Special Education

Administrative Advisory SPED 2010-2:
School-Based Medicaid and Nursing Services

To:Administrators of Special Education and Other Interested Parties
From:Marcia Mittnacht, State Director of Special Education
Date:April 30, 2010
C:Office of Medicaid
Massachusetts School Nurse Organization

The Department of Elementary and Secondary Education (Department) issues this advisory to clarify one aspect of the School-Based Medicaid Program: Reimbursement for nursing services in schools. In developing this advisory we have conferred with the state Office of Medicaid to ensure that the following information is consistent with the Medicaid state plan and claiming for reimbursable services under the School-Based Medicaid Program. We have also discussed the advisory with the Massachusetts School Nurse Organization.

Massachusetts changed its Medicaid reimbursement program for covered school-based services as of July 1, 2009. Under the new School-Based Medicaid Program ("SBMP") methodology, school districts that are participating in the SBMP may seek reimbursement for certain services provided by nurses. Generally, services provided to a student with a disability are reimbursable through the SBMP if they meet all program requirements, including:

  1. the student is eligible for MassHealth;
  2. the services are included in the student's IEP;
  3. the services are considered medically necessary under MassHealth regulations; and
  4. the services are provided by practitioners who meet qualifications as set by the SBMP and who are acting within the scope of their license.1

Most school nurses are qualified providers for SBMP purposes. 2 Additionally, school nursing services may be related services for special education purposes if they are necessary for a child with a disability to benefit from special education or to access the general curriculum. Therefore, if a MassHealth-eligible student with a disability has an IEP that includes school nursing services as a related service, the district may claim Medicaid reimbursement for the nursing services.

There is sometimes confusion as to whether school nursing services may be a related service because they are often provided following a medical diagnosis or prescription, rather than through an IEP Team decision. We are also aware that most schools use "health plans" to reflect a student's health or medical needs and the nursing services that are required to meet those needs. For these reasons, we remind IEP Teams that they must consider the health and medical needs of a student with a disability when appropriate.

The IEP Team must determine whether nursing services are a related service, i.e., necessary either because the student needs the service in order to benefit from the specially designed instruction provided to the student, or because the nursing service allows for access to the general curriculum. If school nursing services are a related service, the nursing services should be described in the student's health plan, which should be attached to and referenced in the student's IEP. Additionally, the IEP service delivery grid should state "School Nursing Service(s) according to the attached Health Plan." No further description is necessary in the IEP. If the student receives other health or medical services that are not related services, the health plan 3 should reflect those services and should clarify which health services are related services and which are not. The Office of Medicaid agrees that the nursing services identified as related services in a health plan attached to an IEP are reimbursable under the SBMP if all other SBMP requirements are met.

We hope this information is helpful. If you have any questions or require additional information, please contact the Special Education Planning and Policy Unit at the Department of Elementary and Secondary Education (781-338-3375).


1 Other MassHealth claiming requirements also apply.

2 Applicable provider qualifications are found in the School-Based Medicaid Program User Guide, Appendix 3, which is available at MassHealth.

3 Medical decision-making about frequency, dosage, or delivery of nursing services is within the expertise of medical providers with the consent of the student's parent. Although attached to the IEP when a student has school health services that are related services, the health plan has an identity separate from the IEP. If medical decisions are made that affect school nursing services, the school nurse is responsible for updating the health plan, which should then be attached to the IEP and shared with the parent and relevant personnel as necessary for the student's effective educational progress. That said, if the parent and district agree to terminate school nursing services that are considered related services, the district should prepare, and the parent should sign, an amendment to the IEP reflecting the agreement to end the services.

 
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