Medicaid School-Based Billing: A Summary of Federal Requirements As the school year moves into its hectic final stretch, it’s important to keep in mind the guidelines for billing Medicaid for school-based services. The following is a primer on the federal requirements based upon questions asked by school-based members at several state association meetings earlier this year. Can an ... Bottom Line
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Bottom Line  |   May 01, 2005
Medicaid School-Based Billing: A Summary of Federal Requirements
Author Notes
  • Ingrida Lusis, is ASHA’s director of health care financing advocacy and can be contacted at 800-498-2071, ext. 4387, or by e-mail at ilusis@asha.org.
    Ingrida Lusis, is ASHA’s director of health care financing advocacy and can be contacted at 800-498-2071, ext. 4387, or by e-mail at ilusis@asha.org.×
Article Information
School-Based Settings / Practice Management / Bottom Line
Bottom Line   |   May 01, 2005
Medicaid School-Based Billing: A Summary of Federal Requirements
The ASHA Leader, May 2005, Vol. 10, 3-15. doi:10.1044/leader.BML.10072005.3
The ASHA Leader, May 2005, Vol. 10, 3-15. doi:10.1044/leader.BML.10072005.3
As the school year moves into its hectic final stretch, it’s important to keep in mind the guidelines for billing Medicaid for school-based services. The following is a primer on the federal requirements based upon questions asked by school-based members at several state association meetings earlier this year.
Can an Individualized Education Program (IEP) be recognized in lieu of a physician referral to show necessity of speech-language pathology services for Medicaid purposes?
The Center for Medicare and Medicaid Services (CMS) has stated that an IEP can be recognized as a referral for speech services as long as the IEP team includes an individual licensed under state law to make such a determination and as long as there is proper documentation to show the referral/recommendation for speech-language pathology services by that individual.
Federal regulations (42 CFR 440.110) state that Medicaid-eligible students with a need for speech-language pathology services must be referred by a physician or other licensed practitioner of the healing arts. Most states require an actual physician referral in addition to the IEP.
As part of an April 2003 Office of Inspector General (OIG) audit of school-based services in Oklahoma, the agency found that some school districts did not obtain a referral for the delivery of speech-language pathology services and requested a refund of federal money. The OIG did concede that a treatment plan could be considered a referral for speech-language pathology services if an individual on the team of professionals signing the treatment plan has the authority to prescribe or refer under state law.
Why do I need an IEP and a referral?
Under Part B of the Individuals with Disabilities Education Act, school districts are required to prepare an individualized education program for each child that specifies all special education and related services that the child needs. The Medicaid program pays for some of the health related services included in the Medicaid-eligible child’s IEP if the services are specified in Medicaid law and included in the state’s Medicaid plan.
The development of an IEP does not automatically entitle coverage for Medicaid-eligible children. In order to quality for Medicaid coverage, the services must be medical in nature.
What speech-language pathology services are covered?
Services for individuals with speech, hearing, or language disorders mean diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech-language pathologist. This includes any necessary supplies or equipment.
Are evaluations and assessments covered under Medicaid?
Medicaid payment is only available for the part of the assessment that is medical in nature and provided by qualified Medicaid providers. If medical evaluations or assessments are conducted to determine a child’s health-related needs for purposes of the IEP, payment for some or all of the costs may be available under Medicaid. However, Medicaid will not pay for evaluations orassessments that are for educational purposes.
Who defines medical necessity?
States define medical necessity. Most states have developed a Medicaid provider handbook which outlines both federal and state requirements for Medicaid reimbursement. The handbooks are available through the state’s Medicaid Web site.
How do I know if I am a qualified provider?
Medicaid will reimburse for Medicaid speech-language pathology services if they are delivered by or under the direction of a qualified SLP. Medicaid regulations [42 CFR 440.110 (c)] state the definition as follows:
(2) A “speech pathologist is an individual who:
Has a certificate of clinical competence from the American Speech and Hearing Association [sic];
Has completed the equivalent educational requirements and work experience necessary for the certificate; or
Has completed the academic program and is acquiring supervised work experience to qualify for the certificate.”
I do not have my CCC-SLP, but hold a teacher credential from my State Department of Education. Is this credential equivalent to the CCC-SLP?
CMS requires that the State Attorney General determine equivalency to the CCC-SLP. Neither ASHA, an individual SLP, nor a school district can make equivalency rulings.
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May 2005
Volume 10, Issue 7