Medicaid Toolkit

State Medicaid regulations may allow for reimbursement for services provided by personnel other than the credentialed provider [PDF] when the service is appropriately supervised. Medicaid agencies often refer to state licensure rules that can have provisions for supervisees. Federal Medicaid regulations [PDF] address the provision of "services provided by or under the direction of a speech [-language] pathologist or audiologist … within the scope of his or her practice under State law."

In the absence of specific guidance from the Centers for Medicare & Medicaid Services (CMS) regarding supervision, some states' Medicaid rules delineate adequate supervision practices by referencing ASHA's position statement, Medicaid Guidance for Speech-Language Pathology Services: Addressing the "Under the Direction of" Rule.


  • The supervisor is ultimately responsible for ensuring that the medically necessary service is provided appropriately.
  • Records of supervisory contacts must be maintained and should include date of supervisor's review and approval of the speech-language and audiology component of the IEP or treatment plan; date of observation for each Medicaid-eligible student; log of indirect supervision contacts (e.g., paperwork reviewed); and date, agenda, and action plan for conferences with supervisee.
  • Supervisors must ensure that they comply with their state's Medicaid requirements regarding documentation and verification of service.
  • Supervisors should refer to ASHA's Code of Ethics in regard to meeting the professional obligation of supervision. If there is a potential conflict in requirements and ethical standards, the supervisor should adhere to the highest standard.
  • The supervisor must comply with Medicaid rules and regulations, licensure laws, education agency credential requirements, and professional policy documents. It is the responsibility of the practitioner to ensure that all federal, state, and local regulations are properly followed and to observe ASHA's Code of Ethics
  • ASHA's recommended minimum qualifications under Medicaid for supervisors are an ASHA Certificate of Clinical Competence (CCC) and a contractual relationship with the employer of the supervised clinician. In addition, it is preferable for the supervisor to have an active interest and training in supervision, 2 or more years of experience after receiving the CCC, and a willingness to serve in this role.
  • ASHA's guidance also addresses frequency, amount, and type of supervision and appropriate paperwork that the supervisee may complete, along with review of that paperwork.


Audiologists and speech-language pathologists may work with state associations to address concerns related to:

  • establishing temporary or provisional licensure for those completing clinical fellowship to enable these practitioners to bill Medicaid directly-in many states, this requires a statutory change of state licensure;
  • regulating speech-language pathology assistants (SLPAs) and audiology assistants to ensure adequate services for Medicaid beneficiaries-approximately 50% of the states currently license or otherwise regulate SLPS (see ASHA's model bill language for adopting qualifications for support personnel in your state);
  • providing supervisors with adequate training in supervision and sufficient time to conduct observations of and provide support to supervisees.


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