What to Know If Your School Bills Medicaid Does your school system seek Medicaid coverage for services? Here are some pointers. Bottom Line
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Bottom Line  |   September 01, 2016
What to Know If Your School Bills Medicaid
Author Notes
  • Laurie Alban Havens, MA, CCC-SLP, is ASHA director of private health plan and Medicaid advocacy. lalbanhavens@asha.org
    Laurie Alban Havens, MA, CCC-SLP, is ASHA director of private health plan and Medicaid advocacy. lalbanhavens@asha.org×
Article Information
School-Based Settings / Practice Management / Professional Issues & Training / Bottom Line
Bottom Line   |   September 01, 2016
What to Know If Your School Bills Medicaid
The ASHA Leader, September 2016, Vol. 21, 30-32. doi:10.1044/leader.BML.21092016.30
The ASHA Leader, September 2016, Vol. 21, 30-32. doi:10.1044/leader.BML.21092016.30
Where does funding for public school special education services come from?
The Individuals With Disabilities Education Act (IDEA) requires school systems to provide the services, but covers only about 16 percent of their cost. Local taxes also support school systems. To help subsidize speech-language and hearing services, school systems may bill Medicaid for services they provide to eligible students.
Under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, Medicaid must pay for “medically necessary” services for health- and developmentally related conditions for eligible children. Speech-language and hearing services fall under this benefit, and some school systems choose to bill Medicaid when they provide these services.
Medicaid billing, however, requires audiologists and speech-language pathologists to understand the requirements of the Medicaid program—which may be different in each state—as well as the regulations and guidance of their state and local school systems. In addition, Medicaid programs may have different—and more extensive—documentation requirements.

Under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, Medicaid must pay for “medically necessary” services for health- and developmentally related conditions for eligible children.

Not all school systems choose to participate in Medicaid. Those with smaller numbers of eligible students, for example, may determine that potential Medicaid reimbursement is insufficient to justify the extra administrative effort that would be required.
Here are some of the relevant rules.
Referral
SLPs are independent practitioners and do not, in most circumstances, need a referral from a physician to provide treatment. However, some Medicaid programs require a physician’s referral. This requirement may often cause delays in or interruptions to treatment programs because of the logistics of obtaining the referral, which may include scheduling doctor’s appointments.
Qualified provider
Each state’s Medicaid program determines its own definition of a qualified provider whose services can be billed to Medicaid. This definition often varies by treatment setting—so in some states, a clinical fellow is considered a qualified provider in the schools, but not in private practice. State licensure is often required for Medicaid qualification, but licensure alone is not a guarantee of ability to bill Medicaid.
Visit limit
Medicaid managed care programs are covering greater numbers of beneficiaries, and some of these managed care organizations limit the number of visits to a provider. Some will authorize additional visits or benefit periods—but these often require re-evaluation or other types of documentation to demonstrate level of function, current status and/or significant progress to justify continuation of treatment.
Speech-language pathology assistant
Although the role of speech-language pathology assistants (SLPAs) is often limited in hospitals and outpatient clinics, SLPAs can sometimes provide and bill for school-based treatment when Medicaid is the payer. Depending on the state, SLPAs’ services may be billed independently or under the national provider identification (NPI) of the supervising clinician. SLPAs’ services may require an additional modifier on the bill to identify that the services were provided by the SLPA and may be billed at a different rate.

Each state’s Medicaid program determines its own definition of a qualified provider whose services can be billed to Medicaid. This definition often varies by treatment setting.

Supervision/other providers
In some school districts, SLPs who do not have ASHA certification may provide treatment, often under the direction of a certified clinician. However, Medicaid guidance may specify, for example, the allowable scope of practice for uncertified clinicians, how frequently they must be observed and their documentation reviewed, and the level of reimbursement for their services.
School vs. private treatment
In some states, Medicaid covers services provided to children in school and privately. Where the child receives services may be determined, in part, by the nature of treatment provided in each setting. The Medicaid plan’s limits on number of sessions is also a factor—if a child is authorized for 12 sessions, for example, and receives school-based and private services, the combined visits are limited to 12.
Group vs. individual treatment
Under Medicaid, group size may vary from two to unlimited numbers. Even if larger groups are allowed, the clinician needs to determine that the needs as identified on students’ IEPs can be met in the group setting.
Make-up sessions
Medicaid regulations may affect how and when missed treatment sessions are made up. For example, if a student misses a session one week and the SLP tries to reschedule it for the next week, the additional session may exceed the weekly frequency called for in the student’s IEP and be disallowed.
It should be noted, however, that the federal Office of Special Education Programs recently reiterated its 2007 guidance on missed sessions under IDEA. The guidance clearly does not require all missed session to be made up, stating, “whether an interruption in services constitutes a denial of a free, appropriate public education is an individual determination that must be made on a case-by-case basis.”
Documentation
Documentation is required for all students receiving services under an IEP, but Medicaid often requires additional documentation. Some school systems have adopted forms that can serve the needs of both programs. Clinicians providing and billing for school-based services may need to be familiar with codes and coding policy—in some school systems, administrators assign billing codes, but in others, it is the clinician’s responsibility. ASHA provides a number of resources for assigning procedure and diagnostic codes.
More information
School-based clinicians should check with their school system, state licensure board and state association for more information. These links can help get you started.
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September 2016
Volume 21, Issue 9