02/12/16: Other Potential “Order, Refer, Prescribe” Options

The recent announcement from the Ohio Department of Medicaid (ODM) and the Ohio Department of Education (ODE) that the Ohio Medicaid School Program (MSP) will begin requiring Physician Prescriptions effective August 1, 2016 has caused great concern among many School Districts and MSP Stakeholders. This ruling by ODM/ODE centers around the Federal requirement that the individual that “Orders, Refers, Prescribes” (ORP) medical services must be enrolled in the State Medicaid Program. Since the start of the Ohio Medicaid School Program back in 2009, MSP OTs, PTs, and SLPs were able to ORP based on language in Ohio’s State Plan Amendment (SPA) that considered MSP therapists to be “Licensed Practitioners of the Healing Arts”. ODM removed this language from the Ohio SPA effective January 1, 2014, which the Centers for Medicare and Medicaid Services (CMS) pointed out in their October 23, 2015 letter to ODM (attached).

We have been meeting with School Districts, Educational Associations (OASBO, BASA, OSBA, OESCA), Therapy Associations, and other Stakeholders, and we feel that there are other options available to Ohio that would be much less burdensome and costly for Ohio School Districts than requiring ongoing Physician Prescriptions. Some of those possible options are:

  • The Ohio Department of Medicaid (ODM) could restore the previously removed language from the State Plan Amendment (SPA) which permitted MSP therapists (OT, PT, SLP) to be considered “Licensed Practitioners of the Healing Arts”. This would then require therapists to do a one-time enrollment in the State’s Medicaid Program as an ORP provider only. ODM has already modified their Medicaid Enrollment software to accommodate a scaled down “ORP Only” enrollment application.
  • ODM could expand the list of ORP allowable providers to include Clinical Psychologists and School Psychologists. Every school district employs or contracts with one or more Psychologist, and Psychologists would be much more aware of the student needs than a Physician, who was not part of the evaluation and plan development team. This would only require the MSP Psychologists to do the one-time enrollment in the State’s Medicaid Program as an ORP provider only.
  • Request an additional one-year waiver (2016/17 school year) from CMS of the ORP requirement. This would give ODM and ODE additional time to work with school districts to develop and implement a fully compliant ORP process. There are many questions that ODM/ODE has yet to answer, and time is running out with the August 1, 2016 deadline. The ORP requirement is a result of the Affordable Care Act (ACA), which may substantially change based on the upcoming presidential election. This extension would give additional time to modify the Ohio MSP ORP process based on any changes to the ACA.
  • The final option is to require OT, PT, and SLP services to be prescribed by a Physician. Currently Ohio is allowing the MSP ORP provider to be a Physician, Physician Assistant, or an Advanced Practice Nurse. Physician Assistants and Advanced Practice Nurses must work under the direction of a Physician, so in reality, it is a Physician that would need to do the ORP. A few school districts have a physician on staff, and I know that several ESCs are looking into the possibility of providing this service to school districts. Our biggest concerns with this options is the timeline involved and finding enough physicians to write over 61,000 prescriptions, not to mention the ongoing prescriptions that would need to be obtained.

The intent of this ACA requirement is to cut down on “Waste, Fraud, and Abuse”, but it appears that the current ORP ruling does just the opposite. This CMS rule requires States to enroll ORP providers into their State Medicaid Program and screen the provider to make sure that their license is current. This direction that ODM/ODE is taking does not screen any current MSP providers, and the providers that it adds to the program (Physicians), would have already been screened in their physician practice. We also must address which students will require a prescription, just Medicaid students, or all students. If it is just Medicaid students, are we now asking billing vendors to share with districts who has Medicaid and who does not? If that is the case, what about the problem of treating one group of students differently than another? These questions and many more need to be answered as soon as possible. ODM/ODE received the CMS letter on October 23, 2015, told school districts on January 27, 2016, and today is February 12, 2016, and nothing additional has been communicated. The current CMS deadline is August 1, 2016, and the pace that ODM/ODE is taking just gets worse by the day.

What can your district do to help resolve this issue?

Contact your State Legislators.
Contact ODM and ODE.
Get with your therapists and get their opinions.
Contact your ESC and find out what their capabilities are.
Check with physicians in your area on their willingness to ORP.

Worthington City Schools is hosting an Interested Parties Meeting at 1:00 on February 25, 2016 (see attached invitation), and plans to have many School Districts, Legislators, Associations, Billing Vendors, and hope to get ODM and ODE to attend also. This critical issue requires school districts take an active role in order to get ODM/ODE to listen and take into account your concerns. The billing vendors often work together to resolve these types of issues on your behalf, but the State really wants to hear from school districts. Please use whatever contacts you have to help resolve this issue in a reasonable and timely fashion.

ODM/ODE Contact Information:

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