Changes to Medicaid in Schools Plan Coming August 1, 2016

On January 27, 2016, the Director of the Department of Medicaid and ODE’s Director of the Office for Exceptional Children hosted a webinar that detailed the Medicaid billing changes coming to school districts as a result of changes to the Affordable Care Act (ACA) made in 2012, but only recently being applied to Ohio’s Medicaid Schools Plan (MSP).

Previously, in an October 2015 letter, the Centers for Medicare and Medicaid Services (CMS) found that Ohio’s MSP is out of compliance with its own state plan and the federal regulations because claims lack an appropriate prescription or referral from a medical practitioner. CMS is the federal entity that provides states with federal funds for Medicaid services, including the MSP. CMS concluded that claims filed under the MSP that do not contain this requirement after August 1, 2016 (the deadline set in the letter for full compliance) will not be reimbursable by Medicaid.

The Ohio Department of Medicaid was working with CMS to obtain an exemption or waiver of the requirements of the ACA as it relates to the MSP, but was unable to do so. The result of this unsuccessful negotiation has significant implications for all schools that provide services to students with disabilities pursuant to an IEP and eligible for Medicaid claim reimbursement.

If the State of Ohio is not in compliance with the ACA requirements, CMS will begin deferring IEP claims and Ohio could lose federal financial participation for Medicare through CMS. In fact, the federal regulations that require a prescription for services are not new requirements. Federal regulations state that Ohio’s State Medicaid Plan must require, among other things, all providers to be enrolled as participating providers, and that all claims for payment for services contain the national provider identifier (NPI) of the physician or professional referring or ordering the services. The change in the federal regulations occurred in 2012; however, Ohio’s noncompliant practice and procedure did not come to the attention of CMS until October.

The specific services for which a prescription, referral or order will be required from a medical provider are audiology, speech/language pathology, physical therapy, and occupational therapy. The provider may order multiple services if those services are in the IEP: for example, speech pathology and audiology or a combination of any of the services that requires a prescription. ODE reiterated during the webcast that services in the IEP must be delivered and cannot be denied, changed or modified based on the ability/inability to submit claims for reimbursement to Medicaid for services through the MSP.

A “provider” was defined in the January 27th webcast conducted by the Department of Medicaid Services and ODE as; a physician (MD or DO) an advanced practice nurse (APN), or a physician assistant (PA). School nurses who are RNs or LPNs are ineligible to order, refer or prescribe for these services. School therapists with a national provider number may not prescribe, order or refer the services either. School therapists will, however, continue to evaluate and provide services to students with disabilities, and document services for Medicaid school reimbursement.