Medicaid Billing for Nursing Services

The questions and answers below provide clarification on the requirements for billing Medicaid for nursing services provided to students with handicapping conditions. What follows are the most frequently asked questions and answers:

Question:  What must be specified on the student's IEP (Individualized Education Plan)?

Answer: The phrase "Skilled Nursing Services," "Intermittent Nursing Services," etc. must be listed on the IEP (e.g. Medical Alerts, Related Services, or other Support Services).

Question:  Must the specific nursing service or medication be detailed on the IEP?

Answer: No, the IEP must recommend intermittent nursing services. The actual procedure need not be detailed in order to maintain the confidentiality of the student’s treatment plan and medical records maintained by the school. You should not indicate the medication on the IEP.

Question: What is an individualized health care plan (IHCP)?

Answer: An IHCP is a plan of medical care for a child with health needs. It is not required by law, but is customarily used in nursing practice and is recommended for all students with special health care needs. Schools are eligible to receive Medicaid reimbursement for skilled nursing services for Medicaid eligible students only if an IHCP is part of a student’s cumulative health record and such services are included in the student’s IEP.

Question:  Who should write an IHCP?

Answer: The Registered School Nurse is responsible for the development and implementation of the IHCP.

Question: What documents must be on file with the IEP and IHCP?

Answer: No documentation is to be kept with the IEP; doing so could violate confidentiality requirements. Although SED and DSS originally called for the IHCP to be attached to the IEP, the requirement was changed.

a. Health history/Health notes (there is no requirement for the number of notes).

b. Medication log.

c. Doctor's orders: orders are required when the student enters school for the first time each school year and when there are any significant changes in the student’s condition or procedure.

d. Written protocols for each procedure, required for the student.

Question:  Who maintains the IHCP and Data Sheets?

Answer: The nurse who provides the services to the individual student is the one who maintains the IHCP and data sheets –s/he has the necessary information for the completion of the forms.

Question: Who writes the IHCP for students in BOCES classes?

Answer: The Registered Nurse who cares for the student writes the IHCP.

Question: Are mandated health services (e.g. height, weight, vision screening, etc.) medicaid reimbursable? 

Answer: Routine, mandated health care services are NOT reimbursed except as they apply to the special education related conditions specified on the IHCP. The IEP must specifically say "nursing services;" the guidelines would be followed (e.g., monitoring height and weight for a student with an eating disorder) and the service could be billed.

Question: Where should protocols, checklists, etc., be kept?

Answer:  In the office of the school nurse who is providing the nursing services indicated on the IEP.

Question:  May a school district bill for dispensing medications?

Answer: Yes, if the need to dispense the medication is indicated on the IEP ("nursing service", "nursing services as needed" or "intermittent nursing service") and only if the medication is dispensed by an RN (or LPN if within the scope of the Nurse Practice Act).

Question:  May a school district bill for emergency first aid?

Answer:  No. You may only bill for skilled nursing services that are required for a student with a disability to benefit from special education. Do not bill for routine first aid.

Further information is available on the following website: http://www.oms.nsyed.gov/medicaid/    or by calling the NY Statewide School Health Services Center at (585) 349-7630.