April 5, 2011 Columns

Bottom Line: Medicaid and Supervision in Schools

Speech-language pathologists in the schools often have many questions related to the provision of speech-language pathology services to students who are eligible for Medicaid. Unlike the federal Medicare program, which is federally funded and administered, Medicaid regulations vary from state to state because each state administers and partly funds its Medicaid program.

In 1967 services provided to children under the Individuals with Disabilities Education Act (IDEA) were added to Medicaid through the Early and Periodic Screening and Detection and Intervention (EPSDT) program. As a result, schools may provide medically necessary speech-language pathology and audiology services to Medicaid-eligible children.

The response to a question in one state is not likely to apply in another state. Even within a state, the answer may change from month to month. This Q&A answers some questions about supervision by SLPs.

As with many Medicaid issues, clinicians should check with the state Medicaid office to obtain the rules for speech-language pathology assistants. SLPs also need to know what questions to ask—such as who can supervise, who can be supervised, what credentials are needed, how many supervisees a supervisor may have, what constitutes direct supervision, how much direct supervision is required, and whether services provided by an assistant or a student can be billed to Medicaid.

Answers will vary among states and may differ from ASHA guidelines; clinicians need to determine the most current ruling in their state. Check specific state regulations to determine the amount of supervision required and qualifications for supervisors of assistants. Always follow the most stringent applicable guideline.

Q: Why do ASHA requirements matter to states?

ASHA requirements matter because there is no federal regulation regarding Medicaid reimbursement; states should look to the professional organization's guidance.

Q: Who can supervise assistants and what credentials do supervisors need?

According to ASHA's position statement, the recommended minimum qualifications for supervisors are ASHA certification and a contractual relationship with the supervised clinician's employer. It is preferable for the supervisor to have an active interest and training in supervision, at least two years of post-certification experience, and a willingness to serve in this role (Position Statement on Medicaid Guidance for Speech-Language Pathology Services: Addressing the "Under the Direction of" Rule). This guidance is generally accepted among the state policies reviewed.

Q: Who can be supervised?

The ASHA position statement recommends that "supervisees (1) hold a standard state education license or certificate in speech-language disorders, (2) be a graduate student intern participating in an ASHA-accredited graduate program and receiving supervision in accordance with the supervision requirements of the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA), (3) be an undergraduate intern participating in an undergraduate program in communication disorders and receiving supervision equivalent to the supervision requirements of the CAA, or (4) be a speech-language pathology assistant." However, state requirements vary. Many states list the SLPA as a supervisee, but some states (e.g., Illinois) have another category of supervisee—the speech-language paraprofessional—in addition to a speech-language assistant. The ASHA standard excludes paraprofessionals other than SLPAs.

Q: How many individuals may an SLP supervise?

ASHA recommends that an SLP supervise no more than three speech-language pathology assistants. Colorado refers to ASHA's policy in terms of number of supervisees as well as direct supervision guideline percentages. In Oregon, the supervising speech therapist (the state's terminology) supervises no more than two full-time or three part-time speech-language pathology assistants. (In this instance, the state's guidance is more stringent than ASHA's.) The policy does not define part-time and does not state the caseload size of the supervising SLP.

ASHA's guidance on the "under the direction of" rule recommends that the supervisor's workload incorporate sufficient time to engage in the full range of roles and responsibilities needed to meet the needs of Medicaid-eligible students ethically and to maintain compliance with federal and state Medicaid requirements.

Q: What constitutes direct supervision?

ASHA's Code of Ethics requires certificate-holders to provide "appropriate supervision." ASHA's speech-language pathology assistant guidelines suggest a minimum of 30% weekly supervision time (at least 20% direct) for the first 90 workdays and 20% (at least 10% direct) after the initial work period. Direct supervision means on-site, in-view observation and guidance by an SLP while the assistant is performing an assigned activity. Ultimately, the SLP is professionally responsible for the client. Regardless of any minimum direct supervision guidelines or rules, SLPs must ensure they are sufficiently knowledgeable about the case, even if that requires more than the minimum amount of supervision time.

Q: Can schools bill Medicaid for services provided by an assistant or student?

Rules vary among the states. In Wisconsin, for example, evaluations by assistants are not reimbursable, but other services are. Wisconsin allows Medicaid billing for evaluations by students during their practicum; however, the student must be under the direct, immediate, on-premises supervision of an ASHA- and Medicaid-certified SLP responsible for recipient care.

In New York, speech-language services may not be billed unless they are provided by a licensed SLP or provided under the direction of a qualified SLP. Any individuals working under the direction of a qualified SLP must be able to contact the supervising SLP directly as needed during treatment.

Q: Where can I find answers to state-specific questions?

Find links to individual state Medicaid agencies at the American Public Human Services Association website.

The Centers for Medicare and Medicaid Services offers links to state Medicaid program websites [PDF] and to regional offices. The state Medicaid office should always be contacted first.The National Association of State Boards of Education identifies leadership in each state. 

Laurie Alban Havens, MA, CCC-SLP, director of private health plans and Medicaid advocacy, can be reached at lalbanhavens@asha.org.

cite as: Havens, L. A. (2011, April 05). Bottom Line: Medicaid and Supervision in Schools . The ASHA Leader.


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