Frequently Asked Questions About Medicaid

• Who can bill for Medicaid speech-language pathology and audiology services?
• What are criteria for a speech-language pathologist to be considered a qualified provider under Medicaid?
• What are criteria for an audiologist to be considered a qualified provider under Medicaid?
• Do I need a referral to provide speech-language pathology or audiology services to Medicaid beneficiaries?
• What speech-language pathology and audiology services are covered under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)?
• Under Medicaid, what services are mandatory and what services are optional?
• Who determines how Medicaid payments are made to providers?
• Where can I find my State's Medicaid Plan?

See also: Medicaid Payment for School-Based Services

Who can bill for Medicaid speech-language pathology and audiology services?

Medicaid covered speech-language pathology and audiology services can be provided by or under the direction of a qualified provider. The qualified speech-language pathologist or audiologist takes professional responsibility for any services provided under their direction. ASHA's Technical Report, Medicaid Guidance for Speech-Language Pathology Services: Addressing the "Under the Direction of" Rule, provides more information on this topic.

What are criteria for a speech-language pathologist to be considered a qualified provider under Medicaid?

Regulations specify that services, if a benefit in the state, will be covered if providers meet the following qualifications:

• 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

What are criteria for an audiologist to be considered a qualified provider under Medicaid?

Regulations specify that services, if a benefit in the state, will be covered if providers meet the following qualifications:

• 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.

Do I need a referral to provide speech-language pathology or audiology services to Medicaid beneficiaries?

Federal Medicaid regulations require that a patient receive a referral from a physician or other licensed practitioner of the healing arts acting within their scope of practice.

What speech-language pathology and audiology services are covered under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)?

As part of the comprehensive developmental history, speech-language pathology and audiology services are included for 1) the identification of children with speech or language impairments, 2) diagnosis and appraisal of specific speech or language impairments, 3) referral for medical or other professional attention necessary for rehabilitation of speech or language impairment, 4) provision of speech and language services, and 5) 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.

Under Medicaid, what services are mandatory and what services are optional?

The Social Security Act (SSA) requires state Medicaid coverage for those individuals who are referred to as "categorically needy." For those individuals who are determined to be categorically needy, the states are required by federal law to provide the following services:

• Inpatient hospital services
• Outpatient hospital services (rehabilitation as required for those under 21)
• Prenatal care
• Vaccines for children
• Physician services
• Nursing facility services for person aged 21 or older
• Family planning services and supplies
• Rural health clinic services
• Home health care for persons eligible for skilled-nursing services
• Laboratory and x-ray services
• Pediatric and family nurse practitioner services
• Nurse-midwife services
• Federally qualified health center services (FQHC), and ambulatory services of an FQHC that would be available for other settings

In addition to the required services listed above, states have the discretion of offering the following services to their categorically needy constituents:

• Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders
• Diagnostic services
• Clinic services
• Intermediate care facilities for the mentally retarded
• Prescribed drugs and prosthetic devices
• Optometrist services and eyeglasses
• Nursing facility services for children under age 21
• Transportation services
• Rehabilitation services
• Home and community-based care to certain persons with chronic impairments

Who determines how Medicaid payments are made to providers?

Each state determines reimbursement rates and coverage of services. States have great flexibility in how Medicaid payments are made to providers and 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 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.

Where can I find my State's Medicaid Plan?

Contact information for the 10 CMS regional offices that have direct oversight of state Medicaid programs can be found on the CMS Web site.

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.