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Presentation on theme: "NEW YORK STATE EDUCATION DEPARTMENT (NYSED)"— Presentation transcript:

Preschool/School Supportive Health Services Program: SSHSP – Medicaid in Education NEW YORK STATE EDUCATION DEPARTMENT (NYSED)

2 Topics SSHSP Overview Program information resources
Updates to the SSHSP Medicaid claim requirements

3 School Supportive Health Services Program (SSHSP)

4 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

5 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

6 SSHSP Policy and Guidance Documents

7 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

8 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; Medicaid- billable services comply with all three!

9 Updates to Medicaid Claim Requirements
What would you have heard about over the last year by monitoring the SSHSP website, receiving ListServ s, attending SSHSP trainings

10 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.

11 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.

12 Clarified Medicaid Policy
SSHSP – Clarification of Skilled Nursing Wording IEP Location for Medicaid Reimbursement Medicaid Alert #15-02_ (3/04/2015) Including Medicaid-reimbursable 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

13 Q & A’s Response Revisions

14 Clarified Medicaid Policy
4/13/2017 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

15 Clarified Medicaid Policy
4/13/2017 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.)

16 Clarified Medicaid Policy
4/13/2017 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’).

17 Clarified Medicaid Policy
4/13/2017 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.

18 Clarified Medicaid Policy
4/13/2017 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.

19 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.

20 Clarified Medicaid Policy
4/13/2017 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]

21 Clarified Medicaid Policy
4/13/2017 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]

22 Clarified Medicaid Policy
4/13/2017 Clarified Medicaid Policy SSHSP – Q & A’s, Medicaid does not have a Re-Evaluation 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.

23 Clarified Medicaid Policy
4/13/2017 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.

24 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

25 Certified Public Expenditures (CPEs) Random Moment Time Study (RMTS)

26 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 school year or thereafter must complete this CPE cost settlement process

27 Revised Medicaid RMTS Policy
Medicaid Alert (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.

28 SSHSP Billing/Claiming
4/13/2017 Medicaid Alert # (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:

29 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: publicbenefits.htm The Federal Department of Education has also issued guidance:

30 Contact Information and Resources

31 SSHSP Contacts NYSED Medicaid Unit (Medicaid in Education) SED: , SED SSHSP Website: PCG, Random Moment Time Study (RMTS) and Annual Cost Reporting: PCG Hotline: , SSHSP Medicaid Policy and Medicaid Claims: NYSDOH: Computer Sciences Corporation (CSC): , #1 (Billing), then #2 (CLINIC) or #2 (Enrollment), w/your NPI# NERIC: Vernea Diehl, , Heather Schubert, ,

32 Additional Contacts NYSED Office of Special Education SED P-12 Website: Regional Associates: NYS Office of the Medicaid Inspector General (OMIG) NYSED Office of the Professions: NYSED Office of Teaching Initiatives: NPI (Federal) Website:


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