Changes make school Medicaid reimbursement less stringent

By Patrick Adrian
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CLAREMONT — New rules directing the reimbursement to schools for Medicaid-covered student services are more lenient than New Hampshire school districts originally anticipated, though two still unanswered questions about the new language still have school administrators holding their breath.

Claremont Special Education Director Ben Nestor updated the Claremont School Board on Monday night about the official rule changes to New Hampshire’s Medicaid to Schools program, which the governor’s Executive Council adopted into law on Friday, Feb. 28.

“There are two key unresolved issues that came up [on Tuesday] at the stakeholder meeting in Concord,” Nestor said. “[The second one] is a major concern.”

The new rules relax some of the restrictions that New Hampshire schools were told to expect last August, Nestor said. Some individualized education program (IEP) related services will still need a medical professional’s order to qualify for Medicaid reimbursement. But unlike the originally-proposed rule, a school’s internal service providers, such as a school psychologist or speech pathologist, may still sign-off on Medicaid claims for services related directly to one’s field, according to Nestor.

Medicaid to Schools is a state-administered program that partially reimburses school districts for costs to provide IEP-related services for Medicaid-eligible students with special needs. Services covered under New Hampshire’s Medicaid plan include physical and occupational therapy, speech pathology, psychological counseling, paraprofessionals and one-to-one aids and transportation.

The Claremont School District receives $500,000 to $700,000 in Medicaid reimbursements per year, according to Nestor.

Last August, New Hampshire school districts learned that the state Department of Health and Human Services (DHHS) would be tightening the program’s rules for school reimbursement, in order to comply with a federal directive.

One particular rule announced that schools may only be reimbursed for services that are ordered by a medical doctor, physician’s assistant or registered nurse, none of which are positions typically employed by a school district. Prior to August, all Medicaid covered services could be ordered by a school’s internal service-providers, such as a school psychologist or speech pathologist.

Following the outcry by districts statewide, the DHHS relaxed the rules “to some extent” in the final draft, Nestor told the board.

The services that will require an order by a medical care professional include paraprofessionals or rehab assistants. Billing for paraprofessionals comprises the largest portion of the district’s reimbursement claims, Nestor said.

Assuming these are the only rule changes, their impact on the district would be manageable, Nestor had told the Eagle Times on Feb. 6. He has already been reaching out to local care providers who can sign-off on claims for students they treat. For other students, there are commercial services who can provide that to schools for a nominal cost.

However, there are two unresolved issues pertaining to the new rule language that could throw the district’s projections off kilter.

The first issue, which one Nestor’s colleagues raised at the recent stakeholder meeting, was whether the medical doctor would need to physically examine the student before being able to order a student-related service, or if the school could simply send the student’s IEP to the doctor for review.

A doctor who attended the stakeholder meeting believed that the state will not require doctors to have face-to-face visits with students, which Nestor said “would throw a huge monkey-wrench in our billing process.”

Based on the doctor’s interpretation, Nestor said he doesn’t anticipate that issue to be a roadblock. In all likelihood, schools will be able to send the form to the doctor for signage.

The second issue, however, could be a huge problem, according to Nestor.

According to Nestor, the new rule narrows the purpose which a school may bill Medicaid for a rehab assistant.

“So if a child needs, for example, bathroom support, as a medically necessary service, we could bill for that,” Nestor said. “But if we were limited to that [definition], versus what a paraprofessional does, we wouldn’t be able to much in terms of reimbursement.”

But since paraprofessionals and rehab assistants comprise the “lion’s share” of the district’s billable costs, that loss of reimbursement could be substantial.

The stakeholders are currently waiting for guidance from DHHS about how to interpret these two issues. If the billable services for rehab assistants remain the same as before, Nestor told the board that the losses in Medicaid reimbursement should be minimal.