Section 7: Medicaid

What is Medicaid reimbursement?

Medicaid is a 1965 joint federal and state entitlement program that guarantees health coverage to eligible individuals. Medicaid eligibility is based on qualifying income and/or other criteria. To qualify, the individual must be any of the following: in a household with their family who is experiencing low income, greater than 65 years of age, a child under 21 years of age, blind, disabled, or pregnant. Parents must provide informed consent prior to a school accessing their learner’s eligibility or benefits for reimbursement. Regardless of consent, schools are required to provide services. Once a parent has provided consent, then the school is required to obtain a release of information prior to communicating with the learner’s medicaid enrolled healthcare provider(s), community partner(s), area education agency, community provider(s), or school vendor to share and obtain necessary health information for reimbursement purposes.

What is the administrator's role when the school is obtaining medicaid reimbursement?

A school administrator must:

• Obtain a national provider identifier (NPI), including a written signature on the application if the district does not have one.
• Sign a cooperative agreement with Iowa Health and Human Services Medicaid Enterprise (HHS) once the NPI is obtained. 
• Set up an Iowa Medicaid Portal Application (IMPA) account to manage financial information and transactions.
• Set up communication between IMPA and free software provided by CMS (PCA Pro32) through an Electronic Data Interchange (EDI) account. (This is only for districts that submit their own claims instead of through a vendor).
• Manage monthly exclusion and reinstatement checks of all school providers engaged in medicaid reimbursement:
  • Ensure that Iowa Medicaid school-based providers are not excluded from providing medicaid reimbursement services using two sources to capture exclusions and reinstatements:
    • The federal list is provided on the HHS-OIG webpage.
    • The state’s list is linked from the Iowa Medicaid Program Integrity webpage. 
    • It is important that a district does not claim medicaid reimbursement for services provided by an excluded individual. 

What is the school nurse’s role when the school is obtaining medicaid reimbursement?

The school nurse creates and sustains relationships with learners and their families who have physical, mental, or behavioral health care needs.  

A school nurse must:

• Communicate within the relationship and provide an opportunity to discuss support for families insurance needs and an opportunity for school reimbursement of learner’s services provided by the school.  Important items to communicate:
  • The services are provided regardless if there is medicaid reimbursement.
  • A child is a child first before their disability or insurance payor.
  • Be prepared to answer questions regarding medicaid.  Information should include that granting permission:
    • Will not reduce the learner’s existing benefits.
    • Will not increase premiums or the family’s ability to seek other medicaid-covered health-related services outside the school setting.
    • Will not decrease the learner’s lifetime medicaid coverage.
    • Will not lead to the learner’s discontinuation of benefits.
    • Does not preclude the parent’s right to refuse or withdraw their consent at any time with no impact to providers or services their learner receives at school.
• Obtain Medicaid Consent from the learner’s parents to agree or refuse the school’s access to their learner’s state insurance plan.
  
  Remember:  A parent may agree or refuse to sign a Release of Information (ROI) regardless of the medicaid consent. The ROI is required to meet Family Education Privacy Rights Act (FERPA) allowing access, amendment and disclosure of records. Schools use the ROI when obtaining and sharing health information with the learner’s health care provider(s), community partner(s), Area Education Agency, or school vendor.
• Obtain health information required for medicaid reimbursement includes:
  • Using the signed ROI and ICD-10 Letter sent and completed by the learner’s medicaid enrolled health care provider. The ICD-10 Letter is strictly maintained in the school’s medicaid audit file. The letter contains protected information under the Health Insurance Portability and Accountability Act (HIPAA).
• Develop an Individualized Health Plan for ongoing health services, to include emergency planning for students with health service needs (stable or unstable).
   

• Document licensed provider services to meet licensure, policy and medicaid reimbursement requirements.  Nurse documentation must include (at a minimum):
  • Learner information,
  • Date,
  • Time,
  • Service,
  • Learner Response To Service,
  • Provider Initial/Signature
    
    Remember:  Documentation must include all nursing services provided by the school nurse and not solely for the school’s medicaid reimbursement or learner’s eligibility to meet licensure and policy requirements. For example: A learner has nursing services for 300 minutes a day and the school is only able to claim reimbursement for 100 minutes a day as stated in the learner’s Individualized Education Program (IEP).  The nurse would document for the whole 300 minutes.
• Document delegation of health services and tasks to other licensed nurses or unlicensed personnel to meet licensure, policy and medicaid requirements.
   

What is the delegated or contracted nurse's role when the school is obtaining medicaid reimbursement?

The school nurse is required to develop an IHP for ongoing health services, to include emergency planning for students with health service needs (stable or unstable). The delegated or contracted nurse works with and consents understanding of their role to implement delegated nursing tasks from the school nurse to a contracted or employed licensed practical nurse (LPN) or registered nurse (RN).

The delegated or contracted nurse must: 

• Document delegated services to meet the delegated licensed health professional’s licensure, policy and medicaid reimbursement requirements.  Delegated licensed health professional’s documentation must include (at a minimum):
  • Learner information,
  • Date,
  • Time,
  • Service,
  • Learner Response To Service,
  • Provider Initial/Signature

Remember: Documentation should reflect the entire time outlined in the IEP. For example, if an IEP states a student will receive 420 minutes of 1:1 nurse per day, there should be 420 minutes of documentation to support services that were in fact provided. 

What is the paraprofessional’s role in documenting medicaid services?

The paraprofessional works with the school nurse and consents understanding of their delegated role.

The paraprofessional must: 

• Document delegated services to meet the delegated licensed health professional’s licensure, policy and medicaid reimbursement requirements.  Paraprofessional documentation must include (at a minimum):
  • Learner information,
  • Date,
  • Time,
  • Service,
  • Learn Response To Service,
  • Provider Initial/Signature

Remember: Documentation should reflect the entire time outlined in the IEP. For example, if an IEP states a student will receive 420 minutes of 1:1 paraprofessional services per day, there should be 420 minutes of documentation to support services that were in fact provided. 

Setting up your audit file:

Education programs and partners that claim reimbursement for services are required to meet privacy laws and maintain an audit file for the reimbursement that is received. The 2019 United States Department of Health and Human Services and Department of Education Joint Guidance outlines responsibilities to meet compliance with privacy laws related to records.  Keep records from both Internal Medicaid Audit File and Learner Medicaid Audit File for 5 years from the medicaid claim submission, or 5 years from the last resubmission in a secure, centralized location for easy accessibility  during an  audit request. 

The following are items to consider when setting up your audit file (noninclusive list):

• Internal Medicaid Audit File: 
  • Signatory sheet includes printed names and signatures of any staff member or contracted service (upon hire) that is providing services to a learner that is eligible for Medicaid Reimbursement, throughout the learner’s life in a specific LEA, AEA, or Signatory Partnership.
  • OIG Exclusion Report:
    • A copy of monthly OIG checks for exclusions and reinstatements of all providers involved in medicaid reimbursable services. 
• Learners Medicaid Audit File:
  • Medicaid Consent must be signed by the parent/guardian before an education program or partner can claim medicaid reimbursement.  This consent must be signed before the Release of Information is obtained.
  • Release and Exchange of Information (ROI) must be signed by the parent/guardian identifying all entities’ records that will be requested or entities’ records that will be shared, before the request for records is obtained from a medicaid enrolled healthcare provider (including the ICD 10 letter) or before any educational record is exchanged with a vendor. 
  • ICD-10 Letter is sent to the learner’s medicaid enrolled healthcare provider after the education program or partner has received written medicaid consent and the ROI consent and must be returned with the necessary code(s) for reimbursement, the medicaid enrolled provider signature, and date. The ICD-10 letter provided by the department is utilized for reimbursement only.
  • A Copy of the Learner’s Eligible Program and Plan(s) (example: The learner’s finalized individualized education program [IEP], the delegation form, to include the individualized health plan [IHP], and/or behavior intervention plan [BIP] or Individualized Family Service Plan [IFSP]).
  • Monthly Attendance Record will be used to align the learner’s dates of attendance with service documentation that is identified in the eligible program or plan.
  • Service Documentation:
    • A copy of each service provider(s) documentation that is identified in the eligible learner’s program or plan.
  • A copy of the Google Map Mileage (shortest distance or most direct route from point A to B, roundtrip):
    • This is required when specialized transportation is an identified service in the eligible learner’s program or plan.
    • Example:  A learner has specialized transportation identified in the IEP and he rides the bus with other learners that do not have an IEP.  Direct mileage to and from the learner’s home to school and back can be submitted for medicaid reimbursement.  Mileage accumulated from the rest of the route can not be submitted for medicaid reimbursement.
  • A copy of the Medication Administration and Delegation form for a learner with a program and attached IHP identifies delegated health service tasks by licensed school nurses (RN) to other nurses (LPN or RN) or paraprofessionals.
  • A copy of Medicaid Remittance Advice is sent by the state (HHS) to the education provider explaining the payment decisions made on submitted claims for health services rendered to the learner, or Medicaid beneficiary, and is located electronically through the Iowa Medicaid Portal Application (IMPA).

How To Report Suspected Fraud, Abuse or Waste:

Iowa HHS ensures state and federal taxpayer dollars are spent appropriately on delivering quality services, necessary care, and preventing fraud, waste, and abuse within the Medicaid Programs.

If a school or individual suspects fraud, waste or abuse, they should contact Iowa HHS Medicaid Enterprise at 1-800-831-1349.

Formula Conversion From Minutes to Units for Medicaid Documentation

Specialized service providers, as identified in a learner’s IEP, complete documentation for the length of time as specified in the IEP.  The length of time is documented in minutes, and must be converted to units.  The number of units is used for submitting claims for medicaid reimbursement.  Reference this formula for an accurate and swift calculation.

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