01/29/16: Medicaid School Program Prescriptions

On January 27, 2016, Dr. Sue Zake, Director, Office for Exceptional Children, Ohio Department of Education (ODE) and John McCarthy, Director, Ohio Department of Medicaid (ODM) presented a webcast pertaining to a change in the Ohio Medicaid School Program (MSP). In this webcast, they announced that effective August 1, 2016, physician prescriptions would be required for all OT, PT, Audiology, and Speech services billed under MSP.

I was very surprised by this announcement, as I was expecting that they would take a different approach to the issue. The issue at hand is how to comply with the Affordable Care Act (ACA) mandate that all State Medicaid agencies must require all Ordering, Referring, or Prescribing (ORP) providers to enroll as a participating provider in their State Medicaid program. That would require the ORP provider to obtain an NPI number and a State Medicaid Provider number. This led ODM to have discussions with the Centers for Medicare and Medicaid Services (CMS), regarding who the ORP provider is in the Ohio Medicaid School Program. If it could be the school district, that would be easy, because the district already has an NPI number and State Provider number. In the process of these discussions, CMS determined that Ohio was out of compliance.

Previously, the State Plan Amendment (SPA), in effect from 08/01/2009 through 12/31/2013), allowed licensed therapists in the Ohio Medicaid School Program to recommend services under the title “Licensed Practitioner of the Healing Arts”. Effective January 1, 2014, ODM filed a new SPA with the Centers for Medicare and Medicaid Services (CMS) removing the language that allowed therapists to recommend without a prescription. ODM also removed language from the MSP section of the Ohio Administrative Code (OAC) that made reference to “Licensed Practitioner of the Healing Arts”, which became effective 04/01/2015. I am not sure why ODM removed this language that we had fought so hard for in 2009 to be part of our program.

The Ohio Medicaid School Program is currently out of compliance because of “lack of an appropriate prescription or referral” and “lack of ORP NPI/Provider number on the billing claim”. This non-compliance will not affect current Medicaid reimbursement, but CMS has only given Ohio until August 1, 2016 to correct the issues. The big question is: How do you get prescriptions for 61,000 Ohio Medicaid students, or how do you get 3,000 therapists enrolled as a Medicaid provider in six months? Regardless of what direction this issue goes, Ohio needs to apply for a longer waiver.

In the past 24 hours I have spoken with school districts, ESC’s, educational associations, other billing vendors, lobbyists, and politicians. I attended the Joint Medicaid Oversight Committee (JMOC) hearing on January 28, 2016 at the Statehouse, where Dr. Zake and Director McCarthy spoke to committee members of the Ohio House and Senate on this ORP issue. Everyone has an opinion on this issue, but the most important opinion lies with our school districts. I encourage you to talk with your Special Education administrators and your therapists and get their opinions. What would be easier and more beneficial, a one-time therapist enrollment or ongoing prescription requirements? Please send your questions, comments, and suggestions to those who are making these decisions that will affect your school district.

John McCarthy, Director
Ohio Department of Medicaid
50 West Town Street, Suite 400            
Columbus, Ohio 43215                

Dr. Sue Zake
Ohio Department of Education
25 South Front Street
Columbus, Ohio 43215

I also encourage you to copy Barb Shaner at OASBO barbara@oasbo-ohio.org on your ORP correspondence. OASBO has always been strong advocates for the Ohio Medicaid School Program. The OT, PT, and SLP Boards are also very interested in this issue.

There are many questions to be answered and there are only six months until the CMS deadline. This ORP issue could affect all students and not just the students on Medicaid. There is nothing that you immediately need to do at this time other than sending your questions and comments to ODE, ODM, HBS, and any other advocacy contacts that you have.  We will continue to keep you updated on this issue and please let us know your thoughts.