Introduction to Medicaid

Federal Medicaid Requirements
State Medicaid Requirements
Medicaid in the School Systems
Documentation Guidelines

Medicaid is a jointly funded program between the federal and state governments to assist states in providing medical care to low-income individuals and those who are categorized as medically needy. Speech-language pathology and audiology are recognized as covered services under the Medicaid program. The federal government establishes broad guidelines and each state then administers its own program and establishes its own income eligibility standards; type, amount, duration and scope of services covered; and payment rates with review and approval by the federal Centers for Medicare and Medicaid Services (CMS).

Federal Medicaid Requirements

Speech, Language, and Hearing Benefits

Although states are provided great flexibility in offering Medicaid services to their constituents, they are required to do so under broad federal guidelines. Most states cover speech-language pathology and audiology services in some manner; however, they are not mandated by federal law to so do, with the exception of providing services to children under the age of 21. CMS, the federal agency responsible for interpreting and administering federal Medicaid laws, provides guidance to states through regulations, transmittals, and letters to states' directors.

Federal law requires that children under the age of 21 be provided services including audiology and speech-language pathology on a comprehensive basis through the Early and Periodic Screening, Diagnostic and Treatment Program (EPSDT). As part of the comprehensive developmental history, speech-language pathology and audiology services are included for

the identification of children with speech or language impairments,
diagnosis and appraisal of specific speech or language impairments,
referral for medical or other professional attention necessary for rehabilitation of speech or language impairment,
provision of speech and language services, and
counseling and guidance of parents, children, and teachers.

Additionally, EPSDT requires that any devices such as hearing aids and augmentative and alternative communication devices be covered when medically necessary. Federal Medicaid EPSDT specifically states that, at a minimum, the program include "diagnosis and treatment for defects of hearing, including hearing aids." Although ESPDT services are required to be provided, ASHA has learned that states have used the waiver program to exempt provision of all but core medical services.

Requirements for Speech-Language Pathology and Audiology Services

Federal Medicaid regulations require that a patient receive a referral for audiology or speech-language pathology services from a physician or other licensed practitioner of the healing arts acting within their scope of practice. Code of Federal Regulations, Title 42, section 440.110[c]

CMS requires that audiologists and speech-language pathologists participating in the Medicaid program meet specific requirements in order to qualify for payment. The regulations outlining provider qualifications for speech-language pathology and audiology services can be found in Chapter 42 of the Code of Federal Regulations, 440.110. The regulations specify that services, if offered by the state, will be covered if the providers meet the following qualifications:

Audiologist Requirements

A qualified audiologist means an individual with a master's or doctoral degree in audiology that maintains documentation to demonstrate that he or she meets one of the following conditions:

The State in which the individual furnishes audiology services meets or exceeds State licensure requirements and the individual is licensed by the State as an audiologist to furnish audiology services.
In the case of an individual who furnishes audiology services in a State that does not license audiologists, or an individual exempted from State licensure based on practice in a specific institution or setting, the individual must meet one of the following conditions:
- Have a Certificate of Clinical Competence in Audiology granted by the American Speech-Language-Hearing Association.
- Have successfully completed a minimum of 350 clock-hours of supervised clinical practicum (or is in the process of accumulating that supervised clinical experience under the supervision of a qualified master or doctoral-level audiologist); performed at least 9 months of full-time audiology services under the supervision of a qualified master or doctoral-level audiologist after obtaining a master's or doctoral degree in audiology, or a related field; and successfully completed a national examination in audiology approved by the Secretary.

Speech-Language Pathologist Requirements

A speech-language pathologist must meet one of the following conditions:

Has a Certificate of Clinical Competence (CCC) from ASHA;
Has completed the equivalent educational requirements and work experience necessary for the certificate; or
Has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

Services Provided "Under the Direction Of"

Some guidance on supervision has been provided by the Centers for Medicare and Medicaid Services (CMS), but the issue still remains unclear. Federal Medicaid regulations state, "Services for individuals with speech, hearing, and language disorders" means diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech pathologist or audiologist for which a patient is referred by a physician (emphasis added; Code of Federal Regulations, Title 42, section 440.110[c] ).

Federal guidance is absent for determining how persons providing services "under the direction of" qualified personnel should be supervised. CMS offered an interpretation of "under the direction" within the context of school-based services in 1992, noting that the "direction" requirement means that a qualified (i.e., ASHA-certified or equivalent) speech-language pathologist must see the patient at least once, prescribe the type of care provided, and periodically review the need for continued services. CMS concluded that the speech-language pathologist accepts ultimate responsibility for care provided.

Schools and state Medicaid agencies may be establishing vague supervision policies that are not consistent with those of ASHA. For more information on ASHA's position read its Position Statement and Technical Report on Medicaid Guidance for Speech-Language Pathology Services: Addressing the "Under the Direction of" Rule.

State Medicaid Requirements

State Medicaid agencies are responsible for administering the Medicaid program on a day-to-day basis. While states must operate within federal guidelines in order to receive federal matching funds, these guidelines give states broad flexibility in operating their programs.

State Plans

CMS requires states to file a State Medicaid Plan, which outlines the policies of the state. CMS reviews the plans to ensure conformity with federal requirements. State plans are developed with input from various sources including the legislature, the state's Medicaid advisory committee, healthcare professionals, and the healthcare community.

Contact information for the 10 CMS regional offices that have direct oversight of state Medicaid programs
Copies of state plans can be found on the CMS Web site or by requesting a hard copy of the document through the regional CMS office.

State Medicaid plans can vary tremendously from state to state in terms of coverage and administration of the program.

Payments to Providers

States have great flexibility in how Medicaid payments are made to providers. They have the option of paying for covered services on a fee-for-service basis, through managed care arrangements, or through some combination of the two. States have broad discretion in establishing payment methodologies and setting payment amounts. Federal Medicaid laws do not establish a specific floor or ceiling on the payment rates for an individual provider. The only federal requirement regarding provider reimbursement is that the rates must be adequate to ensure that enough providers participate in the program to provide appropriate access to those eligible to receive Medicaid services. State payment methodologies are described in the state Medicaid plan.

Medicaid in the School Systems

Although Medicaid is a "medical" assistance program, it recognizes the importance of school-based speech-language pathology and audiology services. The federal Medicaid program actually encourages states to use funds from their Medicaid program to help pay for certain healthcare services that are delivered in the schools, providing that federal regulations are followed. Approximately 75% of all Medicaid school-based services are provided by audiologists and speech-language pathologists.

Section 1903 (c) of the Social Security Act was amended in 1988 to allow Medicaid coverage of health-related services provided to children under the Individuals with Disabilities Education Act (IDEA). Part B of IDEA allows children with disabilities to receive special education and related services, such as speech-language pathology, when the services are recommended in the child's Individualized Education Program (IEP). CMS authorizes Medicaid reimbursement for some or all of the costs of health-related services provided under IDEA when the services are

provided to Medicaid-eligible children,
medically necessary,
delivered and claimed in accordance with all other federal and state regulations, and
included in the state plan.

Documentation Guidelines

Documentation is a key component for any speech-language pathologist or audiologist to receive proper reimbursement for services provided. If a service is not fully documented, health care providers may deny reimbursement. In the schools, SLPs and audiologists should follow Medicaid documentation guidelines.

Medicaid requires providers to keep records for each individual receiving services. These records must contain all screening elements. Documentation must also include the following:

dates of service,
who provided the service,
where the service was provided,
any required medical documentation,
medical condition of the recipient,
length of time required for service, and
third party billing information.

Conclusion

Medicaid coverage policies vary from state to state, and a thorough understanding of how the state plan works is critical in understanding coverage of speech-language pathology and audiology services. It is also essential for speech-language pathologists and audiologists to understand federal guidelines. With an understanding of both the federal and state Medicaid programs, speech-language pathologists and audiologists can ensure that the services they provide adhere to the requirements of each.