Updated
May 5, 2002
Robert Powell, J.D., CSHA Legislative
Counsel
Q & A
Medi-Cal
billing in the public schools became controversial in California
when San Diego City Schools became the first Local Education
Agency (LEA) to bill Medi-Cal for health and other support services
in 1994. Schools
in other states have been billing Medicaid since 1993 and many
schools in California now bill the federal Medicaid program (called
Medi-Cal in California) for specified health services, including
speech and language therapy and audiological assessments.
Many questions have been raised by speech-language
pathologists (SLPs) and by the California Speech-Language-Hearing
Association (CSHA) since 1994. Answers below were derived from
the state Department of Health Services (DHS), the state Department
of Education (CDE), and CMS [formerly federal Health Care Financing
Administration (HCFA)].
Q.
When schools receive reimbursements for health-related services
(i.e., special education speech therapy) from government education
budgets and the federal Medicaid program, would the school be considered to be "double-dipping" or
being paid for the same service twice from two funding sources?
A. No,
Medi-Cal is a federal-state shared funding program (approximately
50% state dollars and 50% federal dollars). The state's education dollars are considered
the state's share of matching funds. Medi-Cal reimbursed
dollars to school are considered the federal share of this matching
program. Thus the Medi-Cal reimbursement rates to schools
are one-half of the normal Medi-Cal reimbursement rate schedule
(i.e., 30 minutes of speech therapy is normally billed at $ 24
.36 and reimbursed to schools by the federal government at $12.18).
Q. Does the school use the SLP's
license to bill for Medi-Cal services?
A. No,
the school has its own school LEA Medi-Cal billing number. The SLP's professional license
is not part of the billing process. The Local Education Agency
(LEA) simply has to insure that evidence of the school speech-language
pathologist's (SLP) license is on file for audit purposes relating
to program personnel standards.
Q. Can
a school bill Medi-Cal for speech assessments and/or speech therapy
provided by a school credentialed SLP who does not hold a license?
A. The
federal Medicaid program personnel standards authorize speech
therapy by non-licensed personnel "under
direction" of a licensed SLP. Federal CMS authorized California
to utilize school credentialed SLPs under supervision of "licensed" SLPs
in 2001. California has recently revised its policy manual (Medi-Cal
Update Outpatient Services Local Educational Agency Bulletin
329 and Manual pages 15-20, March 2002) for
SLP “supervision" as follows:
The supervising speech pathologist is
individually involved with patient care under his or her direction
and accepts responsibility for the actions of the credentialed
language, speech and hearing specialists that he or she supervises.
The amount and type of supervision required should be consistent
with the skills and experience of the credentialed LSH specialist,
and with the standard of care necessary to provide appropriate
patient treatment. The annual duties of the supervising speech/language
pathologists include, but are not limited to:
Periodically observe assessments, evaluation
and therapy.
Periodically observe the preparation
and planning activities.
Periodically review client/patient records
and monitor and valuate assessment and treatment decisions of
the LSH specialists.
A licensed speech pathologist shall be
available by telephone (conventional or cellular) during the
workday to consult with the credentialed speech, language hearing
specialists, as needed.
Q. As the licensed SLP pathologists
assigned by my school to supervise credentialed SLPs for purposes
of the LEA Medi-Cal Billing Program, m I responsible for services
provided?
A. See
correspondence below which includes the follow Aug. 2000 statement
from the San Francisco federal office administrator Pat Daley
:
“The
Health Care Financing Administration's interpretation of the
term “under the direction of a speech pathologist” is that
the speech pathologist is individually involved with patient
under his or her direction and accepts ultimate responsibility
for the actions of the personnel that he or she agrees to direct.
We advise states that the speech pathologist must see the patient
after treatment has begun. The speech pathologist would also
need to assume the legal responsibility for the services provided.
Therefore, it would be clearly in the pathologist's own interest
to maintain close oversight of any services for which he or
she agrees to assume direction.”
Q. Does the
school SLP supervising and/or providing services being billed by
the school to the LEA Medi-Cal Billing Program, need to carry personal
malpractice insurance?
A. Malpractice
is generally an individual professional issue/concern, whether
or not a third-party payor is involved. School SLPs
working competently within their job description are typically
covered by their district's insurance policy.
Q. Will the Medi-Cal dollars generated
by speech, language and hearing (SLH) services be returned to the
SLH program?
A. California's
LEA Medi-Cal Billing Program mandates a school-community "Collaborative" with
participating agencies (i.e., county health agency) to set priorities
for program dollars with an aim to improve the educational, health,
mental health and social outcomes for children. Some local
schools have a SLP or special education representative on
this committee. Some local special education programs and/or
SLPs have negotiated for LEA Medi-Cal Program funds for additional
clerical assistance, computers, CE funds, etc. Some local
union contracts also address these finding issues.
Q. How
are Medi-Cal requirements for services to be "medically necessary" and "physician
referred" satisfied under the LEA School-Based Medi-Cal
program?
A. Physician approved protocols for minimum standards of medical
need for referral for speech and audiology services must be
on file in the school district as well as procedures to coordinate
with the primary care provider (MD, HMO or health plan). Ongoing documentation of therapy and progress is to
be maintained as a standard of practice. Requirements include
school compliance with physician protocols, which include criteria
for services according to the child's IEP.
Q. If the school bills Medi-Cal for
a child receiving speech and hearing services, is that child and
are non-school SLP providers precluded from other Medi-Cal programs
(i.e., Fee-for-Service; Managed Care Medi-Cal?
A. No, non-school SLP services are
not prohibited and the law allows for concurrent services to be
provided and billed. If a child is enrolled in a Medi-Cal Managed
Care Plan, the school may have a collaboration agreement with that
managed care plan. If the child is not enrolled in a Medi-Cal Managed
Care Plan, that child can be seen in the context of the Fee-for-Service
system and appropriate non-school SLP or audiologist can bill the
Fee-for-Service system for those services.
Q. Does the state require parental
consent prior to billing the Medi-Cal program?
A. The
Medi-Cal system has traditionally utilized a concept of negative
consent -- student health services are billed unless the
parent specifically denies consent. Parents
must provide written permission prior to the district attempting
to bill private insurance.
Q. Are schools engaging in discrimination
by billing only Medi-Cal for services?
A. Federal
law mandates that Medicaid be used as "the payor of last resort." Private
insurance companies must first be pursued prior to LEA billing
for Medicaid funds. A reasonable effort must be made by the
LEA to collect from other possible payors before Medicaid can be
billed. However, parents can refuse consent for the use
of their private insurance funds.
Q. Does the school using a billing
company violate confidentiality?
A. No,
the billing company for the school is considered an agent
of the district and thus authorized to receive information. Billing
company staff must protect the confidentiality of patient
information as required by state and federal law.
Q. Where can I find more information?
A. References:
W & I
Code Section 14132.06
http://www.leginfo.ca.gov/cgi-bin/waisgate?WAISdocID=62714522707+0+0+0&WAISaction=retrieve
California's
Welfare and Institutions Code
http://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=wic&codebody=&hits=20
DHS Outpatient LEA Medi-Cal Billing Program
Policy Manual
http://files.medi-cal.ca.gov/pubsdoco/pubsframe.asp
42
CFR 440.110(c)(2) [requirement
for ASHA Certificate of Clinical Competence (CCC) or equivalent
professional qualifications.] See CA AG Opinion and federal
correspondence below.
SB
231 (Ortiz) of 2001:
http://www.leginfo.ca.gov/pub/bill/sen/sb_0201-0250/sb_231_bill_20011010_chaptered.html
analysis:
http://www.leginfo.ca.gov/pub/bill/sen/sb_0201-0250/sb_231_cfa_20010920_143311_sen_floor.html
Your local school's LEA Medi-Cal Program
administrator:
Example:
LA USD Medi-Cal Reimbursement Program Coordinator & Resource
Nurse
Pam
Wagner, 213/625-5354; pamwag@earthlink.net
Department of Health
Services Staff
Pat
Morrison, Chief, Administrative Claiming & Support Services,
DHS Medi-Cal Benefits Branch
PMorriso@dhs.ca.gov
Barbara
Schultz, Consultant, LEA Medi-Cal Program, DHS Medi-Cal Benefits
BSchultz@dhs.ca.gov
Web Information:
DHS School LEA
Medi-Cal Billing Program:
http://www.dhs.ca.gov/mcs/mcpd/MBB/ACSS/LEAdescription.htm
California's
Welfare and Institutions Code Sections 14132.06.
CSHA
Web site under Position Papers:
HCFC
Letter RE Licensing & Medi-Cal
From: Patricia
Daley PDaley@hcfa.gov
Sent: December 13, 2000
To: Pace,
Leanna (DHS-MCPD) LPace@dhs.ca.gov
Cc: sruiz@hcfa.gov
Subject: Licensing
Requirements for Speech-Language Pathologists & Audiologists
Leanna,
In a June 16, 1999 letter, HCFA was advised by California's Attorney General
that the California licensing requirements for speech-language pathologists
and audiologists are comparable to the American Speech-Language-Hearing Association
(ASHA) requirements for certification (ASHA certification is required under
Federal regulations at 42 CFR 440.110 in order to provide Medicaid speech,
language, and hearing services). This letter was from Heidi R.
Weisbaum for Bill Lockyer, California Attorney General, to Sally K. Richardson,
then Director of the Center for Medicaid and State Operations in HCFA.
This is to inform you that HCFA has accepted your letter of
equivalency for purposes of SPA's 98-001 and 98-002. This
means that for purposes of providing Medicaid speech-language,
hearing services, licensed speech pathologists will be considered
equivalent to the Federal requirements in 42 CFR 440.110.
Please
note that this equivalency ruling applies only to licensed individuals;
credentialed speech pathologists do not meet equivalency standards
and would only be qualified to provide Medicaid services under
the direction of licensed speech pathologists.
We note that in 1994, the California Commission on Teacher
Credentialing indicated that most California programs are
geared toward ASHA standards. HCFA
encourages California to make ASHA certification a standard in its licensing
and credentialing programs. Medicaid beneficiaries deserve access
to the best health care services available and we believe that ASHA's
certificate of clinical competency certification ensures quality care.
Thank
you for your patience in this matter. We apologize
for the delay in responding.
June 11, 2001
Gail L. Margolis, Deputy Director
Medical Care Services
Department of Health Services
714 P Street, Room 1253
Sacramento, CA 95814
Dear Ms. Margolis:
Enclosed is a copy of California State
plan amendment (SPA) No. 98-002, which we have approved
effective January 1, 1998, as requested? This SPA makes changes to
Local Education Agency (LEA) services. It adds additional
educational institutions to the list of providers of LeA services,
and adds credentialed practitioners as providers of school-based
health treatment services. These changes were originally
contained in two SPAs, 98-001 and 98-002, but SPA 98-001 was
withdrawn in a letter from the Department dated March 10, 1999,
and the issues were combined in SPA 98-002.
This
SPA was submitted on March 31, 1998, and HCFA requested additional
information on June 19, 1998. The
State responded on March 10, 1999, but in subsequent discussions
with HCFA, several issues arose which the State determined that
additional research was needed. In a letter dated May 25,
1999, you requested that HCFA's second 90-day review clock for
this SPA be stopped pending DHS's submission of additional information. This
additional information was received by HCFA on May 25, 2001.
One
of the issues of concern was whether speech pathologists and
audiologists in the State of California meet the requirements
of 42 CFR 440.110(c)(2), which requires them to be certified
by the American Speech and Hearing Association (ASHA) or have
equivalent professional qualifications. When
there is no ASHA certification, HCFA has required States to seek
the opinion of their State Attorney General regarding the equivalency
of provider qualifications to Federal rules by comparing the training
and work requirements for ASHA certification to the State's provider
qualifications. California submitted this comparison from
the State Attorney General in a letter to HCFA dated June 16, 1999. This
letter satisfies the requirements of 42 CRF 440.110(c)(2).
Another
issue of concern involved billing for services listed in Individual
Health Support Plans (IHSPs). Federal
financial participation (FFP) is not available for services listed
in IHSPs because there is a liable third party payor. In the
revised SPA submitted by the Department on May 25, 2001, IHSPs
have been removed from his SPA. In addition, we have been
assured by your staff that schools will not be able to claim
FFP for services provided pursuant to an IHSP.
Two
pen-and-ink changes were made to form HCFA-179 with the concurrence
of your staff. The
Federal fiscal impact of this SPA was added to Block 7, Block
8 and 9 were amended to show that Limitations on Attachment
3.1-B was being amended in addition to Limitations on Attachment
3.1-A.
Questions concerning this approval should
be directed to Pat Daley at (415) 744-3592.
Sincerely,
Linda Minamoto
Associated Regional Administrator
Division of Medicaid
Enclosure
cc: Elliott Weisman, HCFA, Center for Medicaid
and State Operations
Linda
Tavener, HCFA, Center for Medicaid and State Operations
Barbara
Hardiman, DHS, California State Plan Coordinator
Date August
2001
From:
Ms. Pat Daley, CMS (HCFA) Reg IX SF 415/744-3592
HCFA
PROGRAM ISSUANCE Transmittal Notice
REGION
IV PROGRAM IDENTIFIER: MCD-22-95
TO:All
Title XIX Agencies and Welfare Agencies in AL, GA, KY, MS, SC,
TN
SUBJECT: Guidance Regarding the term “Under the Direction of” in
Regard to Speech Pathology and Audiology Services
The
purpose of this notice is to provide you with guidance on the
term “under
the direction of” for the purposes of speech pathology services,
especially when provided as school health and early intervention
services furnished under the Individuals with Disabilities
Education Act (IDEA).
Some
states have developed programs that provides services to children
under idea which permit “teachers of speech and hearing impaired” to
provide services “under the direction of a speech pathologist” who
is qualified to provide these services under the Medicaid regulations
at 42 CFR 440.110(c).
The
above regulation provides that services for individuals with
speech, hearing, and language disorders be provided by or under
the direction of a speech pathologist or audiologist, for which
a patient is refereed by a physician. A speech pathologist
or audiologist is defined as an individual who has a certificate
of clinical competence from the American Speech and Hearing Association,
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 certification.
The
Health Care Financing Administration's interpretation of the
term “under
the direction of a speech pathologist” is that the speech pathologist
is individually involved with patient under his or her direction
and accepts ultimate responsibility for the actions of the
personnel that he or she agrees to direct. We advise states
that the speech pathologist must see the patient after treatment
has begun. The speech pathologist would also need to assume
the legal responsibility for the services provided. Therefore,
it would be clearly in the pathologist's own interest to maintain
close oversight of any services for which he or she agrees
to assume direction.
If
there are any questions, please contact one of the members
on the non-institutional coverage team (Andriette Johnson at
(404) 331-5888, Mal Williams at (404) 331-5889. Jessie
Spillers at (404) 331-0077, Cathy Kasriel at (404) 331-5028 and
Joel Morris at (404) 331-0055)).
/s/
Wilma
Cooper, Chief
Operation
and Policy Branch
Division
of Medicaid
File:
C-NI-6 Speech Pathologist/Audiologist
CA
AG's Opinion RE Licensing & C.C.C.
Bill
Lockyer
State of California
Attorney General Department of Justice
110 West A Street, Suite 1100
San Diego, CA 92101
P.O. Box 85266
San Diego, CA 92186-5266
June 16, 1999
Ms.
Sally K. Richardson, Director
Center of Medicaid & State Operations
Health Care Financing Administration
7500 Security Boulevard
Baltimore, MD 21244-1850
RE:
California Licensing Requirements for
Speech-Language Pathologists and Audiologists
Dear
Ms. Richardson:
At
the request of the California Speech-Language Pathology and Audiology
Board ("Board"), we are responding to the Health Care
Financing Administration's concerns about whether the California
licensing requirements for speech-language pathologists and audiologists
are equivalent to the certification offered by the American Speech-Language-Hearing
Association.
After
reviewing the qualifications for licensure as a speech-language
pathologist or audiologist in California' and the American Speech-Language-Hearing
Association (ASHA) qualifications for certification, we believe
the two are equivalent for the purposes of 42 C.F.R. section
440. l 10, subsection (c)(2).2
'The
licensing requirements for speech-language pathologists and audiologists
are codified at California Business and Professions Code sections
2532- 2532.6.2(a), and Title 16 California Code of Regulations
(C.C.R.), sections 1399.156-1399.161. (See attached copies.)
2Code
of Federal Regulations, title 42, section 440.1 lo, subsection
(c)(2) defines a "speech pathologist or audiologist [as]
an individual who
(i)
Has a certificate of clinical competence from the American
Speech and Hearing Association;
(ii)
Has completed the equivalent educational requirements and
work experience.
A
comparison of their respective requirements is set forth below.
Educational
Requirements
California
and ASHA both require a graduate degree or its equivalent, specific
course work in speech-language pathology and/or audiology, supervised
clinical practice experience, supervised professional experience,
and passage of an exam. More specifically, California, like ASHA,
requires a masters' degree or its equivalent from an approved
institution.3 An approved institution is one either accredited
by ASHA or listed in the Guide to Graduate Education in Speech
Pathology and Audiology which is published by ASHA.4 The Board
has advised us that all of the schools in California offering
masters' degree programs in speech-language pathology or audiology
are accredited by ASHA.
Also,
in California, foreign-educated applicants who have a master's
degree must meet the same educational requirements as non-foreign
applicants, i.e. their course work will be evaluated to determine
if it is equivalents If an applicant does not have the required
master's degree, foreign-educated or not, the applicant must
have completed at least 30 semester units "towards a master's
degree while registered as a graduate student" in a speech-language
pathology and/or audiology program.6 All applicants must satisfy
the requirement for 300 hours of clinical practice. (See below.)
ASHA
accepts foreign-educated applicants who have a graduate degree
and who have completed 21 semester hours in a graduate program
and 250 clinical practice hours at a program accredited by the
Council on Academic Accreditation.' Thus, California's requirements
are a little more restrictive than ASHA's requirements. Further,
the Board has informed us that only about 3% of California applicants
do not have a master's degree, and these are primarily applicants
who have done all the course work towards the graduate degree,
but have decided not to do the thesis.
necessary
for the certificate; or
(iii)
Has completed the academic program and is acquiring supervised
work experience to qualify for the certificate.
Business
and Professions Code section 2532.2, sub. (a). 416 C.C.R. section
1399.156, sub. (b). Business and Professions Code section 2532.2,
sub. (b) 616 C.C.~. section 1399.157. 'ASHA Membership and Certification
Handbook, Section III, Standard I.
In
addition to the applicant's degree being awarded from an ASHA
accredited institution, California applicants must complete at
least 60 semester units in courses about "normal development,
function, and use of speech, hearing and language", as well
as courses and training in "the management of speech, hearing,
and language disorders."8 For speech-language pathology
applicants, at least 40% of the required 60 semester units must
be "related to disorders of speech, voice, or language";
for audiology applicants, at least 40% must be "related
to disorders of hearing and the modification of communication
disorders involving speech and language resulting from hearing
disorders."9 Moreover, "these 60 units do not include
credit for thesis, dissertation, or clinical practice."'°
By
contrast, ASHA requires 75 semester credit hours for all course
work, but six semester credit hours of clinical practice may
be included in the 75 total hours. As stated above, under California
law, credit for clinical practice is not included in the 60 semester
units. Additionally, California does not allow any credit for
thesis or dissertation, while ASHA does for professional course
work. " Thus, once the thesis, dissertation, and clinical
practice hours are subtracted from the 75 hours required by ASHA,
the number of hours required by California is approximately the
same.
Clinical
Practicum Requirements
California
requires 300 clock hours of practicum or clinical practice.'2
ASHA requires 350.'3 The Board informs us that approximately
85% of California's licensees are ASHA certified, and thus, have
completed the 350 hours of clinical practice.
Required
Professional Experience
Both
California and ASHA require 36 weeks of full-time "professional
experience" or 72 weeks of part-time experience.'4
- Business and
Professions Code section 2532.2, sub. (b).
- Ibid.
- Ibid.
- ASHA Membership
and Certification Handbook, Section III, Standard II-B.
- Business and
Professions Code section 2532.2, sub. (c), and 16 C.C.R.
sec. 1399.158(c)
- ASHA Membership
and Certification Handbook, Section III, Standard III-B.
- Business and
Professions Code section 2532.2, sub. (d) and 16 C.C.R.
sections 1399.160-1399.161; ASHA Membership and Certification
Handbook, Section III,
Standard V.
Examination
Requirements
California
and ASHA both require that an applicant take and pass the National
Examination in Speech-Language Pathology or the National Examination
in Audiology administered by the Educational Testing Service
of Princeton, New Jersey. 15 The current passing score is 600
or higher for both entities.
The
Board informs us that ASHA has a reciprocal agreement with Canada
to accept its national examination. California does not have
a reciprocal agreement with any country.
Continuing
Professional Development
California
recently enacted regulations mandating continuing professional
development and education.'6 After January 1, 2001, licensees
will have to certify that they have taken at least 24 hours of
continuing professional education in the two years prior to their
renewal date.'' ASHA does not have a mandatory continuing education
requirement.
For
all of the foregoing reasons, the California licensing requirements,
while not identical to the ASHA certification requirements, appear
to be equivalent to the ASHA requirements, and appear to meet
the definition of a speech pathologist or audiologist specified
in Title 42 of the Code of Federal Regulations, section 440.110,
subsection (c)(2).
(15)Business
and Professions Code section 2532.2, sub. (e) and 16 C.C.R. section
1399.159,
sub. (a); ASHA Membership and Certification Handbook, Section III, Standard
IV.
(16) 16 C.C.R. section 1399.199.1-1399.199.14, effective April 7, 1999.
(17)Business and Professions Code section 2532.6; 16 C.C.R. section 1399.199.4.
We
hope the above has addressed your concerns. If you have any further
questions, please contact the Board's staff counsel, LaVonne
M. Powell at (916) 445-4216.
Sincerely,
HEIDI
R. WEISBAUM
Deputy Attomey General
For
BILL LOCKYER
Attorney General
cc:
Ms.Linda Peltz
Health Insurance Specialist
Disabled & Elderly Health Program
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