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Special Services Home > Medicaid > Questions and Answers

Maine Care Questions submitted by MADSEC August 3, 2010

General Questions

  1. Will the schools be receiving a guidance manual for billing from DHHS/DOE?  If so when?

We hope to have a manual out before the November 15th.  We had hoped to get it out before now, but because of the MIHMS go live, we have been a little busy.

  1. If schools bill for a Maine Care eligible student and that has private insurance, how will this be handled?

MaineCare is required to bill any available third party insurance.  This is not a change.  It is important that schools let parents know about that when they are asking for families to consent to the school billing MaineCare for services to their child.

  1. If the student does have private insurance and Maine Care pursues the private insurance, how will the schools be able to assure that this has no impact on the family’s private insurance, as IDEA requires? 

Again, this is a requirement of Medicaid.  The school needs to be sure that families understand that their private insurance will be billed when asking for consent to bill MaineCare.

  1. Why do school board members need to be listed on the provider application?  What is the purpose?  This will cause extra work for schools as school board members change at least yearly and at times more often. 

Listing the governing board on the provider enrollment form is a federal requirement.

  1. If an auditor reviews the provider’s documentation, what will they be looking for to document medical necessity under each section?

For OT, PT and speech therapy, the documentation will simply be the recommendation of the practitioner of the healing arts.  They are licensed to make the determination of the need for service and that will suffice.  For Sections 28 and 65, the documentation should include an assessment of the child, including a determination of the child’s disability (medical) and the service or services that are needed to address that disability.

  1. How should the provider’s usual and customary charge be determined?  Does this need to be determined for each section?

The reimbursement rates for each service are published in the applicable section of the MaineCare Benefits Manual.

  1. There is a October 2008 settlement of a Maine District Court Case (K.S., on behalf of minor child, T.S., et al., vs. Brenda Harvey, Commissioner, Maine Department of Health & Human Services). Since schools as providers will now be billing fee for service will this case have any impact on schools as it did on CDS?

No.

Certified Seed

  1. Why the change is the position that can certify seed?  Shouldn’t the Superintendent be the certifying signature as Title 20A, 1055 says that one of the responsibilities of a Superintendent is “Keeping all financial records and accounts”.  There is nothing in Title 20A that allows Special Education Directors to commit funds. 

It is the Superintendents who are signing the certified seed letters.

Section 28, Rehabilitative and Community Services for Children with Cognitive Impairments and Functional Limitations

  1. Are the schools as a provider able to bill for ages 5 to 21 under this section?

Yes.

  1. This section requires a specific Comprehensive assessment format, will training be available on this?

The “comprehensive assessment” found on the Children’s Behavioral Health Services (CBHS) web site is required only for community based Section 28 services and not for school based services.  However, schools should review the assessment form on the web site to assure that they are appropriately assessing children for this service.  Based on their assessment, schools establish eligibility for the service and define the appropriate services in order to develop a treatment plan.  This information is then sent to CBHS for approval and prior authorization. 

  1. Once the assessment has been completed, which includes a family assessment; will schools as a provider be required to address all the needs identified by the assessment?

See above.

  1. How will schools need to document the required family participation for this section?

Family participation should be addressed in the treatment plan.

  1. This section requires a discharge plan and review every 90 days, how will schools as providers, document this?

Schools must define criteria for discharge for each student and that should be reviewed when schools do their quarterly reviews.  This information should be maintained in the student’s file.

  1. The treatment plan for this section requires the provider to document the methods used for treatment.  Methods (types of interventions) are not to be written into an Individual Education Plan.

There is an addendum that included the Plan of Care and required the Short term goals and objectives with measures. The addendum entitled “MaineCare Documentation” can be found at: http://www.maine.gov/education/medicaid/mainecaredocumentationform2010.pdf

  1. The section requires the provider to provide the member with a copy of the initial and reviewed ITP within 10 days of signing.  Will this be necessary if the IEP is used as the ITP as Maine Special Education Regulations is within 21 days of the IEP meeting?

The treatment plan is separate from the IEP and providers need to comply with all of the requirements in Section 28 if they plan to seek reimbursement for that service.  Keep in mind that the majority of Section 28 providers will likely not be public schools but private special purpose schools and private preschool providers.

  1. Under 28-04, schools are not included as a location for this service.  Can this service be provided in a school setting?

Schools are considered “community” based settings and as such are included in the locations where section 28 services can be provided.

  1. Who and how is it determined whether a crisis plan/safety plan is applicable?  If it is applicable how is this documented?

We expect to see a crisis/safety plan in the file if section 28 services are provided.

  1. 28.01-16, is every school as a provider going to need to go through a utilization review for this section, yearly?

The “utilization review” for school based services will be the review and approval of the services included in the child’s IEP for the period covered by the IEP. 

  1. What are the requirements for BHP certification under Section 28, the 50 hour course or the 28 hour course?

For Section 28 school based services, the 28 hour course is required.

  1. Supervisors for BHPs, does the requirement of 4hrs per month mean for each BHP that you employ?

Yes.

Section 65, Behavioral Health Services

  1. Will the language in the rule be changed to reflect the understanding between DOE and DHHS that a BHP in Day treatment for the schools needs to have 90 credit hours plus the 28 hour BHP certification?

That clarification will be made in the rule.

  1. Why have schools been limited to billing under only 2 sections of Section 65?

Schools are limited to two sections because schools are not licensed mental health agencies and the two sections under which schools can bill are the only sections that are appropriate for them to provide.  Mental health agencies have extensive requirements around training, supervision and record keeping that do not apply to schools.

  1. Since schools can only bill for Day Treatment or evaluations and a student  in order to qualify for day treatment 65.06-13-A “must need treatment that is more intensive and frequent than Outpatient and less intense than hospitalization” it appears schools will not be able to bill for a student to have only social work services and not day treatment?   Is this correct? 

Yes.

  1. Under the repealed Section 104 schools billed for social work services, under the new Section 65 this appears to be Outpatient services, is there a reason schools are not able to bill under Outpatient services?

Section 104, which carried with it a bundled payment, was designed to pay for any service that a child may need while the child was at school.  With the repeal of that section, schools must bill separately for each service a student receives.  The school must be an eligible provider of the service and the student must qualify for the service.  Social work services are currently only billable within the context of a day treatment program.

  1. Will schools need to do a Vineland on all students for them to be eligible for Day Treatment services?

No.  The rule will be revised to reflect other appropriate assessments for students receiving day treatment services.

  1. Are services for Birth to 5 year olds included in this section?  Can CDS (Child Developmental Services) be a provider under this section?

Yes.

  1. Can Social Skills Training be billed under this section?

The rule indicates that “Behavioral Health Day Treatment Services are structured therapeutic services designed to improve a member’s functioning in daily living and community living.”  This would seem to indicate that social skills training would be an appropriate part of a day treatment program.

  1. What needs to be included in a comprehensive assessment under Section 65, Day treatment?

Each student should have a comprehensive psycho-social assessment indicating the student’s diagnosis and need for the treatment provided.  While not specifically listed at this time, a CALOCUS would be very appropriate in documenting the student’s need for this level of care.

  1. Why are certified 093s, School Psychological Services Providers, not included as evaluators under Neurobehavioral Status Exam/Psychological Testing? 

Because School Psychological Services Providers are not qualified to do neuropsychological testing.

  1. If a student requires the services of a BHP for behavioral and is receiving speech, OT,or PT at the same time can both services be billed for? 

Yes.

Section 109, Speech and Hearing Services

  1. DOE 293 certified clinicians are listed as a qualified provider, what services are they able to provide in this section?

Yes.

  1. Does a DOE 293 certified clinician need to be supervised?  If so by whom?

No.

  1. Is CDS, Child Development Services, considered a provider under this section?

If a CDS site employs a speech pathologist, they could certainly provide this service, but the therapist would need to be enrolled as a rendering provider.

  1. It appears that this section requires a copy of the discharge summary must be sent to the referring physician, if the referral is by a practitioner of the healing arts does a discharge plan still need to go to the physician?

Section 109.09-1 H states “A discharge summary with a copy sent to the referring practitioner of the healing arts.”

  1. Will every eligible student under this section require a discharge summary?  What is included in a discharge summary?

The rule does indicate that there should be a discharge summary in every file, but if a child is continuing in the service, clearly there would not be a discharge summary. The discharge summary is required only if a child is being discharged from the service. 

  1. Do you need to do a re-evaluation under this section every 6 months?  Does a re-evaluation need to include standardized evaluations?  Will the plan need to be updated every 6 months?

The six month re-evaluation requirement only applies to adults age 21 and over.

  1. Does this section require prior authorization as there is a procedure to request prior authorization?

No.

  1. What are the diagnosis that should be listed on the record under this section?

The diagnosis (ICD-9 code) needs to be listed on the billing form but not necessarily of the treatment plan, though the reason for the service should.

  1. Can you bill for co-therapy under this section?

No.

  1. If students receive private services under this section in the community, will they also be able to receive services in the school setting.

If that level of service is appropriate for a child, yes.

  1. Does the plan require short term objectives?

Yes.

Section 68, Occupational Therapy

  1. Is CDS, Child Development Services, considered a provider under this section?

If a CDS site employs an occupational therapist, they could certainly provide this service, but the therapist would need to be enrolled as a rendering provider.

  1. Will providers be able to bill for group OT services?

Yes

  1. Will schools be required to have a plan to coordinate with other health agencies?

Not specifically, though it would certainly be considered best practice for a school based OT to coordinate services with a community based OT if the child was receiving services in both places.

  1. What are the types of OT that should be listed on the record under this section?

I don’t know what this question means.

  1. Can you bill for co-therapy under this section?

No.

  1. If students receive private services under this section in the community, will they also be able to receive services in the school setting.

If that level of service is appropriate for a child, yes.

  1. Does the plan require short term objectives?

Yes.


Section 85, Physical Therapy

  1. Is CDS, Child Development Services, considered a provider under this section?

If a CDS site employs a physical therapist, they could certainly provide this service, but the therapist would need to be enrolled as a rendering provider.

  1. Will providers be able to bill for group PT services?

Yes.

  1. Will schools be required to have a plan to coordinate with other health agencies?

Not specifically, though it would certainly be considered best practice for a school based PT to coordinate services with a community based PT if the child was receiving services in both places.

  1. What are the types of PT that should be listed on the record under this section?

I don’t know what this question means.

  1. Can you bill for co-therapy under this section?

No.

  1. If students receive private services under this section in the community, will they also be able to receive services in the school setting.

If that level of service is appropriate for a child, yes.

  1. Does the plan require short term objectives?

Yes.

Individual Plans

  1. If the IEP is going to be able to be used as the treatment plan will the Maine Care sections be changed to reflect this?

The IEP is not the treatment plan.  A separate plan must exist for all of the MaineCare reimbursable services.

  1. Will DHHS Maine Care review the materials that are being put together by the DOE as addendum to the IEP so that the providers are assured that it will meet the requirements of an audit by Maine Care or the federal auditors?

Yes.

  1. In Section 2 of an IEP, we currently put one of the 13 disability categories in Special Education Law, will this be considered a diagnosis or will there be something else we will need to put in this section to meet Maine Care rules?

A medical diagnosis will be required in order to bill MaineCare for a service provided but the diagnosis need not appear on the IEP or in the treatment plan.

  1. Does the treatment plan need to be signed and by whom?

The treatment plan needs to be signed by the practitioner of the healing arts who develops the plan and by the parent(s).

  1. Does the position of the person delivering the service need to be listed on the plan or the actual name of the person delivering the service?

The position is adequate.