IDEA Part B: Medicaid and Other Third Party Reimbursement

What IDEA Says

The IDEA Part B regulations state the public agencies' ability to use Medicaid or other insurance programs to pay for required services (§300.154). In addition to requirements prohibiting the use of the parents' benefits—if such use would result in the parents incurring additional expenses or a decrease in the available lifetime coverage—the 2006 regulations require the public agency to obtain consent each time access to public insurance proceeds is sought (§300.154 (e)(2)(i)). Parents do not have to give consent each time a service is provided. However, parents do have to be informed of the number of hours that will be accessed for intervention services. Parents must also be notified that their refusal to allow access to public benefits or insurance programs does not preclude the public agency from providing all required services at no cost to parents.

Implications for ASHA Members

ASHA members should be aware if public or private funds are being used in the provision of services. Medicaid has specific provider qualifications, supervision guidelines, and documentation requirements that need to be met for reimbursement and coverage of medically necessary services in the individualized education program (IEP).

While the IDEA regulations allow the state educational agency (SEA) to establish personnel qualifications, in the Analysis of Comments and Changes section of the regulations for §300.156, the U.S. Department of Education states that ... "the fact that Medicaid will not pay for providers who do not meet Medicaid provider qualifications should serve as an incentive for states that want to bill for medical services on children's IEPs to impose consistent requirements for qualifications of related service providers." This guidance sends a clear message to SEAs that consistent provider qualifications are necessary to ensure compliance with other federal programs.

Audiologists and speech-language pathologists (SLPs) should also be aware that parental consent is required when a school bills either Medicaid or private health plans for services provided in the schools. Additional information on Medicaid requirements can be found on ASHA's website.

What Members Can Do

ASHA members should become familiar with the Medicaid regulations and how they differ from the IDEA requirements. Members should also be familiar with the state's implementation policies of Medicaid regulations. Each state has an approved plan for implementing the school-based Medicaid program and plans differ among states. Audiologists and SLPS should serve as a resource to their school administrators on the differences between the two programs.

ASHA members should also familiarize themselves with ASHA documents addressing supervision of support personnel (see the "Under the Direction of" documents).