Issue #11-01

This Medicaid Alert serves as notification that school districts and §4201 schools which were previously eligible for Medicaid reimbursement for Targeted Case Management (TCM) SSHSP services may resume Medicaid billing for TCM services provided on or before June 30, 2010. SSHSP TCM services provided on or after July 1, 2010 are not eligible for Medicaid reimbursement as the New York State Plan Amendment (SPA) #96-41 for the Preschool/School Supportive Health Services Program (SSHSP) TCM was rescinded effective July 1, 2010.

Students eligible for TCM reimbursement include Medicaid eligible, school-age students referred to the Committee on Special Education (CSE) for an eligibility determination and students who have been classified as disabled by the CSE and for whom an Individualized Education Program (IEP) has been developed. TCM is not reimbursable for preschool students.

Medicaid may be billed for five distinct TCM procedures:

• Initial Evaluation Reviews (Rate code 5491)
• Annual IEP Reviews (Rate code 5492)
• Triennial/Re-evaluation IEP Reviews (Rate code 5493)
• Amended/Requested IEP Reviews (Rate code 5494)
• Ongoing Service Coordination (Rate code 5495)

The four reviews may only be claimed on or after the date the IEP review was completed. TCM services provided on or before June 30, 2010 must follow previously established documentation requirements to be Medicaid reimbursable. These requirements are summarized in the attached document, SSHSP Targeted Case Management Billing Guidance.

If you have any questions or comments regarding this alert, please contact your local Regional Information Center representative or the NYS Education Department, Medicaid-in-Education Unit at medined@nysed.gov.