EPSDT SCHOOL-BASED SERVICES: AN OVERVIEW FOR PROVIDERS. Oklahoma Health Care Authority Revised May 2004

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1 EPSDT SCHOOL-BASED SERVICES: AN OVERVIEW FOR PROVIDERS Oklahoma Health Care Authority

2 Purpose of Manual This manual is intended as a reference document for schools that are enrolled as Medicaid providers. It contains requirements for participation in and reimbursement of EPSDT School-Based Services. The manual explains covered services, their limits, and who is eligible to receive and provide the services. Extensive material is included in the Appendices, including a listing of contact persons and phone numbers and other reference information. The manual will be updated as necessary. Information about the Medicaid program and eligibility policies is contained in the Medicaid State Plan and administrative rules. The State Plan Amendment for School-Based Services is on file at OHCA. A copy of the applicable administrative rules can be obtained from the OHCA website at School providers are responsible for ensuring compliance with current state/federal Medicaid policies pertaining to the services they render. This manual does not supersede Medicaid rules and is not to be used in lieu of them. Page 1

3 CHAPTER 1 MEDICAID OVERVIEW The Federal Medicaid Program Medicaid is a joint state-federal program that provides health care for low income and disabled individuals. The costs of providing health care and services to individuals that meet specific eligibility criteria established by each state are shared by the state and federal governments. The matching rates (referred to as the federal medical assistance percentage or FMAP ) are calculated annually by the federal government and are based on the state s per capita income. Oklahoma s state share is generally around 30%; the Federal share match is about 70%. Some services must be covered by each state s Medicaid plan, while other services may be provided at a state s option. One mandatory Medicaid service is the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, which provides Medicaid eligible children under age 21 with a broad array of health care screening, diagnosis and treatment services. Legal Authority Medicaid Eligibility Application For Medicaid/ SoonerCare Certified Degree Of Indian Blood Eligibility Verification The Medicaid program is authorized by Title XIX of the Social Security Act and Title 42, Code of Federal Regulations. Administrative rules pertaining to School-Based Services are found at OAC 317: to OHCA is the single State agency responsible for administering Oklahoma s Medicaid program. Eligibility for Medicaid benefits are based on need (i.e., determined by family income) and/or on categorical status (such as children eligible for Title IV-E foster care or adoption assistance or Supplemental Security Income, SSI ). In Oklahoma, children from birth through age 17 are eligible at 185% of the federal poverty level (FPL). (Although Medicaid has other eligibility requirements, such as citizenship and Social Security Number (SSN), the same income guidelines have been used for the National School Lunch Program since December 1, 1997.) The Oklahoma Department of Human Services (DHS), through its local offices, is responsible for determining eligibility for Medicaid /SoonerCare. Applications can be made in person or mailed in. Eligibility must be redetermined or recertified at least every six months. Individuals with Certified Degree of Indian Blood (CDIB) cards must apply for Medicaid benefits in the same manner as other applicants. For Medicaid reimbursement, a child must be eligible on the date of service. The following options can be used to determine a recipient s eligibility: Request Medicaid eligibility information on an individual basis, such as at school registration (e.g., ask for health insurance information, including Medicaid, on an enrollment form or health card); Query parents or guardians, or children who have reached the age of majority or emancipated youth, at the time services are initiated or at the time of an IEP or treatment team meeting; Districts with current contract status and an active PIN number may access the OHCA secured website for current eligibility information; Districts with current contract status may submit a list of students to OHCA s fiscal agent, EDS, for eligibility verification; Page 2

4 Eligibility Verification System (EVS) this is an automated system which can be accessed by phone and can be used to check up to three names at one time. The toll-free number is (800) The child s Medicaid case number or SSN and date of birth must be known. The eligibility information is very current, but the process can be time-consuming. It is more efficient to use when checking eligibility for individuals for specific months of services, rather than initial eligibility for a large number of children. Contact OHCA, Customer Services for further information; On-Line PS/2 Verification System this is an on-line eligibility verification system that can be purchased by schools that enter into a data link contract with DHS. There are minimum monthly charges to operate the system, but it is reported by schools to be efficient and accurate. Contact DHS/Family Services Division for further information; Commercial Vendors Software is available from commercial vendors for on-line eligibility verification; DHS Match -- Contact your county DHS office directly to discuss the option of establishing an initial list or match. Facilitating Medicaid Eligibility Schools can facilitate a family s application for Medicaid/SoonerCare through the provision of information on eligibility and benefits or assistance with the application process. Outreach can be provided on an individual basis, through the distribution of materials on a school-wide basis, or through more formal eligibility outreach campaigns. Parents can indicate their interest in receiving SoonerCare health benefits information for their children on the Application for Free and Reduced Price Meals and waive confidentiality so their names can be furnished by the school to the appropriate county DHS office. Contact the Child Nutrition Program at the OSDE for further information on this waiver of confidentiality. EPSDT The focus of the EPSDT program is on preventive medical care and ensuring that parents can access medical care for their eligible children in a timely manner, before a condition becomes worse and the care more costly. Comprehensive screenings are provided at periodic intervals, and where necessary, children are referred for further diagnosis and treatment services. OHCA lists the following recommendations concerning these periodic screenings. (See Appendices for a more detailed EPSDT Periodicity Schedule.) Six screenings during the first year of life; Two screenings during the second year of life; One screening each year for ages two through five; One screening every other year for ages six through 20. Components of a screen Components of a comprehensive EPSDT screen include the following: Comprehensive health and developmental history--gross and fine motor development; communication skills, language and speech development; self-help, self-care skills; social-emotional development; cognitive skills; visual-motor skills; learning disabilities; psychological/psychiatric problems; peer relations; vocational skills; nutritional assessment; Page 3

5 Comprehensive, Unclothed Physical Examination-- complete unclothed physical examination, including oral dental examination; height and weight measurements; Appropriate immunizations Appropriate Lab Test(s)--anemia, sickle cell test, tuberculin test; lead toxicity screening (a blood level assessment is mandatory where age and risk factors indicate it is medically appropriate); iron deficiency; serum cholesterol screening, if feasible; Health Education Anticipatory guidance; Vision and Hearing Screens Dental Screening Services Performing EPSDT Screens Screening SoonerCare Recipients Schools are not required to perform EPSDT screens, but may do so under limited circumstances discussed below. A school may perform the EPSDT screens and receive reimbursement under the following circumstances for children covered by SoonerCare: 1. When the Medicaid eligible child s SoonerCare provider authorizes the school to perform the screen, or 2. When the SoonerCare provider fails to schedule an appointment within three weeks of the school making and documenting a request for a screen. When a school intends to perform an EPSDT screen on a child, a copy of the EPSDT SCREENING & NOTIFICATION DOCUMENT ; Addendum of the EPSDT School-Based Services contract must be mailed to a SoonerCare member s primary care provider prior to the screen as notice of the school s intent to bill for the screen. When a school performs an EPSDT screen on a child, the original above referenced Addendum must be retained in the child s record and the screening results must be forwarded to the SoonerCare provider. Screening Fee-for-Service Recipients A referral is not needed for schools to perform EPSDT screens for children covered by fee-for-service Medicaid. This includes children in Department of Human Services (DHS) or Office of Juvenile Affairs (OJA) custody and placement. Page 4

6 CHAPTER 2 OVERVIEW OF SCHOOL BASED SERVICES Introduction The EPSDT School-Based Services program provides for reimbursement to local, regional and state educational agencies (referred to hereafter as schools ) for providing medically necessary health and related services to Medicaid eligible children. Private schools are not eligible to participate in this program. The school must enroll as a Medicaid provider to receive Medicaid reimbursement for health related services rendered to Medicaid eligible children. The school bills Medicaid for the services rendered by its qualified providers, who must be school employees or contracted staff. Services are focused on the Medicaid eligible population that is enrolled in the public school system. Services may be provided in the school setting, the home or another site in the community. Through work accomplished jointly in 1997 by the Oklahoma State Department of Education (OSDE) and the Oklahoma Health Care Authority (OHCA), the scope of EPSDT School-Based Services was expanded. New service categories were added to the existing program in an effort to make EPSDT School-Based Services both comprehensive and reflective of the types of health related activities that are already occurring in schools. Dental Screening Examination was added in the school year. OHCA operates a comprehensive health care system for Medicaid clients. Additional information on Medicaid coverage can be found on the OHCA website at Child Eligibility For EPSDT School-Based Services Parental Notification/ Permission Payment for EPSDT School-Based Services is available for all Medicaid individuals between the ages of birth and 21. Payments are subject to the conditions and limitations that apply to these services. Payment can only be made for services provided to individuals who have active enrollment status as a Medicaid recipient on the date services were actually provided. There is no Medicaid requirement that parental consent must be obtained to bill Medicaid. When a family applies for Medicaid benefits in Oklahoma, they are agreeing to the billing of Medicaid by enrolled Medicaid providers. However, schools may wish to notify parents that Medicaid or other third parties may be billed. Parents can be assured that, as an enrolled Medicaid provider, the school will not share any information with OHCA (or the State s fiscal agent) that is not specifically related to the reimbursement of EPSDT School-Based Services. The Link between Providers and Schools have historically paid for and provided health and related services to their students, through Individualized Education Programs (IEPs) that are excluded from the SoonerCare benefits package. It is the responsibility of schools to ensure there is coordination between the recipient s SoonerCare provider and the school when EPSDT School-Based services are provided to a Medicaid eligible child. Page 5

7 . Provider Enrollment In order to bill Medicaid for EPSDT School-Based Services, local education services agencies (LEAs), including educational co-ops, must enter into an Intergovernmental Agreement for EPSDT School-Based Services (referred to hereafter as contract ) with OHCA. The purpose of the contract is to establish a school-based service delivery system, in accordance with the EPSDT program, whereby physical and mental health problems which adversely affect a child s development and impair educational functioning can be identified early, and needed diagnostic and treatment services can be delivered by the school. Services are reimbursed on a fee-for-service basis. Contracts submitted prior to July 31are effective for one year, from July 1 through June 30 of the following year. Any contract received August 1 December 31, will have an effective date starting the date contracts are received by the OHCA/EPSDT Unit. The deadline for submitting contracts to OHCA is December 31. Contracts must be submitted in triplicate. A Medicaid provider number is issued by OHCA with the approved contract. Additional information on provider enrollment can be obtained from OHCA. (Note: Contacts regarding the provider enrollment process are included in the Appendices.) Enrollment of Co-ops When health related services are provided and paid for by the co-op, the co-op enters into a contract with OHCA and is assigned a provider number and PIN. The co-op does not have to contract with OHCA if it is only submitting billing on behalf of its participating districts. In this instance, billing is submitted under each respective district s Medicaid provider number. If a district, as part of a co-op, provides and pays for health related services aside from the services being billed by the co-op, the district must enter into a separate contract with OHCA. Page 6

8 CHAPTER 3 CONTRACT ISSUES Matching Funds Schools expend the funds for the health and related services that are provided to their Medicaid eligible students. For schools who have entered into a contract with the OHCA to provide EPSDT School-Based Services, the school must certify, on an annual basis, the availability of non-federal (state/local) funds expended for these compensable services equal to the required state share match (See Appendices for current federal and state share match rates). Effective, July 1, 2004, schools will no longer be required to certify matching State dollars to OHCA but instead will receive the State share match from OHCA as an advanced payment. On a quarterly basis, OHCAwill then bill back all advanced payments of State share made on behalf of the school via an invoice. OCAS Coding Schools can only use state/local monies for matching Medicaid. If a federal grant has a cash match requirement, the funds used for the match cannot also be used as a match for EPSDT School-Based Services. Medicaid expenditures and reimbursements must be coded in accordance with the Oklahoma Cost Accounting System (OCAS). Proceeds from Medicaid will not be treated as program income under 34 Code of Federal Regulations (CFR) of the Individuals with Disabilities Education Act (IDEA) Amendments of Expenditures of Medicaid reimbursements for IDEA services will not be considered part of the state/local maintenance of effort (MOE) requirement under the IDEA, Amendments of Rate Maximum allowable rates have been established for each type of service. The school is reimbursed approximately 70% of this rate. Treatment encounters have both an individual and a group rate. If treatment is provided in a group setting, the group rate cannot be billed for more than five Medicaid eligible children in the group on a particular date of service. Effective July 1, 2004 OHCA shall pay schools 100% of Medicaid allowable costs pursuant to the provisions and requirements contained in their school based contract. Payments for services shall be made when properly completed claims are submitted to the OHCA fiscal agent. On a quarterly basis, OHCA will bill back all advanced payments of State share made on behalf of the school via an invoice. Provider claims for reimbursement must be based on state and local dollars expended for direct services. Providers may not bill Medicaid for amounts that exceed the district s expenditures for direct services. Providers may adjust the amount billed to Medicaid based on these expenditures (up to the maximum allowable amount). Administrative Fee Schools shall pay OHCA an administrative fee of 1% of paid claims process to cover the cost of administrative functions in the issuance of Medicaid payments during the contract period. The fee is currently based on 1% of federal dollars paid to the district within any given quarter (Note: effective July 1, 2004, the fee will be based on 1% of total claim payment). OHCA will invoice the school on a quarterly basis. Page 7

9 Procedure (Billing) Code Subcontracting The procedure code is the code used to identify EPSDT School-Based Services in the State s Medicaid billing system (refer to contract Addendum EPSDT SCHOOL HEALTH SERVICES ). Schools may choose to contract with third party agents to perform their billing functions or to furnish health services to their students. However, these functions cannot be performed simultaneously by the same third party agent. (Note: See Appendices for a compliance checklist for subcontracting with a third party agent.) Subcontracting for Health Services Schools can contract with individual State licensed providers or with provider agencies for health services in the school. The school must ensure that the individual provider meets the established provider qualifications for the EPSDT School-Based Service(s) being performed. The school retains responsibility for the accuracy of any/all service documentation/progress notes when submitted for billing to the OHCA fiscal agent. The school is also responsible to ensure that all children receive appropriate services, not just those who are Medicaid recipients. Examples of contract arrangements that can be made by schools include, but are not limited to, the following: Contract with nurses (RN or LPN under RN supervision) to provide nursing services; Contract with a licensed, independent speech language pathologist to provide speech therapy and speech language evaluations; Contract with licensed professional counselors (LPC), licensed social workers (LSW), licensed marriage and family therapists (LMFT), licensed psychologists, or licensed behavioral practitioners (LBP) or with an agency that employs these disciplines (agency must have JCAHO, CARF, COA or AOA accreditation), to provide psychotherapy counseling to children pursuant to the individuals IEP developed by the school district. Independent Practitioners A school may contract with outside providers (e.g., independent State licensed practitioners) to perform covered services. The school, as the Medicaid provider, bills Medicaid for these services. The school may want to consider including a clause in its contract with the independent practitioner to the effect that the independent practitioner will not bill Medicaid for any services covered under his/her contract with the school. Out-of-State Credentials If a Medicaid eligible child goes to a bordering state for services provided by an independent practitioner, which are not provided under contract with a school, the services are not reimbursable under the EPSDT School-Based Services program. (The independent practitioner would have to enroll as a Medicaid provider in the State of Oklahoma and meet all applicable requirements for reimbursement.) Covered services provided by an individual that has out-of-state credentials with whom a school contracts are reimbursable, if the school is an enrolled Medicaid provider in the State of Oklahoma. Page 8

10 Subcontracting for Billing Services Schools can contract with a billing agent to prepare and submit their Medicaid claims. The school is solely responsible for claims submitted by its billing agent. The school should review and approve the billing prior to claims submission to the OHCA fiscal agent. Billing agents must not have access to confidential progress/clinical notes. Third Party Liability/Free Care Under the third party liability (TPL) principle, Medicaid pays for services only after other potential third parties (e.g., private insurance, health maintenance organizations and other federal programs) have paid for such services. Medicaid is the payor of last resort. In other words, Medicaid does not pay for services that are provided free of charge to others (the free care rule). An exception to this principle relates to Medicaid eligible children receiving services under federal IDEA. Medicaid may be primary payor for covered medical services in a child s IEP. In order for schools to bill for non-iep health related services ( free care services) for Medicaid recipients, the school district must: 1) Establish a sliding fee scale; 2) Identify insurance for all children and; 3) Bill third party insurance for non-medicaid children. Parents may not be compelled to file a private insurance claim. If parents do not agree to have their insurance company billed, Medicaid cannot be billed for these services either. Private Insurance Billing Under the IDEA Amendments of 1997, children are entitled to a free and appropriate public education (FAPE). Parental consent must be obtained to access private insurance for the services required to provide FAPE to their child. Parents must also be informed that, even if they refuse to permit access to their private insurance, the required services will be provided at no cost to them. The school may pay for the required service or cost the parents would incur to use their insurance (such as a deductible or co-pay amount), including use of its Part B funds under IDEA. Public Insurance Billing Under the IDEA Amendments of 1997, parents may not be required to enroll in public insurance programs in order for their child to receive FAPE. Parents may not be required to incur an out-of-pocket expense, such as a deductible or co-pay amount, if a claim were filed for such services. The school may pay the cost that the parent would otherwise be required to pay if their public insurance were used, including use of its Part B funds under IDEA. A school may not use a child s public insurance benefits if it would decrease available lifetime coverage or any other insured benefit, result in the family paying for services provided outside of school that would otherwise be covered by the public insurance, increase premiums or lead to discontinuation of insurance, or put the child at risk of losing eligibility for home and community-based waiver services. The Page 9

11 use of Medicaid for these services will not reduce the child s Medicaid benefits. Care Coordination Linking the child to his/her medical home so that preventive health care can be furnished on a regular basis is a critical part of care coordination. Schools should inform SoonerCare providers of the children in their district who have an urgent need for an EPSDT screen within a given school year. Referrals to SoonerCare providers should be documented on the EPSDT SCREENING & NOTIFICATION STATEMENT ; Addendum of the EPSDT school contract, as well as contact with parents if the medical provider is unknown. The school should coordinate the ongoing health services that the child is receiving with the child s SoonerCare provider. Schools can obtain the name of a child s SoonerCare provider in the following ways: Ask parents/guardians or children (who have reached the age of majority or emancipated youth) to provide the name of their SoonerCare provider on registration material, at the time services are initiated, or when Medicaid eligible children are identified. Access the name of the child s SoonerCare provider by obtaining eligibility verification through OHCA s fiscal agent, EDS. Access the name of the child s SoonerCare provider through the Eligibility Verification System (EVS), an automated phone system operated by OHCA, or a dedicated line with DHS. Contract Obligations Schools are obligated, under the Intergovernmental Agreement for EPSDT School-Based Services, to do the following: Deliver Medicaid-covered services; Ensure that Individual/Group Treatment Encounters are provided pursuant to the Medicaid recipient s IEP. Ensure that services are medically indicated and necessary; Ensure that individual service providers are appropriately qualified under guidelines established by OHCA and subcontracted behavioral health service agencies are consistent with current OHCA outpatient behavioral health guidelines (JCAHO, CARF, AOA, or COA accreditation is required); Perform EPSDT screens in limited circumstances and forward the results to the child s PCP; Assist in facilitating EPSDT screens for individuals covered by fee-forservice Medicaid, or perform EPSDT screens for these individuals; Designate a school district employee, as Medicaid Coordinator, to attend the annual training provided by OHCA and to be available for all necessary EPSDT meetings, conferences or audits (Note: Medicaid Coordinator may not be district contracted staff); Designate district OCAS personnel to attend an annual training conducted by OSDE. The school must provide OHCA the name of the district contractor/representative for OCAS; Ensure that if the school district subcontracts for the provision of health services and billing, these functions are performed by separate entities; Notify OHCA of all subcontractors and the functions they perform within Page 10

12 Page days of entering this agreement, or within 10 days of any change in subcontractors; Submit claims according to OHCA s instructions; Certify that the estimated State Match is available and has been appropriated in the school district s budget (Addendum I of the contract). Addendum I must be completed and submitted with the contract. Effective July 1, 2004, schools will no longer be required to certify State Match dollars; Provide the non-federal match for services provided under the agreement and provide OHCA with the Certification of Match (Addendum III of the contract) by August 31of each year. The contract will not be processed and executed until OHCA has received the Addendum III for the prior contract year. Effective July 1, 2004, schools will no longer be required to certify State Match dollars; Code Medicaid expenditures and reimbursements in accordance with the Oklahoma Cost Accounting System (OCAS); Credit funds received through Medicaid reimbursement for special education and/or health related services. Pay OHCA an administrative fee of 1% of paid claims processed to cover cost of administrative functions in the issuance of federal dollar payments during the contract period. The fee will be based on 1% of federal dollars paid to the district within any given quarter. (Note: effective July 1, 2004, the fee will be based on 1% of total claim payment). OHCA will invoice school on a quarterly basis; Effective July 1, pay OHCA back the advanced state share made on behalf of the school. OHCA will invoice school on a quarterly basis. Keep required documentation on the services provided and payments claimed for a period of six years from date of service.

13 CHAPTER 4 COVERED SERVICES: GENERAL SERVICE REQUIREMENTS Introduction The general service requirements that apply to all EPSDT School-Based Services are described below. Any exceptions to this general information that apply to a specific service are noted in the service chapters that follow. Chapters 6-11 contain more detailed information on each EPSDT School-Based Service. Each service chapter includes a definition of the service, specific provider qualifications, unit of service, rate, and service authorization requirements (as specified in the Medicaid State Plan and the administrative rules.) The service chapters (and sections) have been designed as pull-outs for easy distribution to individual service providers. A district should provide all individual service providers with a copy of this chapter and the applicable service chapters or chapter sections. Medical Necessity Medicaid reimburses for services for which a child has a determined medical need. The services provided to an eligible child should be individualized and consistent with the symptoms or confirmed diagnosis of a specific disorder or delay. OHCA has adopted the following standards (OAC 317:30-3-1) concerning the establishment of medical necessity: (1) Services must be consistent with accepted health care practice standards and guidelines for the prevention, diagnosis or treatment of symptoms of illness, disease or disability; (2) Documentation submitted in order to request services or substantiate previously provided services must demonstrate through adequate objective medical records, evidence sufficient to justify the client s need for the service; (3) Treatment of the client s condition, disease or injury must be based on reasonable and predictable health outcomes; (4) Services must be necessary to alleviate a medical condition and must be required for reasons other than convenience of the client, family, or medical provider; (5) Services must be delivered in the most cost-effective manner and most appropriate setting; and (6) Services must be appropriate for the client s age and health status and developed for the client to achieve, maintain or promote functional capacity. Provider Qualifications Licensure/Certification Schools can only be reimbursed for services that are rendered by employed or contracted staff who meets the qualifications established for the EPSDT School- Based Services program at the time the service is rendered. Each service category has its own provider qualifications. Providers may only perform the service activities that are within their scope of practice. Provider qualifications requiring a State license refers to a professional license issued under State law by the applicable State licensing board (e.g., Licensed Speech Language Pathologists are licensed by the Board of Examiners under the Page 12

14 Speech Pathology and Audiology Licensing Act). Provider qualifications requiring certification refers to certification by the OSDE, unless otherwise specified. (Note: See Covered Services chapters for provider qualifications specific to each service.) Temporary Licensure Temporary licensure meets the Medicaid provider qualifications for a licensed practitioner as long as the requirements for the temporary license also meet the rules of the OSDE and OHCA for that professional type. Services Provided Under Supervision Services may not be provided under supervision, unless specifically authorized and in accordance with State laws governing professional practice. These exceptions are noted in the service chapters, as applicable. Service Authorization Services, with the exception of Child Health Encounter, Dental Screening Examination, and initial evaluations, must be authorized (i.e., specified) in the child s individualized treatment plan. The plan should identify the need for service(s); the scope, frequency and duration, the provider and a beginning and ending date. Speech Language Pathology services require a referral from a physician or licensed practitioner of the healing arts. Occupational Therapy services and Physical Therapy services require a prescription from a physician or licensed practitioner of the healing arts. In the state of Oklahoma, only persons with the designation of Doctor are practitioners of the healing arts, (59 Oklahoma Statute (2001)). Title designates 9 types of doctorates that allow a person be a practitioner of the healing arts. Those persons include a Ph.D or Ed.D regarding a person with a doctoral degree in speech and language pathology or audiology. Referral may only be made by practitioners within his/her scope of practice. Treatment Plan The individual treatment plan serves as the service authorization document. It should include a signature by the health care professional(s) authorized to determine the need for specific EPSDT School-Based Services. If the professional is a subcontractor, a school district employee s signature must also be on this document. For children with disabilities who have IEPs, IDEA federal regulations require documentation of parental notice and participation in implementing or changing related services, as well as informed written consent to conduct evaluations. IHSP There may be circumstances where a child with a disability has both an Individual Health Services Plan (IHSP) and an IEP. The IDEA requires documentation on the IEP to address all related services that are necessary for the child to benefit from their education. In such cases where there is an IHSP, in addition to the child s IEP, the IHSP is treated as secondary to the IEP. In order to bill Medicaid for services that are delivered based upon goals/objectives identified in an IHSP, the IHSP must be developed by a team inclusive of school personnel and qualified service delivery provider(s). Page 13

15 An IHSP is an individualized treatment plan for EPSDT School-Based Services. As mentioned above, the IHSP is secondary to the IEP and the IDEA requires that all related services be identified in the child s IEP. The IHSP addresses services for children with serious or chronic health-related problems for which services during the school day are needed. Examples may include children with diabetes, seizures, or asthma for which ongoing nursing intervention is required. There are also children who have an IHSP (treatment plan) for psychological and/or psychotherapy counseling services. These services must also be included in the child s IEP. An IHSP must be signed by the provider(s) that determined the need for service(s) (this may also be the provider(s) that will be performing the service(s)) and by a school employee. A parent signature on an IHSP is not a written Medicaid program requirement. However, in schools, parents must be notified (and have the opportunity to respond) prior to implementing an IHSP and must provide informed written consent to conduct intake, assessment or psychological evaluations. An IHSP should be reviewed within the timelines indicated in the plan, based on the child s particular needs. The IHSP is sometimes used as the primary treatment plan for non-iep health related services of recipients who do not have an IEP in place. However, in order for schools to bill for non-iep health related services for Medicaid recipients, the school district must: 1) Establish a sliding fee scale; 2) Identify insurance for all children and; 3) Bill third party insurance for non-medicaid children. Parents may not be compelled to file a private insurance claim. If parents do not agree to have their insurance company billed, Medicaid cannot be billed for these services either. Service Limitations Place of Service Unit of Service Daily limits have been established for all EPSDT School-Based Services. This means that a maximum number of service units will be reimbursed for a child on a given day. The Child Health Encounter has an annual limitation; however additional units for medically necessary services may be requested through the prior authorization process (if need for additional units; contact the OHCA EPSDT Unit for guidance). These service limitations are noted in the service chapters, as well as any applicable procedures for obtaining prior authorization for additional service units. For Medicaid reimbursement purposes, services may be provided at the school, at the child s home or at another site in the community. Each service has a specified unit for billing purposes. This is time spent in a direct service. Direct service should be face-to-face with the child (exceptions may be completing a child health history; or providing health education to the parent/guardian; but at all times service must be individualized to the child s needs). There is no reimbursement for time reviewing/completing paperwork/documentation related to the service or for staff travel to/from the site of service, unless otherwise specified. Most units of service are time-based, meaning that the service must be of a minimum duration in order to be billed. A unit of service that is time-based is Page 14

16 continuous minutes; the time cannot be aggregated throughout the day. Example: A physical therapist provides therapy service to a Medicaid eligible child from 9:00 a.m. to 9:20 a.m. One unit of service should be billed. (Physical therapy is billed in 15-minute increments.) The additional five minutes cannot be billed because it does not constitute a full unit of 15 continuous minutes. There are no minimum time requirements for Evaluation Services, for which the unit of service is generally a completed evaluation. The only exception is the Psychological Evaluation, which is billed in hourly increment. Page 15

17 CHAPTER 5 DOCUMENTATION Documenting Medical Necessity In order to bill Medicaid for EPSDT School-Based Services, documentation must reflect medical necessity. Medical necessity must be documented through the provider assessment/evaluation/testing of the child that clearly identifies the child s delay and/or disability and how the child s education is affected by the identified delay and/or disability (IDEA requires the same principles in determining the need for services). Documentation All EPSDT School-Based Services are subject to state and federal audit. The following documentation must be kept at the school district site when a Medicaid-reimbursable service is delivered: Child s name and Medicaid number (and person code) Date of service Description of the service performed Duration (or unit) of the service, with start and stop time Brief comment/progress note with an original signature by the service provider, including credentials No standard service logs or documentation forms are required. The documentation must be maintained onsite at the district in a manner and format that is efficient for the individuals providing the service but also accessible in the event of an audit. Progress Notes The intent of a progress note is to tie the service being performed and the outcomes achieved back to the individual treatment plan goals and objectives. At a minimum, progress notes must include a brief description of the service or treatment activity--what occurred or what was worked on with the child and, as appropriate, some indication of the child s progress (e.g., improved, no change, etc.) and need for continued treatment or follow-up, based on the observations and treatment rendered during that particular encounter with the child. No standard format for progress notes is required. SOAP (subjective, objective, assessment, plan) notes are one format for writing progress notes utilized by some health care professionals, but are not a required format. A written progress note is the supporting documentation that a service was actually provided and necessary. Consideration of the following questions will assist providers in writing a thorough progress note: Why did the child present for the service/treatment? (Why is this service necessary?) What was observed during the service/treatment encounter (i.e., ongoing assessment)? What kind of treatment did the child receive during this service/treatment encounter? What was the outcome of this service/treatment encounter? (What is necessary, if anything, for follow-up or continued treatment?) Page 16

18 The start/stop time of the service must be included in the progress note. Progress notes must be kept on-site of the district and accessible for review or audit purposes. The service provider must sign progress notes. Initials may be used as long as the provider s original signature with credentials and initials also appear on the documentation form. When services such as occupational or physical therapy are provided by a licensed assistant under the direction of a licensed therapist, the licensed therapist should review and sign the progress notes as part of their supervisory responsibility. Start/Stop Time Documentation must include the beginning and ending time of service delivery for all services. Electronic Documentation Electronic documentation is acceptable. However, hard copies of the documentation, with an original provider signature must be maintained on-site of the servicing district and accessible for review or audit purposes. Records Retention Original records documenting the extent of services provided to individuals under the EPSDT School-Based Services contract and payments claimed for these services must be maintained on-site of district for six years from date of service. This documentation requirement includes documentation for services provided by subcontractors. Records can be archived according to district record management policy but must be accessible for review or audit purposes. Audit Requirements All EPSDT School-Based Services are subject to state and federal audit. As the Medicaid provider, the school certifies that the services being claimed for Medicaid reimbursement were medically necessary and were furnished under the provider s direction. Both fiscal and clinical compliance will be monitored. (Note: See Appendices for quality assurance tools, including an audit preparation checklist.) The Surveillance and Utilization Review System (SURS), a unit within OHCA, is responsible for conducting audits of EPSDT School-Based Services. Generally, these are post-payment reviews as they occur after a school receives reimbursement for the services that are being reviewed. SURS will review documentation of the services provided by a school (e.g., need for services, treatment plans and case/progress notes) and compliance with Medicaid rules and regulations, including the qualifications of individual service providers. SURS uses a computerized method of statistical analysis to identify providers who are outliers or perceived over-utilizers. SURS may look into the circumstances that resulted in service utilization or payments being larger than or outside the average of those made to comparably-sized schools over a period of time. Page 17

19 CHAPTER 6 CHILD HEALTH ENCOUNTER Definition The child health encounter may include a diagnosis and treatment encounter or a home visit. A child health encounter may include a child health history, physical examination, developmental assessment, nutritional assessment and counseling, social assessment and counseling, genetic evaluation and counseling, indicated laboratory and screening tests, screening for appropriate immunizations, health counseling and treatment of childhood illness and conditions. Provider Qualifications SDE certified special education related services professionals (such as school nurses, school psychologists) or other State licensed or certified health care professionals (such as speech language pathologists, licensed professional counselors). Service Unit An encounter is in time increments up to 3 units of service, as follows: 5 10 minutes of service is 1 unit; over 10 minutes to 20 minutes is 2 units; over 20 minutes is 3 units. Rate Service Limitation $11.67 per unit 30 units per year. Additional units must be prior authorized. Daily maximum limit: 6 units Service Authorization Documented referral Clarification Types of Providers Based on the above provider qualifications, the following are providers who may perform this service for Medicaid reimbursement: (Professionals may only perform the specific service activities that are within their scope of practice.) School nurse/licensed registered nurse Licensed practical nurse (under supervision) Licensed psychologist Certified school psychologist Licensed speech language pathologist Speech pathology assistant (under supervision of a licensed independent practitioner in accordance with the Speech Pathology and Audiology Licensing Act) Licensed occupational therapist Licensed physical therapist Licensed audiologist Licensed professional counselor Licensed social worker Licensed marriage and family therapist Licensed behavioral practitioner Certified vision impairment teacher Orientation and mobility specialist Certified deaf education teacher Page 18

20 Scope The intent of a Child Health Encounter is that it is the initial assessment or screening tool that determines the need for additional evaluation or treatment services, and where appropriate, leads to the development of an individualized treatment plan. There may be circumstances when the encounter is used to provide health counseling or treatment of an incidental nature (i.e., there is no need for ongoing treatment services). The following is intended to clarify the scope of a Child Health Encounter: Service is child-specific and child-focused; most will require a face-to-face encounter with the child. (Exceptions may be completing a child health history with, or providing health education to the parent or guardian.) Service is performed based on a child s medically indicated need. Screening for immunizations must include some contact with or on behalf of the child. Health screenings, such as for vision or hearing, may be billed in the following instance: A child has an individualized medical need that warrants a screening or assessment to determine the need for further services (i.e., there is a referral for screening). IEP authorization for vision and hearing screens performed as part of an annual review fulfills the referral requirement. Documentation should reflect that the screens were done pursuant to the IEP. Self-referrals for service are not prohibited. The daily limit may not exceed a total of six units. The six units may be up to six separate medically necessary health encounters (that are each 5 10 minutes in duration) or the six units may be comprised of fewer separate health encounters that are longer in duration (e.g., three separate health encounters of two units (10 20 minutes in duration) each. Service Exclusion Medicaid reimbursement for Child Health Encounters does not include the following: Paper immunization screenings for school enrollment purposes Preventive health screenings Administering/monitoring of medication (Note: This may be appropriately billed as a Nursing Service. See Chapter 5 Section E.) Services provided on a routine or ongoing basis Classroom education on health/mental health prevention Prior Authorization When a child has received the 30 units of Child Health Encounter permitted per year, prior authorization must be obtained from OHCA to claim additional encounters. Contact OHCA for instructions on requesting additional encounters. Page 19

21 CHAPTER 7 INDIVIDUAL/GROUP TREATMENT ENCOUNTER Definition An individual/group treatment encounter may occur through the provision of individual or group treatment services to children who are identified as having specific disorders or delays in development, emotional, or behavioral problems, or disorders of speech, language or hearing. These types of encounters are initiated following the completion of a diagnostic encounter and subsequent development of a child s IEP. Includes: Hearing and Vision Services (See Section A) Speech and Language Therapy (See Section B) Occupational Therapy (See Section C) Physical Therapy (See Section D) Nursing Services (See Section E) Psychological Services (See Section F) Psychotherapeutic Counseling Services (See Section G) Assistive Technology Services (See Section H) Provider Qualifications Specific to the professional areas of services as defined under OHCA rules. (See specific provider qualifications for each service category under the Individual/ Group Treatment Encounter in Sections A - H that follow.) Service Unit Rate Service Limitation Service Authorization Completed 15-minute increments unless specified otherwise. $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: varies by service Services must be authorized in the child s IEP and, where indicated, must have a doctor referral/prescription Page 20

22 CHAPTER 7 - SECTION A HEARING AND VISION SERVICES Definition May include habilitation activities, such as auditory training, aural and visual habilitation training, including Braille, and communication management; orientation and mobility; counseling for vision and hearing losses and disorders. Provider Qualifications Service Unit Rate Service Limitation Service Authorization State licensed, master s degree audiologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. State licensed, master s degree speech language pathologist who (1) holds a certificate of clinical competence from the ASHA; or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. State certified deaf education teacher Certified orientation and mobility specialist State certified vision impairment teacher Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: 8 units Services must be authorized in child s IEP. Page 21