Module Nine: Medicaid


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Module Nine in the Series of Coding, Reimbursement, and Advocacy Modules. Developed by ASHA's Medicaid Committee

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Medicaid is the largest payer of health care services in the United States. Medicaid is part of the Centers for Medicare and Medicaid (CMS). It authorizes reimbursement to providers of health care services that go to qualified children and adults. While each state dispenses funds for this population, the state and federal government both input funds for this use. CMS sets the broad guidelines for provider and recipient qualifications and approves the state plans regarding this program.

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Each state administers its Medicaid program resulting in a considerable variation from state to state. States can be more restrictive than the federal guidelines. A service must be specifically identified in the state plan or furnished under EPSDT to make Medicaid payment permissible. State regulations and standards differ greatly in other areas of Medicaid including provider qualifications, credentialing and supervision, reimbursement justification, and documentation.

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It's important to recognize that audiology and speech-language pathology services are mandatory for children, but are optional for adults. The state has the flexibility to determine how they will meet that mandatory requirement in terms of what qualifies an individual for the services provided.

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Early & Periodic Screening, Diagnosis, & Treatment (or EPSDT) is mandated for medically necessary services for children ages birth to 21 years. It includes, screening, diagnostic, and treatment services. When a screening indicates the need for further evaluation, diagnostic services must be provided. Consequently, necessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedure. Knowledge of one's state medical necessity criteria and documentation requirements are essential to maximizing reimbursement.

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Although Medicaid eligibility for the population is mostly based on income levels, disabled individuals may qualify. Considerations such as age, pregnancy status, income and household size also factor into eligibility for Medicaid. People who are blind, afflicted with a permanent disability, pregnant, age 65 or older, or 18 and under generally qualify for Medicaid.   In most states people who are receiving Supplemental Security Income (SSI) benefits qualify for Medicaid.

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Physicians, non-physician practitioners, and other suppliers can qualify to provide Medicaid services. CMS may update qualified providers in the published final rule in the Federal Register. For speech-language pathologists providing Medicaid services outside of the school setting, a master's degree, ASHA certification, and state licensure is needed. It allows for services to be provided "under the direction of" a qualified provider.

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In 1998, federal law was amended to permit Medicaid payment for services provided to children under the Individuals with Disabilities Education Act (IDEA). Some states require that schools bill for Medicaid-eligible services, while other states consider billing optional. School-based SLPs and audiologists should know state and local Medicaid requirements. State Medicaid agencies may have specific requirements for billing when services are provided in the schools.

  • There are five conditions that must be met for Medicaid to reimburse for IDEA-related services.
  • The child receiving the service must be enrolled in Medicaid.
  • The services are medically necessary.
  • The services must be covered in the state Medicaid plan or authorized by the federal Medicaid statute.
  • The services must be listed in the child's individualized education program (IEP).
  • The school district or local educational agency (LEA) must be authorized by the state as a qualified Medicaid provider.

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There may also be differences related to documentation for services provided "under the direction of"—including "sign off" by qualified personnel—and the payment rates for school-based providers. The supervisor must comply with Medicaid rules and regulations, licensure laws, education agency credentials, and professional policy documents. There may also be differences related to documentation for services provided "under the direction of"—including "sign off" by qualified personnel—and the payment rates for school-based providers.

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State Medicaid regulations may allow for reimbursement for services provided by personnel other than the credentialed provider when the service is appropriately supervised. Medicaid agencies often refer to state licensure rules that can have provisions for supervisee. The supervisor is ultimately responsible for ensuring that the medically necessary service is provided appropriately.

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Each speech-language pathologist and audiologist must follow their professional code of ethics when providing services to the Medicaid eligible population or any other persons served by our services. These providers must also abide and comply with all regulatory requirements. Ultimately, 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.

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Documentation is required and varies from state to state as well as setting. It is important to be aware of one's state Medicaid documentation requirements in order to ensure reimbursement as well as to reduce audit penalties. As with all else, requirements can change, be watchful of bulletin updates. For those who practice in schools, the school district may require Medicaid documentation for all students on the caseload, and the billing office then submits only the documentation for the Medicaid eligible students.

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There is a federal definition of medical necessity, though some states have written their own definitions. Each state is allowed to determine its own criteria for medical necessity and the accompanying services and providers for these treatments and conditions.

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Commonly required documentation includes patient information with notes reflecting the need for skilled service with appropriate codes, dates of service, and plan.

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Audit proofing your documentation can substantially reduce/eliminate a determination resulting in payment back to the state Medicaid agency.  Some states have collaborated with state Medicaid agencies to write the guidelines for documentation. Others have created audit tools for their state association members. Audiologists and SLPs should be aware of what helpful information may be available to them in their state.

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The purpose of Managed Care Organizations is to combine the functions of health insurance, the delivery of care, and the administration of services. A Physician – Hospital Organization (PHO) is one example. Contracts can address provider reimbursement details and levels of service among others aspects. Medicaid managed care has grown rapidly in the past several years and will likely be the type of plan to cover almost all individuals receiving Medicaid services.

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Almost all states have some form of coverage and reimbursement for services delivered via telehealth; however, not all cover audiology and/or speech-language pathology. Where coverage is allowed, it varies widely from state to state in setting and licensure requirements. Medicine/Physician driven advocacy almost always takes the lead state to state in what a telehealth program may begin to look like. Ancillary professions, such as audiology and speech-language pathology usually need to address telehealth practice details to fit their profession through their Administrative Rules governing their State Licensure Law. When billing treatment provided via telehealth, the letters "GT" represent a modifier that is listed beside the treatment code, to indicate the telehealth platform.

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While more individuals may be covered by Medicaid, audiology and speech-language pathology services are still optional for adults.

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This concludes Module Nine on Medicaid developed by ASHA's Medicaid Committee.

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