School Supportive Health Services Program (SSHSP) and Preschool
Supportive Health Services Program (PSHSP)
The
SSHSP and the PSHSP were developed jointly by the New York State Department of
Education (SED) and the New York State Department of Health (DOH) to assist
school districts, §4201 schools and counties and in obtaining Medicaid
reimbursement for certain diagnostic and health support services provided to
students with, or suspected of having disabilities. SSHSP applies to the 5-21 year old population and PSHSP applies
to the 3-4 year old population pursuant to §4410 of the Education Law.
Traditionally,
all costs provided by educational institutions have been funded through
educational resources. In 1988, Section
1903 of subdivision (c), of the Social
Security Act (SSA), added by §411(k)(13)(A) of the Medicare Catastrophic Act of
1988 (PL 100-360), clarified Congressional intent by stating that nothing in
Title XIX of the SSA shall preclude Medicaid coverage of services included in a
disabled student's Individualized Education Program (IEP). This paved the way to supplement already
allocated state and local educational monies marked for such services with
Federal Medicaid dollars without impacting the State Medicaid Budget. New York State implemented the Federal Law
in 1989 by amending Section 368 (d) and (e) of Chapter 558 of the Social
Services Laws to authorize State Department of Social Services (SDSS) to make
payment of Federal Medicaid Assistance (MA) funds for PSHSP and SSHSP services.
In order to bill for Medicaid eligible services and
evaluations, the following conditions must be met:
·
The district/county must be an
approved Medicaid provider,
·
The student must be eligible for
Medicaid,
·
The district/county must incur a
cost,
·
The service/evaluation can not be
paid for (either partially or in full) by Federal funds, and
·
Provider Agreements and Statement
of Reassignments must be completed by outside contractors other than BOCES.
Services
(physical therapy, occupational therapy, speech pathology/therapy,
psychological counseling, skilled nursing services), evaluations (basic and
comprehensive psychological evaluations, medical evaluations, medical
specialist evaluations, audiological evaluations) and special transportation
must be provided by qualified professionals either under contract with, or
employed by, school districts/§4201 schools/county agencies. Furthermore, the school districts/§4201
schools/counties must be enrolled as Medicaid providers in order to bill
Medicaid.
In
addition, school districts/§4201 schools/counties are able to claim Medicaid
reimbursement for five additional services identified as Targeted Case Management
(TCM).
TCM services are not reimbursable for preschool students. TCM is a comprehensive service that includes
coordinating medical and non-medical procedures for the student. TCM is a Medicaid service that is
reimbursable through the SSHSP. TCM may
be claimed for students referred to Special Education or identified as disabled
through the Individuals with Disabilities Education Act.
To
facilitate the administration of the SSHSP/PSHSP program, DOH evaluated the
costs of providing these services to students with disabilities and developed a
monthly fee for each service, with the exception of evaluations and special
transportation. Evaluation fees are set
per evaluation. Special transportation is reimbursed on a per diem basis,
representing a round trip cost.
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Eligibility and Confidentiality.
School districts/§4201 schools/county agencies
who elect to participate in SED's billing process receive their listing of
Medicaid eligible students through a file matching process handled by Central
New York Regional Information Center (CNYRIC).
This identified special education population is transmitted to CNYRIC
where a file match is performed against DOH's file of MA eligible
students.
A
list of Medicaid eligible recipients, along with a Non-Matching report that
includes a near-match/multiple match/match not found list, is created for the
school districts/§4201 schools/counties. School Districts/§4201 schools/county
agencies and SED have signed Confidentiality Agreements with DOH to ensure that
the confidentiality of the MA files is maintained.
SED's
confidentiality requirements mandate parental consent is given to the school
districts/§4201 schools/county agencies before the identity of a special
education student can be released. Since DOH cannot have access to educational
data unless parental consent is provided, the MA application and
recertification forms were amended to include a section in the signature area
providing this consent.
It is
the responsibility of the school districts/§4201 schools/county agencies to
obtain the parental consent for students who receive Supplemental Security
Income (SSI). These students receive
their MA eligibility automatically by virtue of their receipt of SSI and, as a
result, their parents never sign an MA application/recertification form.
The
following is the Department of Health policy for informing service providers
who are working for a Medicaid provider (school district) that a student is a
Medicaid recipient:
Schools and Preschools may disclose Medicaid eligibility
information to their health related services professional staff and contract
providers when it is for the purpose of providing services directly connecting
with or used only for purposes of the administration of the Medicaid State Plan
for School Supportive and Preschool Supportive Health Services.
Eligibility information provided school
districts/§4201 schools/county agencies, therefore, may be shared with staff
and other individuals associated with the agency that must provide the
documentation required to claim MA reimbursement.
Once
the listing of Medicaid eligible students is provided to the school
districts/§4201 schools/county agencies, the related health supportive services
and TCM services provided to these students must be identified. The MA provider may claim Medicaid services
at the appropriate fee once documentation exists establishing that services
were provided in conjunction with Federal and State policies.
For
Preschool Agencies who elect not to use the SED billing process the preschool
fees and supporting documentation remain the same. However, the billing process is determined by the provider and,
therefore, becomes the provider's total responsibility to develop a paper claim
and submit the claim directly to Computer Science Corporation (CSC) manually.
Payment
by CSC to school districts and counties represents only the Federal share of
the MA claim. The State and local match
is made through the use of State and local educational funding sources.
NOTE: Computer Science
Corporation (CSC) is the agency responsible for operating the Electronic
Medicaid System (eMedNY) in New York State.
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The
purpose of this section is to remind schools of the federal requirements
relating to the use of public insurance funds for students with
disabilities. Certain students with
disabilities in New York State have access to public insurance. Federal
regulations establish that a public agency may use a student’s Medicaid or
other public insurance benefits programs in which a student participates to
provide or pay for special education programs and services with the following
limitations:
School
districts/§4201 schools /counties:
1)
May
not require parents to sign up for or enroll in public insurance programs in
order for their child to receive a free appropriate public education (FAPE)
under Part B of the Individuals with Disabilities Education Act (IDEA);
2)
May
not require parents to incur an out-of-pocket expense such as the payment of a
deductible or co-pay amount incurred in filing a claim for services, but may
pay the cost that the parent otherwise would be required to pay; and
3)
May
not use a child’s benefits under a public insurance program if that use would:
a)
Decrease
available lifetime coverage or any other insured benefit;
b)
Result
in the family paying for services that would otherwise be covered by the public
insurance program and that are required for the child outside of the time the
child is in school;
c)
Increase
premiums or lead to the discontinuation of insurance; or
d)
Risk
loss of eligibility for home and community-based waivers, based on aggregate
health-related expenditures.
The use of Medicaid
funds to provide or pay for special education services through New York State’s
School/Preschool Supportive Health Services Program will not require
parents to incur an out-of pocket expense; will not decrease a child’s Medicaid
benefits or available lifetime coverage; and will not increase premiums or lead
to the discontinuation of insurance or a student’s eligibility for home and
community-based waivers.
Note: This information has been previously issued
in a letter from Robert Scalise dated July 23, 2001.
If you have any
questions regarding the above requirements, please contact Robert Scalise
either at 518-474-3227 or rscalise@mail.nysed.gov.
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