School-Based Skills Development Services

Introduction

School-Based Skills Development services are Medicaid covered medically necessary diagnostic, preventative, and treatment services. These services include therapeutic interventions designed to ameliorate motor impairments, sensory loss, communication deficits, and/or psycho-social impairments. These services are specifically designed to enhance a student’s health and functional abilities and/or prevent further deterioration. They are necessary for the student to benefit from special education.

General information, pertaining to Utah Medicaid providers and Medicaid billing, is located in the Section 1: General Information Provider Manual on Utah Medicaid’s website.

Program Standards

Authority

The Medicaid Catastrophic Coverage Act of 1988, Section 411(k)(12) permits Medicaid to pay for related services included in a Medicaid eligible recipient’s IEP when services are medically necessary and are covered in the Medicaid State Plan. Effective August 1, 1993, with the approval of CMS, Utah’s Medicaid State Plan was amended to allow coverage of medically necessary services included in the IEPs of Medicaid eligible children ages 3 through 21.

Definitions

The following definitions apply to this program:

Administrative Fee: The fee assessed to cover costs incurred by the Department of Health and Human Services to administer the Medicaid program.

Allowable Costs: The percentage of costs incurred by the provider to deliver covered skills development services to the Medicaid population.

Bundled Daily Rate: One charge that the provider bills to Medicaid for each student on a daily basis. The charge covers all Medicaid covered Related Services rendered to a student, excluding only itinerant nursing services.

Costs: The provider’s total compensation (salaries and benefits) and allowable indirect costs as approved by the cognizant agency for employees and contractors providing “hands-on” special education and related services.

EPSDT: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, designed to ensure Medicaid eligible recipients from birth through age twenty access needed medical care.

Federal Financial Participation: The federal share of Medicaid payments authorized and directed under Section 1903(a) of the Social Security Act.

HIPAA: The federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information, and help the healthcare industry control administrative costs.

Individualized Education Plan (IEP): A written plan for a student with a disability developed and implemented in accordance with the Utah State Board of Education Special Education Rules.

Itinerant Nursing Services: School Based Skills Development services provided to medically fragile students in special education who require continuous, one-to-one skilled nursing throughout their school day.

Medicaid Administrative Claiming (MAC): is a means by which the states’ school districts are able to claim partial reimbursement for administrative activities that support and ensure the integrity and delivery of Medicaid services provided both within the school setting and through coordination with community Medicaid providers.

Medically Necessary Service: A service that is reasonably calculated to prevent, diagnose, or cure conditions in the recipient that endanger life, are causing suffering or pain, cause physical deformity or malfunction, or threaten to cause a handicap, and there is no other equally effective course of treatment available or suitable for the recipient requesting the service that is more conservative or substantially less costly.

Providers: Providers are enrolled school districts or charter schools.

Qualified Intellectual Disability Professional (QIDP): As defined in 42 CFR 483.430, and according to Utah’s Division of Professional Licensing (DOPL) Title 58 where applicable.

Related Services: Developmental, corrective, and other supportive services required to assist a student with a disability to benefit from special education. Related services are identified in the Individuals with Disabilities Education Act (IDEA), Part B Regulations, 34 CFR Section 300.34. Not all Related Services are considered medically necessary.

Special Education: Instruction which is specially designed to meet the unique needs of a student with a disability.

State Match: The current percentage of the State’s share of Medicaid expenditures as defined in 42 CFR 433.10.

Consent

Providers will have a process in place to ensure they will obtain a one-time written consent, in accordance with 34 CFR 300.154(d)(2)(v), from the parent before accessing the child’s public benefits or insurance for the first time. This consent must specify the following:
1. The personally identifiable information that may be disclosed (e.g., records or information about the services that may be provided to a particular child)
2. The purpose of the disclosure (e.g., billing for services)
3. The agency to which the disclosure may be made (e.g., Medicaid)
4. That the parent understands and agrees that the public agency may access the child’s or parent’s public benefits or insurance to pay for services

Program Eligibility

Providers may bill Medicaid for covered Related Services rendered to students, if all of the following criteria are met:
1. The student is Medicaid eligible and is in the age range 3 through 21.
  1. The district may check Medicaid eligibility by sending a student list to the School-Based Program Manager, using the Eligibility Lookup Tool at www.medicaid.utah.gov, or through Access Now by calling 1-801-538-6155 or 1-800-662-9651, and following the prompts.
2. Students must have a Medicaid covered Related Service specified in the IEP, in the Related Services section, and is receiving these services from a qualified provider. If the student only receives one service, and this is a Related Service, that service may be stated in the Special Education section of the IEP.

Scope of Services

Covered Services

School-Based Skills Development Services Include:
1. Evaluation and Assessment for the purpose of identifying and documenting a special education student’s health related service needs.
2. Motor Skills Development designed to enhance a student’s fine and gross motor skill including muscle coordination and strength, ambulation, range of motion, grasp and release, and oral motor functioning. Examples of these services are occupational therapy and physical therapy.
3. Communication Skills Development designed to enhance a student’s ability to communicate through the development of functional expressive speech, functional use of adaptive equipment and devices, or improved oral-motor functioning. An example of this service is speech language pathology.
4. Nursing Services and Personal Care Services
  1. Nursing Services designed to enhance or maintain a student’s health status through services such as medication administration, seizure control, treatment and repositioning to maintain skin integrity, tub feeding, catheterization , and weight management.
  2. Personal Care Services designed to maintain or develop a student’s functional abilities through training and support with daily living skills including toileting, hand washing, oral motor, eating, and bathing skills. Personal Care services do not include nursing services that would require additional specialized training and oversight.
5. Behavioral Health Services designed to mitigate behaviors such as aggression, self-abuse, property destruction, severe non-compliance or withdrawal when, and to the extent, those behaviors significantly impact a student’s ability to benefit from special education. Examples of these services include behavioral redirection, counseling, and psychological services.
6. Vision and Hearing Adaptation Services (necessitated by a student’s absence or loss of vision and/or hearing) are specifically designed adaptation training services to develop/enhance a student’s functional abilities to assist him or her to benefit from special education.
7. Itinerant Nursing Services are services provided in accordance with physician orders, to medically fragile students in special education who require continuous, one-to-one skilled nursing throughout their school day. Itinerant Nursing Services are provided within the school environment, and may include:
  1. Catheterization or catheter care
  2. Care and maintenance of tracheotomies
  3. Prescription medication administration as part of the IEP
  4. Oxygen administration
  5. Tube feedings
  6. Suctioning
  7. Ventilator Care
  8. Evaluations and assessment (RNs only)
Telemedicine
1. Telemedicine is two-way, real-time interactive communication between the member and the physician or authorized provider at a distant site. This electronic communication uses interactive telecommunications equipment that includes, at a minimum, audio and video equipment that complies with HIPAA and UHIN privacy and security standards for telehealth.
  1. Telemedicine services must be determined to be clinically appropriate, and include but are not limited to: consultation services, evaluation and management services, and mental health services.
    
    *For more information regarding telemedicine, please refer to Utah Medicaid’s Section 1: General Information Provider Manual.
Service Categories and Service Plans
1. Services that may be stated in a student’s IEP as a category; i.e. Social Skills, Transition Skills, Functional Skills, Daily Living Skills, Self-Help, etc., must be broken down. The exact Medicaid covered services to be rendered must be stated in the Related Services section.
  Example: If Social Skills services include behavioral interventions, the behavioral intervention services must be specifically stated in the Related Services section of the IEP.
2. Services that may be stated in a student’s IEP as a plan, i.e. Health Plan or Behavior Intervention Plan, must be broken down. The exact Medicaid covered services to be rendered must be stated in the Related Services section of the IEP.
Credentials and Supervision
The following matrix outlines the licensure, certification, or other credentials required to deliver or to supervise the delivery of Medicaid covered School-Based Skills Development services:

Provider Type	Licensure	Authorized to deliver	Supervision	Authorized to Supervise
Physician	DOPL Licensed	All services	No Supervision Needed	All services
RN	DOPL Licensed	Itinerant Nursing Services, Nursing Services, Personal Care	No Supervision Needed	Personal Care
LPN	DOPL Licensed	Itinerant Nursing Services, Nursing Services, Personal Care	No Supervision Needed	Personal Care
Mental Health Practitioner	DOPL Licensed	Behavioral Health Services	No Supervision Needed	Behavioral Health Services
Speech Language Pathologist	Certification	Communication	No Supervision Needed	Communication
Speech Language Technician	Certification	Communication	Must be Supervised	None
Special Education Teacher	Certification	Communication, motor, personal care, behavioral health services, vision and hearing adaptation	Must be supervised for all services except personal care and behavior	Personal Care and behavioral health services
Audiologist	DOPL Licensed	Vision and Hearing Adaptation	No supervision Needed	Vision and Hearing Adaptation
Occupational Therapist	DOPL Licensed	Motor, Personal Care	No Supervision Needed	Motor, Personal care
Occupational Therapist Assistant	Certification	Motor, Personal Care	Must be Supervised	None
Educational psychologist, school psychologist, social worker, school counselor	DOPL Licensed	Behavioral Health	No Supervision Needed	Behavioral Health
School Vision and Hearing Specialist	Certification	Communication, Vision and Hearing Adaptation	No Supervision Needed	Communication, Vision and Hearing Adaptation
Para-educators	N/A	Behavior, motor, communication, personal care	Must be supervised for all services	None
Physical Therapist	DOPL Licensed	Motor, Personal Care	No Supervision Needed	Motor, Personal Care
Physical Therapist Assistant	Certification	Motor, Personal Care	Must be Supervised	None

Non-Covered Services/Activities

The following services and activities are outside of the scope of the School-Based Skills Development services and are not reimbursable under this program:
1. Durable and non-durable medical equipment (including assistive technology devices), appliances, and supplies. When medically necessary, these items are available to a Medicaid eligible student through other programs and enrolled providers.
2. Services provided prior to the implementation (or subsequent to the expiration) of a student’s IEP
3. Medicaid covered Related Services, which are not specified in a student’s IEP.
4. Services specified in a student’s IEP, but the nature or purpose of the activity is:
  1. academic or educational and covered under the State’s educational “core curriculum” including addition, subtraction, multiplication, letter and sound identification, reading, history, science, and other services that do not meet the criteria of Medically Necessary Services.
  2. to teach consumer and homemaker skills, including, but not limited to, shopping, budgeting, bed making, table setting, vacuuming, dishwashing, and laundry skills
  3. extracurricular in nature, including training and participation in regular physical education, recreational and cultural activities, athletics/sports, and special interest/leisure activities
  4. any other service that may be appropriate for the Related Service section of an IEP, according to the USBE standards, but are not Medicaid covered services as outlined in this manual, (e.g., adaptive physical education)
  5. vocational or job training activities designed to prepare a student to obtain or maintain paid or unpaid employment (such as objectives written to address specific job skills and work habits, use of public transportation, community awareness and access, and following work related directions)

Service Coordination

The Provider is responsible to coordinate the provision of School-Based Skills Development services with students’ primary and specialty providers.

Utah Medicaid providers should be familiar with coverage of preventative, diagnostic, treatment, and outreach services for EPSDT eligible recipients in order to assist families to appropriately utilize Medicaid benefits available.

Service Payment

Claims Processing

Upon enrollment in the Medicaid program, providers will receive instructions and assistance from the Medicaid agency to enable them to submit claims monthly.
Provider must be able to submit claims using HIPAA compliant software using the UHIN tool.
Payment will be made to the provider for students who are Medicaid eligible during the billing period.
Submitted claims must contain the following information:
1. The names of all (Medicaid) students who received Medicaid covered Related Services during the billing period;
2. Each student’s date of birth and social security number or Medicaid Identification Number;
3. The number of units of covered service(s) each student received during the billing month;
4. The dates of service in the month (example: 01/11/18- 01/31/18)
  1. If a student transfers into or out of a district, the claim should reflect the exact dates that the student attended the district during the billing month. Billing for the entire month, when the student was not present in the district for the entire month, will not allow the district that the student came from or went to, to bill for the same student during the same month.

Billing Codes, Modifiers, and Limitations

The following billing codes and modifiers may be used, as appropriate, when submitting a claim for School-Based Skills Development Services:
1. T1018 is used for Bundled Daily Rate services.
  1. This code may be billed once per day of attendance (1 unit per day on a claim) for a maximum of 23 units billed per month, as long as services were rendered in the billing month.
  2. The daily rate does not change, and will be billed the same, no matter the length of time or the number of Medicaid covered services the student receives throughout the school day
2. T1002 is billed for itinerant nursing services rendered by an RN.
  1. Physician orders for continuous one-to-one nursing care during school attendance, are required to bill this rate.
  2. This rate must be billed in 15 minute increments. Each 15 minute increment is one unit on a claim.
  3. The maximum number of units in a month that may be billed for this code is 800.
  4. The TM modifier must be billed with this code.
3. The T1003 code is billed for itinerant nursing services rendered by an LPN.
  1. Physician orders for continuous one-to-one nursing care during school attendance, are required to bill this rate.
  2. This rate must be billed in 15 minute increments. Each minute increment is one unit on a claim.
  3. The maximum number of units in a month that may be billed for this code is 800.
  4. The TM modifier must be billed with this code.
4. When nursing services rendered under the T1002 or the T1003 codes result in a period of time less than 15 minutes, the minutes must be rounded. If the resulting time is 0-7 minutes, do not bill for the time. If the resulting time is 8-14 minutes, 1 unit of nursing services may be billed.
  1. The following is an example of rounded minutes when using the T1002 or T1003 codes: If a nurse rendered services for 34 minutes, bill 2 units. If a nurse rendered services for 39 minutes, bill 3 units.
5. Nursing services billed using the T1002 or the T1003 codes may only be billed for the day that the services are rendered. Partial minutes cannot carry over from one day to the next in order to complete a 15 minute unit.
  1. The following is an example: 9 minutes of nursing services on Tuesday cannot be added to 6 minutes of nursing services on Wednesday to make one who 15 minute unit.
6. Districts may bill nursing services during transportation at that nursing rate, when deemed appropriate. In order to bill the T1002 or the T1003 code for nursing services during transportation, the total nursing minutes stated in the IEP must also include the minutes for transportation. Nursing minutes are billed in 15 minute increments. Simply stating “transportation” in the IEP, or adding time to transportation in the IEP, is not sufficient. This does not clearly identify the expected time associated with the nursing services, nor does it clearly tie the “transportation” activities to a specific Related Service.
  1. Example: If a student receives 2,000 weekly nursing minutes at school, and also receives nursing services on a bus for 30 minutes a day, five days a week, the total time stated in the IEP must be 2,150 in order for the district to bill both services at the nursing rate.
  Note: The T1018 and T1002 or T1003 codes cannot be billed on the same dates of service

ICD- 10 Diagnosis codes

The following diagnosis codes must be used when billing for school-based services:
1. F8189 is used for non-behavioral services
2. F89 is used for behavioral services
When both diagnosis codes apply, use the code that corresponds to the dominant service.

State Match and Administrative Fee

The School-Based Skills Development provider will receive a quarterly bill for the estimated State Match. The bill will be sent 45 days prior to the beginning of each new quarter and payment must be made at least 15 days prior to the start of the quarter.

The provider will receive a bill for the Administrative Fee 45 days prior to the beginning of the fourth quarter of each state fiscal year. The Administrative Fee will be calculated as a percentage of the total Medicaid payments. It will include both FFP and State Match amounts paid to the provider for School-Based Skills Development services during the state fiscal year.

The Administrative Fee is calculated as follows:

Fiscal Year Medicaid Payments	Fiscal Year Administrative Fee
$1-$500,000	3 percent of total
$500,000- $1,000,000	$15,000 + 2 percent of amount exceeding $500,000
Greater than $1,000,000	$25,000 + 1 percent of amount exceeding $1,000,000

Claims for payment of services will be placed on hold if the State Match or the Administrative Fee is not paid.

Record Keeping

Required Documentation

The School-Based Skills Development provider must maintain sufficient records to document the following for services billed to Medicaid:
1. That the student received service(s) pursuant to an IEP which met the requirements in accordance with section 1-4 Program Eligibility of this manual.
2. The student received one or more Medicaid covered Related Services during the billing month
3. The Related Services rendered to the student during the billing month match the services outlined in the student’s IEP
4. The student’s official attendance record shows that the district is not billing for more days than the student attends school.
  1. That the student received at least one Medicaid covered service on at least one day of school attendance
5. The rendering provider(s) met the required licensure, certification, or other criteria described in Section 2-1 of this manual, or was supervised by an individual who met the requirements.
  1. That the rendering provider has signed and dated the documentation of services rendered and that the documentation clearly states the provider’s name
  2. That the rendering provider and the supervising provider (if applicable) have both signed and dated the documentation of services rendered and that the documentation clearly states both names, clearly indicating who rendered the service and who is supervising.
  3. Electronic signatures are acceptable when the district has a system to maintain an auditable signature record and when the district has a way to protect against modification of the record after the signature
The service documentation must include the following:
1. The type of service rendered
2. The amount of time spent rendering the service
3. The rendering provider and supervision of services if applicable
4. The signature of the rendering provider and the supervising provider if applicable.
5. Clinical documentation demonstrating the exact activities performed with a student and how that service was rendered. Clinical documentation should be in line with the standards of practice for each provider’s specialty.
Itinerant Nursing service documentation must meet the requirements outlined and must additionally ensure that logs or contact notes specifically document the following information:
1. The date of each billed service
2. The number of 15 minute units billed
3. The nature and purpose of each billed service as it related to the student’s IEP
4. The name of the individual(s) who provided the billed service
5. A copy of the signed physician’s orders for services

Record Retention

All documentation pertinent to a claim paid to the Provider by Medicaid, must be kept for a period of 5 years after the date of payment.
1. Records must be retained even after a student leaves the district or LEA.

Provider Reporting

Cost Reporting

Medicaid’s regulations prohibit payments to governmental agencies in amounts which exceed an agency’s costs to provide a service. School district providers and charter schools, as governmental entities, are not allowed to make a profit. The Department’s payments to the Provider are subject to reconciliation. Providers are required to report all documents necessary for the Department to determine allowable costs and conduct its reconciliation, which include the following:
1. The names, role, total annual salary, and benefits of all individuals who will directly supervise and/or deliver the service(s)
2. 2. The total number of Medicaid and non-Medicaid students classified as Level C per the Utah State Board of Education Guidelines, and meet the requirements according to grade level as outlined in section 1-4.
The Provider will conduct quarterly time studies as required by the Department in a Department approved format as outlined in section 6-3.
The Provider is responsible to ensure that the Medicaid funds it receives as part of the School-Based Skills Development Program are only used to support and enhance the provision of Medicaid covered Related Services.
By December 31st of each year, the Provider will submit a financial report to the Department, in a Department specified form, documenting the following:
1. The total amount of Medicaid School-Based Skills Development revenues the Provider received during the prior State Fiscal Year.
2. The total expenditures for the program from the prior State Fiscal Year

Medicaid Administrative Claiming

Utah school districts may claim Medicaid administrative Federal Financial Participation for a share of the costs incurred to perform activities which support the proper and efficient operation of the Medicaid program in schools. Some or all of the costs of these administrative activities may be reimbursable at a 50% match rate. The school districts’ expenditure information is used to calculate an Administrative Claim.
1. The objective of the Medicaid Administrative Claim is to isolate and identify only those school district costs that are associated directly with administrative activities that support the provision of Medicaid covered health related services in the Medicaid program.
2. The district may submit the Medicaid Administrative Claim to the Department of Health and Human Services through the Department approved process.

Participation Criteria

In order for a school district or charter school to claim Medicaid administrative funding, the following criteria must be met:
1. The school district must be enrolled as a Medicaid Provider
2. The school district must actively bill Medicaid for direct care services
3. The school district must participate in the department approved time study
4. The school district must attend required trainings
5. The supported activity must be necessary for the proper and efficient administration of the Medicaid State Plan

Cost Data

Cost data will be submitted by the district quarterly. Calculations from the cost data will be used to support the quarterly Administrative Claim. The reported cost data will include the following information:
1. Employee level salary data
2. Employee benefit data
3. The district’s indirect cost rate
4. The district’s Medicaid Discount Factor
5. The district’s Indirect Capital Allocation
6. The district’s time study percentage related to Medicaid eligible direct care an administrative services

Time Studies

The time study is a mechanism for identifying and categorizing Medicaid administrative and direct care activities performed by school or school district employees. This serves as the basis for developing claims for the costs of administrative activities that may be properly reimbursed under Medicaid. It is also used to calculate the Allowable Cost for the annual cost reconciliation for direct care services.
Participating Utah school districts will conduct time studies to capture the activities performed by staff during 5 consecutive days per quarter. Time study participants will complete a 5 day, self-reporting time study for the quarters October-December, January-March, and April-June. Time study results from these 3 quarters will be used to calculate the summer quarter July-September. All districts participating in the Medicaid Administrative Claiming must complete the time studies. No Medicaid Administrative funding will be available to a district for a quarter in which it failed to complete an approved time study.
The time study universe will include all individuals (including contracted individuals) in the participating districts whose responsibilities include direct, health related activities. All individuals in the universe will be required to participate in order to have their costs considered. There is no sampling within the universe. The universe may include contracted vendors and will be updated quarterly to account for staffing changes.
1. The following personnel will be included in the time study universe:
  
  Physical Therapist
  Occupational Therapist
  Psychologist
  Social Worker
  Vision or Hearing Specialist
  Audiologist
  Speech and Language Pathologist
  RN or LPN
  Physician
  Augmentative/Assistive Communications Team
  Special Education Teacher or Resource Teacher
  Special Education Director/Coordinator
  Special Education Staff Assistance, Para Educator
  Counselor/Mental Health Practitioner
  Adaptive Physical Education Personnel
  Aides and Assistants to all of the above
Administrators, typically the special education directors, coordinators, and administrative staff who support the activities of time study participants, will be included in the claim, but are not required to complete the time studies. Their personnel costs will be included with the time study participant’s costs in applying the study results in the calculation of the claim.
Staff who are fully funded by federal dollars will not participate in the time study, nor will their costs be considered for this Medicaid Administrative Claiming program. This is a reimbursement program and federally funded staff have no local costs to be reimbursed.
Conducting the Time Study
1. Time studies will capture a traditional work week. They will capture 8 working hours, 5 days a week, based on a traditional school day. Staff working a non-traditional work day will be given credit for extra time by adding the extra time to the 5th day of the time study.
2. The 5 day sample will be randomly selected and provided to the district
3. The time study participant cannot code for more than one activity per 15 minute period.
4. The completed time study forms and time study logs will be collected for summarization of data and calculation of activity/time percentages by district.
Time Study Activities
1. The following activities will be coded in the time study:
  
  Non-Medicaid Outreach
  Medicaid Outreach
  Facilitating Applications for Non-Medicaid Programs
  Facilitating Medicaid Eligibility Determination
  School Related and Educational Activities
  Direct Medicaid Services
  Transportation for Non-Medicaid Services
  Transportation Related Activities in Support of Medicaid Covered Services
  Non-Medicaid Translation
  Translation Related to Medicaid Services
  Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services
  Program Planning, Policy Development, and Interagency Coordination Related to Medicaid Services
  Non-Medicaid/Non-Medicaid Related Training
  Medical/Medicaid Related Training
  Referral, Coordination, and Monitoring of Non-Medicaid Services
  Referral, Coordination, and Monitoring Medicaid Services
  General Administration
Time Study Codes
1. The following codes will be used for activities when entering time study information:
  
  Code A Non-Medicaid Outreach
  Code B Medicaid Outreach
  Code C Facilitating Application for Non-Medicaid Programs
  Code D Facilitating Medicaid Eligibility Determination
  Code E Direct Medical Services
  Code G Transportation for Non-Medicaid Services
  Code H Transportation Related to Activities in Support of Medicaid Covered Services
  Code I Non-Medicaid Translation
  Code J Translation Related to Medicaid Services
  Code K Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services
  Code L Program Planning, Policy Development, and Interagency Coordination Related Medical Services
  Code M Non-Medicaid/Non-Medicaid Related Training
  Code N Medical/Medicaid Related Training
  Code O Referral, Coordination, and Monitoring of Non-Medicaid Services
  Code P Referral, Coordination, and Monitoring of Medicaid Services
  Code Q General Administration

Updated July 2020