MEDICAID IN EDUCATION

The Medicaid program was established by the U.S. Congress in 1965 to fund health and long term care services for millions of children and adults in low income working families in America. It also provides services to the elderly and individuals with disabilities. This program is financed and operated jointly by the states and the federal government. A wide range of medically necessary services can be covered by the Medicaid program. Each state can determine which of these services will be covered. Therefore the Medicaid programs in each state and the services covered may vary.

In 1988, the U.S. Congress changed the Medicaid statute to allow public schools to receive Medicaid reimbursement for some health related services specified in a student’s IEP. The services must be medically necessary and the student must be eligible for Medicaid and special education. In North Carolina the following services can be reimbursed: audiology, occupational therapy, physical therapy, speech and language, psychological/counseling and nursing services.

Lauren Holahan and Laurie Ray are the resource contacts in the Exceptional Children Division, North Carolina Department of Public Instruction:

UPDATES/INFORMATION FROM DMA:

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Important Information in the October DMA Bulletin re: post-payment reviews

The Exceptional Children Division continues to offer statewide support and guidance on public schools' access to Medicaid reimbursement. Please closely review the upcoming Medicaid bulletins, especially those for October, November and December. These bulletins are always available by link from our Medicaid webpage at www.ncpublicschools.org/ec/medicaid.

The Division of Medical Assistance (DMA) in the North Carolina Department of Health and Human Services plans to implement post-payment reviews in order to ensure all policy requirements and medical necessity criteria are being met. While services provided by LEAs are excluded from prior authorization, these services are subject to post-payment review. Providers will provide documentation, via mail or fax, upon request. Overpayments will be recouped based on review findings in accordance with NC Medicaid policy 10C.

Please refer to the DMA bulletins for complete details and all information about these reviews that is available at this time. Also monitor our Medicaid webpage, as additional information about these reviews will be posted there as it becomes available. Contact Lauren Holahan at lauren_holahan@med.unc.edu or 919.843.4466 or Laurie Ray at laurie_ray@med.unc.edu or 919.636.1827 with any questions or comments.


Downloads for Medicaid Training Sessions


Sample Nursing Forms

  • Medication Documentation Form
    (doc, 159kb)
  • POC for School Nursing
    (doc, 33kb)
  • Medicaid Nursing Treatment and Procedures Progress Notes
    (doc, 55kb)


Key Changes to the North Carolina Medicaid Plan for LEAs
Please be aware of the recent changes to the North Carolina Medicaid Plan which was approved by the Centers for Medicare and Medicaid Services on July 14, 2008. The effective date is July 18, 2007. This amendment and other policy changes include significant changes to policy and procedures for North Carolina. Some of the key changes to our State Medicaid Plan and the Policy are listed below.

Policy Section

  • Medical doctor order required prior to treatment for all IEP treatment services and medications effective July 1, 2008.
  • State Plan Amendment (SPA) approved effective date of July 18, 2007.
  • Addition of nursing services
    • RN must develop plan of care for nursing services.
    • LPN and delegated staff work under the supervision of RN for nursing services.
    • Three rates of reimbursement: RN, LPN, delegated tasks.
    • Nursing services must be included in the IEP for reimbursement.
    • Services must be rendered in accordance with NC Board of Nursing regulations.
    • Documentation required as outlined in Division of Medical Assistance (DMA) policy.
    • Staff must be employed by or under contract with the school.
  • Pre-vocational assessment and training removed from reimbursable occupational therapy services.
  • Audiologist qualifications changed to licensure only.


Financial Section

  • Beginning with cost reporting periods ending on or after June 30, 2008, the DMA will begin using a cost-based methodology for all Local Educational Agencies (LEAs).
  • Cost-based methodology will consist of a cost report, time study and reconciliation.
  • If payments exceed Medicaid-allowable costs, the provider will remit the federal share of the overpayment at the time the cost report is submitted; and
  • If the actual, certified costs of an LEA provider exceed the interim payments, the DMA will pay the federal share of the difference to the provider in accordance with the final actual certification agreement and submit claims to the Centers for Medicare and Medicaid Services (CMS) for reimbursement of that payment in the federal fiscal quarter following payment to the provider


Random Moment Time Study Section

  • The CMS have approved North Carolina’s School-Based Random Moment Time Study (RMTS) methodology, which was implemented October 1, 2007.
  • Participation in the School-Based Random Moment Time Study is required for LEAs to be reimbursed for both the Medicaid Administrative Claiming and Direct Service/Fee for Service Programs.
  • LEAs are required to reach an 85% return response rate per district per quarter.
  • If an individual district has non-returns greater than 15% and greater than five moments for a quarter, the LEA is in default and will receive a warning letter.
  • If the same LEA is in default (as previously defined) the next quarter, after being warned, the LEA will not be able to participate in the time study for a one-year period of time.
  • Based on approval of the time study, the State agrees to monitor the time study to assure proper use of the time study codes and proper application of the methodology.
  • The State agrees to provide summary reports to the CMS Regional Office detailing the results, issues and concerns identified in the monitoring process on a quarterly basis.
  • The State agrees to provide oversight of outside entity contracted to operate or monitor the time study process.


DMA Contacts
Policy - Nora Poisella - Nora.Poisella@ncmail.net or 919.855.4310
Financial - Kimberly Ibrahim - Kimberly.Ibrahim@ncmail.net or 919.855.4200
Time Study - Sandy Frederick - Sandy.Frederick@ncmail.net or 919.855.4153


Resources


Effective May 23, 2008, all claims must contain a National Provider Identifier (NPI)
The N.C. Medicaid Program will no longer accept claims submitted without an NPnbsp;I after May 23, 2008. LEAs can go to: http://www.dhhs.state.nc.us/dma/NPI.htm for all information and latest updates. LEAs should also go to the NPI and address database http://www.dhhs.state.nc.us/dma/WebNPI/default.htm to be sure all their information is correct.


Under the direction of
All practitioners logging service and school-based Medicaid program administrators are encouraged to review national and NC State Board licensure rules for their profession (e.g. PT, OT, SLP) regarding supervision of licensed assistants. Services provided "under the direction of" are currently an area of focus for auditors.


EPSDT Policy Instructions Update
On August 17, 2007, the Division posted the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Policy Instructions Update. These instructions became effective September 01, 2007, and clarify the Division’s initial EPSDT Policy Instructions issued January 28, 2005. Please review the instructions carefully. Providers and case managers should communicate the information contained in the instructions to recipients under 21 years of age and/or their representatives. Children who have previously been denied or terminated from services may be eligible for additional Medicaid services if the services are medically necessary and if a request for services is made in accordance with Medicaid’s policies and procedures. The EPSDT Policy Instructions Update is located on the following website: http://www.ncdhhs.gov/dma/EPSDTprovider.htm

Instructions
(pdf, 248kb)


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