School districts may submit claims for nursing following these guidelines:

1. The school district may bill Medicaid only for nursing services on the student's Individualized Education Program (IEP). Inclusion on the IEP is a requirement and these services may be included anywhere you determine more appropriate on the IEP, e.g., Medical Alerts, Related Services, Other Support Services.

2. Reimbursable nursing care may be provided, in accordance with the Nurse Practice Act, by Registered Nurses or Licensed Practical Nurses employed by or under contract to the school district or a Home Health Agency. [See Appendix C-1 and C-2.]

3. Home Health Agencies which contract with school districts to provide nursing services must also sign both provider agreements and assignment forms before the school district bills for nursing services. [See Appendix C-1 and C-2.]

4. Nurses employed as independent contractors by the school district must also sign both provider agreements and assignment forms before the school district bills for nursing services. [See Appendix C-1 and C-2.]

5. School districts may submit claims for the following nursing services: [Sample detailed list of services are included in this Appendix on Pg. B-2 and B-3.]

a. dispensing medications,

b. medical treatment and procedures,

c. health assessments, and

d. observing a Medicaid treatment or procedure, self-administered

6. Medical documentation of nursing services must comply with Medicaid record keeping requirements and include all of the following:

a. nursing services indicated on the IEP is a requirement,

b. nursing plan of care procedures maintained on an individualized health care plan where appropriate

(Appendix C),

c. health history,

d. medication log where appropriate (Appendix C),

e. doctor’s orders: orders are required when the student enters school for the first time during the school

year. New orders are required when there are any significant changes in services or the student's

condition and skilled nursing services are required,

f. written protocols for each procedure,

g. skills checklist approved and signed by the parent or guardian (Appendix C), and

h. nursing services reimbursement record (Appendix C).

NOTE: Only school districts that can support the delivery of nursing services using the above guidelines should plan

to bill Medicaid.

School district medical staff is encouraged to secure their own written protocols and skills checklists. NYSDOH has been in contact with the Connecticut State Education Department, Division of Special Education (contact person -Nadine Schwab) and recommends their publication Serving Children with Special Needs. This handbook is an excellent reference for written protocols for medical procedures. Copies may be obtained by contacting: Public Information, Connecticut State Education Department, State Office Building Room 304, P.O. Box 2219, Hartford, Connecticut 06145-2219 or calling (203) 566-5677. An example of a skills checklist (Appendix C, Pg. 7) is also provided for your perusal. We obtained this checklist from a $35.00 publication entitled Guidelines for Care from Project School Care, The Children's Hospital, Boston (1989). The contact person for Project School Care is Stephanie Porter, R.N. You or your colleagues may be aware of other publications and worksheets that will fulfill the documentation requirements. We request that you obtain these or other suitable publications that will provide written guidelines. Information and telephone numbers regarding this handbook are attached (Appendix G).

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Medicaid Reimbursement for Nursing Services

Provided to MA-Eligible Students with Disabilities

Definition:

Medicaid reimbursable nursing services are health care activities provided pursuant to a student's Individualized Education Program (IEP). Health care activities include dispensing medications, medical treatments and procedures, and health assessments.

Medical treatments and procedures include, but are not limited to:

Feeding: preparing nourishment

gastrostomy feeding, stoma care and dressing change

total parenteral nutrition (IV) feeding and site care nasogastric tube feeding/tube care

Ostomies: Ostomy Care

Ostomy irrigation

Respiratory: assisting postural drainage

percussion

oral suctioning

nasal suctioning

nebulizer administration

initiation and monitoring of oxygen: continuous/intermittent nares and oral care

tracheostomy care and suctioning

tracheostomy stoma care and dressing change

tracheostomy tube change/reinsertion

Catheterization: inserting a Foley catheter
monitoring intake/output
external catheter assistance
sterile intermittent catheterization
reinserting indwelling urinary catheter
clean intermittent catheterization
external care of indwelling catheter
catheter irrigation for patency

Medications: giving oral medication

giving medications via gastrostomy, nasogastric tube or catheter

giving medications via inhaler or nebulizer

administering non-emergency intramusclular (IM) medications

insulin injections (sub cutaneous)

giving intravenous (IV) medication

assessing for signs of hyper/hypoglycemia

Spirometer administration

Medical Support System:

monitoring intravenous fluids

heparin (IV) lock care and reinsertion

monitoring shunt functioning (hydrocephalus)

central line care including dressing change an emergency intervention

insulin pump care

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emergency care of student, i.e., seizure, choking, respiratory arrest, cardiac arrest,

asthma attack, anaphyastic (allergic reaction)

Specimen Collecting:

blood sampling
blood glucose monitoring
urine sampling
urine glucose monitoring
stool sampling

Other Nursing Procedures:

taking vital signs; height and weight

daily health assessments; including heart, lungs

abdominal auscultation; inspection of eyes, ears, nose, mouth, throat, and head

palpation of neck, abdomen

respiration, blood pressure

applying sterile dressing

prevention and care of decubitus ulcers

cool and warm applications

heat applications and skin monitoring

applying clean dressing

special skin care assessment; tracheostomy stoma,

gastrostomy stoma, central line insertion site and IV insertion site cast care

caring of incontinent student

bowel and bladder training programs

equipment care and maintenance

documenting services

Health Assessment:

The collection, documentation and analysis of information or data about a student's

health situation leading to the development and initiation of an individualized health care plan to

determine the student's state of health, patterns of functioning and need for health services, counseling

and education. This includes assessing on an as-needed basis, the student's current health status,

reviewing medical diagnoses, treatments, or orders and requesting a change in a physician’s order if

necessary, reviewing nursing diagnoses and collaborative health problems, assessing routine and

emergency health care needs, confirming health procedures, equipment and supplies.

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The questions and answers below are to provide clarification to the requirements for billing Medicaid for nursing services provided to students with disabilities. Following are the most frequently asked questions and answers:

1. WHAT MUST BE SPECIFIED ON THE STUDENT’S IEP?

The phrase “Skilled Nursing Services,” “Intermittent Nursing Services,” etc. does have to be listed on the IEP (e.g. Medical Alerts, Related Services, or Other Support Services).

2. MUST THE SPECIFIC NURSING SERVICE OR MEDICATION BE DETAILED ON THE IEP?

No, the IEP must recommend intermittent nursing services. The actual procedure need not be detailed in order to maintain the confidentiality of the student’s treatment plan and medical records maintained by the school. You should not indicate the medication on the IEP.

3. WHAT IS AN INDIVIDUALIZED HEALTH CARE PLAN (IHCP)?

The IHCP consists of the demographics of the student followed by the medical information, and a chart, which is used to document specific interventions. (Appendix C, Pg. C-8)

4. WHO WRITES THE IHCP?

Generally, the school nurse is responsible for the implementation of the IHCP.

5. MUST WE GIVE THE BILLING CLERK (DATA ENTRY STAFF) THE

INDIVIDUALIZED HEALTH CARE PLAN IN ORDER TO BILL MEDICAID?

No, the information on that form is confidential and should remain with the student’s other confidential medical records.

6. WHAT DOCUMENTS MUST BE ON FILE WITH THE IEP AND IHCP?

No documentation is to be kept with the IEP; doing so could violate confidentiality requirements. Although SED and DOH originally called for the IHCP to be attached to the IEP, the requirement was changed.

Documents on file with the IHCP:

a. Health history/Health notes (there is no requirement for the number of notes),

b. Medication log,

c. Doctors orders; orders are required when the student enters school for the first time each

school year and new orders are required when there are any significant changes in the

student’s condition or procedure,

d. Written protocols for each procedure, and

e. Skills checklist approved and signed by the parent/guardian, only when necessary.

7. WHO MAINTAINS THE IHCP AND DATA SHEETS?

The nurse who provides the services is the one who maintains the IHCP and data sheets. S/he has the necessary information for the completion of the forms.

8. WHO WRITES THE IHCP FOR STUDENTS IN BOCES CLASSES?

The nurse who cares for the student writes the IHCP.

9. WHAT DOES “15 MINUTE INCREMENT” MEAN?

Basically what it says. Some services, such as tube feeding, might take an hour and would be considered as four 15-minute services. There are no services which take less than 15 minutes (e.g., dispensing medication – which can include the time for the nurse to get out the medication and for the student to take medication, the time needed for the nurse to check for adverse reactions, and the time needed for the nurse to log the service, etc., - should equal as close to the 15 minute increment as possible). Do not bill Medicaid for any service which takes decidedly less than 15 minutes.

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10. ARE MANDATED HEALTH SERVICES (E.G., HEIGHT, WEIGHT, VISION SCREENING, ETC.)

MEDICAID REIMBURSABLE?

Routine mandated health care services are not reimbursed except as they apply to the special education related conditions specified on the IHCP. The IEP must say “nursing services” and the rest of the guidelines are followed (e.g., monitoring height and weight for a student with an eating disorder).

11. WHERE SHOULD PROTOCOLS, CHECKLISTS, ETC., BE KEPT?

In the office of the school nurse who is providing the nursing services indicated on the IEP.

12. WHY MUST THE PARENT SIGN THE SKILLS CHECKLIST?

The skills checklist is meant to be a communication tool between the school and the parent/guardian. Many times the parent/guardian has been doing a specific procedure for a number of years before it became necessary for the school to do it, and the skills checklist is a way for the school and parent/guardian to come to a mutual understanding of what is going to occur in the school building. Also, there are times when the parent/guardian has done nothing relative to the specific procedure, and the skills checklist can be used as a teaching/learning tool for the parent.

13. MUST THE CSE CONVENE EACH TIME A CHANGE IS MADE TO THE IHCP?

No – now that the SED has indicated the IHCP is not to be attached to the IEP, it is not considered part of the IEP and therefore does not need CSE action for a change.

14. IS TRANSPORTATION REIMBURSABLE FOR SKILLED NURSING SERVICES?

Yes, transportation is reimbursable for any Medicaid eligible service. Transportation must be indicated on the IEP with a notation similar to “Transportation provided in accordance with official district policy.” A list of students transported in accordance with district policy must be maintained. If daily logs reflecting the actual provision of transportation are maintained, they should be retained for documentation.

15. MAY A SCHOOL DISTRICT BILL FOR DISPENSING MEDICATIONS?

Yes, if the need to dispense the medication is indicated on the IEP (“nursing service”, “nursing services as needed,” or “intermittent nursing service”) and only if the medication is dispensed by an RN (or LPN if within the scope of the Nurse Practice Act) or the school nurse. Prior to July 1, 1996, there must be an indication somewhere on the IEP, if only in the comment section, that a service is being delivered that requires skilled nursing (RN, LPN). July 1, 1996 and after, the IEP must indicate “skilled nursing service,” “nursing services,” “nursing services as needed,” or “intermittent nursing service.” Any more specificity is not necessary, required, or recommended.

16. MAY A SCHOOL DISTRICT BILL MEDICAID FOR MEDICATIONS DISPENSED BY AN AIDE?

No, only the administration of medication by a Registered Nurse or an LPN, in accordance with the Nurse Practice Act, is billable under the SSHSP.

17. MAY A SCHOOL DISTRICT BILL FOR EMERGENCY FIRST AID?

No. You may only bill for skilled nursing services that are required for a student with a disability to benefit from special education. Do not bill for routine first aid.

Further information is available within the SED Thomas Neveldine memo dated August 1995 – Updates and clarification on the current Medicaid payment process and implementation of procedures for Medicaid reimbursement for School Supportive Health Services.

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