
health care professionals, copies of new health care professionals
licenses
Yes
No
Managed Care: Commission-administered time study; schools submit
expenditure reports quarterly; schools submit annual cost reports
Yes
Managed Care: Schools must apply to be providers annually; all
schools receive an annual review; Site surveys; all schools must
conduct a peer review (10% of students) annually
Yes
Must have Physician
involvement
Periodic time/cost studies
No
Yes
Nevada
Fiscal agent provides trainings, medical review, audit and handling
disputed payments
Yes
Yes
Oregon
The department has 2 school based policy staff that provide annual
trainings and extensive reviews:
Yes
No
Alaska
Managed Care: Facility site reviews and develops corrective action
plans
No
No
Managed Care: Fiscal and clinical compliance audits
Yes
Idaho
Washington
Texas
Kentucky
Utah
Montana

Desk Reviews (optional in 2014); MPI Audits; Medicaid
technical assistance; Statewide trainings every 2 years;
Yes
(for OT, PT, SLP)
Yes
(for unlicensed professionals and
nursing)
California
Managed Care: Trainings and audits
Colorado
The Department has 2 school based policy staff that provide annual
audits of all school districts
Yes
No
Monitor through the fiscal agent surveillance review (Physician’s
orders and supporting documentation)
Yes
Yes
Kansas
Yes
Yes
(for OT, PT, SLP and Nursing)
In Summary….

 Federal Guidance: Providers must follow federal and
state regulations to receive federal matching dollars.
 School-based Medicaid services has been identified as
high priority by CMS
 Compliance is necessary to avoid outcomes as
identified in OIG audit reports
 Extensive amount of collaboration took place prior to the
final rules effective date of July 1, 2013.
 State Comparison: Apples to Oranges: Each state has
their own federally approved state plan that identifies the
standards and requirements for the services that are
reimbursable in their schools.
 Financial Comparison: Idaho Medicaid continues to
demonstrate a high level of annual cost per student as
compared to other states.
We are here for you!

 Frede’ Trenkle-MacAllister
Alternative Care Coordinator, BDDS, Medicaid
(208) 287-1169
TrenkleF@dhw.idaho.gov
 Shannon Dunstan
Early Childhood and Interagency Coordinator
Idaho State Department of Education
(208) 332 – 6908 (office)
sdunstan@sde.idaho.gov
Resources/References


CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)

www.oig.hhs.gov

Kansas:

Kansas Health Policy Authority

http://www.kdheks.gov/hcf/program_improvements/downloads/School-Based-Services-032210.pdf

http://www.ksde.org/Portals/0/SES/funding/medicaid/medicaid-SchoolBasedFactSheet.pdf

NAME survey/education and Research Committee

https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/LEA_01132014_14010.pdf

Montana:

Montana Department of Public Health and Human Services:

http://medicaidprovider.hhs.mt.gov/pdf/manuals/schools052013.pdf

NAME survey/education and Research Committee

Oregon:



Colorado:



Linda Williams, Division of Medical Assistance Programs, Policy Analyst
NAME survey/education and Research Committee
Shannon Huska, Colorado Department of Health Care Policy and Financing, School Health Services Program Administrator
The Department of Health Care Policy and Financing, Colorado, Annual Report

http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1251579136390
Washington:


Jim Harvey, Washington State Health Care Authority, School-Based Health Care Services Program Specialist
Washington State health care authority:

http://www.hca.wa.gov/medicaid/billing/documents/guides/schoolbasedhealthcareservices_bi_03102013-12312013.pdf
Resources/References


Indiana:


Virginia:




NAME survey/education and Research Committee
http://www.ritap.org/sites/default/files/Medicaid/guidebook.pdf
NAME survey/education and Research Committee
California:


: http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/localedu.pdf
Arizona:


NAME survey/education and Research Committee
Rhode Island:


NAME survey/education and Research Committee
Iowa:


NAME survey/education and Research Committee
New Jersey:


NAME survey/education and Research Committee
NAME survey/education and Research Committee

http://www.dhcs.ca.gov/provgovpart/pages/lea.aspx

http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp
New York:

NAME survey/education and Research Committee