Medical Assistance (MA) Billing
Explanation
MA billing is a system where Minnesota's Department of Human Services (DHS) reimburses school districts for specific health-related services provided to special education students.
DHS has specific paperwork requirements (which are described in DHS's MHCP Provider Manual), and it is the responsibility of school districts—not DHS—to fulfill those requirements in order to receive reimbursement. Districts may only bill for services provided within the current school year.
SCRED member districts engage in MA billing for two reasons:
It's the law. Minnesota legal statute 125A.21, subd. 2(a) dictates that districts must seek reimbursement from third parties and "maximize" attempts to collect MA revenue.
The revenue benefits our students. Any money received from third party billing can only be used (1) for the costs of billing itself and (2) for the benefits of students with special needs. Within the SCRED member districts, MA revenue is used to offset non-reimbursable special education costs (which frees up general education revenue).
Five Reimbursement Requirements
In order for the school to actually bill and receive reimbursement, five requirements must be met:
The student must be eligible for MA billing
The student must be receiving an MA billable service
ICD-10-CM code(s) must be assigned
Service documentation must be complete and accurate, including Start and End times for each service provided. Service documentation and attendance records must match.
The school must have parental consent to bill MA
Provided that requirements 1 and 2 have been met, we proceed with 3 and 4 even if we don't have 5 (consent to bill) yet. Why? First, because it's a requirement from the Department of Human Services (DHS). Second, as long as services have been documented, we can back bill once we receive consent.
MA Billing Process Flowchart
Two circumstances prompt case managers to engage with the MA billing process: either (A) your student just began receiving an MA billable service or (B) your student just became eligible for MA billing.
From either entry point, various steps must be taken in order for the school to meet the five requirements that must be met in order to actually bill and receive reimbursement.
An assigned individual in each district (typically a Due Process Secretary) periodically checks the MA eligibility website and emails case managers a list of students who are eligible. MA eligibility must be determined for all students, including those who have been referred for an initial special education evaluation.
There are eight different types of MA billable services (see below). Even within these eight categories, for a service to be considered billable, it must be:
Medically necessary and compliant with MA service requirements (see details below regarding specific covered vs. non-covered activities)
Provided and/or supervised by qualified staff working within their scope of practice (see details below regarding qualification and training requirements)
Included in the student's IEP/IFSP
Reflected as a need in the student's evaluation report
Personal Care Assistant (i.e., Paraprofessional) Services
PCA services must be supervised by a qualified professional who is operating within their scope of practice (see examples in each section). These qualified professionals are responsible for ensuring that PCAs are trained on the specific needs of the student—as identified in the IEP and written in the PCA Plan of Care (see the section below on 'Services Documentation' for more information about PCA Plans of Care)—display competency in providing the required services, and understand documentation requirements. In order to qualify as a PCA for the purposes of MA billing, paraprofessionals must pass the DHS Individual PCA Training Course and provide the district with a copy of their certificate of completion. Billable PCA services fall under the three categories described below:
Activities of Daily Living (ADLs)
Eating: Assisting with hand washing, applying orthotics, transfers, food preparation, and feeding.
Toileting: Assisting with elimination and diapering, transfers, mobility, positioning, feminine hygiene, use of toileting equipment and supplies, cleansing, skin inspection, adjusting clothing, or re-dressing.
Grooming: Assisting with personal hygiene, basic hair care, oral care, shaving, applying cosmetics and deodorant, or eyeglass and hearing aid care.
Dressing: Assisting with choosing, applying, or changing clothes; applying orthotics and prosthetics; or special clothing (TED hose).
Bathing: Assisting with basic personal hygiene and skin care for bathing or showering. This includes transfers, positioning, assisting with soap, rinsing, drying, skin inspection, and applying lotion or other products.
Transferring: Assisting with moving from one seat/bed to another, using a lift, pivoting. Includes two person lifts and standing by to assist.
Mobility: Assisting with ambulation. This includes assisting with using a wheelchair, walker, or cane.
Positioning: Assisting with positioning, repositioning, or turning for necessary care and comfort. This includes relieving pressure areas, positioning with pillows, wedges, or bolsters whether in a chair, bed, sofa, or wheelchair.
Depending on the specific ADL being supported, school personnel who would be qualified to supervise PCAs in this area include, but are not limited to: PTs, OTs, school nurses, and developmental disabilities specialists (e.g., DCD-licensed teachers). The specific ADLs of positioning, transfers, and toileting can be supervised by a PT or school nurse; however, they cannot be supervised by: speech pathologists, audiologists, school psychologists, social workers, or special education teachers because positioning, transfers, and toileting are not considered to be within the scope of practice of those professions.
Health-Related Tasks
Covered services include health-related tasks that do not require the skill of a nurse, such as:
Assistance with range of motion and passive exercises to maintain muscle function and strength
Assistance with self-administered medication (e.g., cueing student to take medication, handing the student medication that has been set-up, opening medication, and ensuring that the student takes medication). PCAs do not dispense or administer medication.
Intervention for seizures including monitoring and observing while the child is having a seizure. Continuous monitoring for seizures is not covered.
Tracheostomy suctioning and ventilator care. Clean procedures are covered, but PCAs do not provide sterile procedures.
School personnel who would be qualified to supervise PCAs in this area include school nurses.
Observation, Redirection, or Intervention of a Behavior Episode
There are three categories of behavior that require covered services:
Level 1 Behaviors: Self-injurious behavior, physical aggression towards others, or destruction of property.
Behaviors occur at different frequencies, intensities, and in different situations. For PCA services to be billable, the level 1 behavior must be current, and episodes must occur either daily or on an ongoing basis (e.g., four times a week). To qualify for PCA services in this area, the student's behaviors must occur due to a medical or mental health condition.
The school can only bill for time when the PCA is fully engaged, working face-to-face or hands-on with the student during episodes that require the immediate response of another person to prevent injury to self, injury to others, or damage to property. The clock can start when the student begins to demonstrate lower-intensity behaviors that typically escalate into level 1 behaviors if, at that point, the PCA begins to implement specific strategies designed to prevent level 1 behavior. For example, for a student who appears agitated, pushes away from their desk, and stands up, if a PCA begins using verbal de-escalation strategies and/or begins moving objects away from the student (to prevent property destruction or other level 1 behaviors), the school could count that time for the purposes of billing.
Increased vulnerability due to cognitive deficits or socially inappropriate behavior (only for students who receive another PCA service (i.e., ADLs)). For example, for a student who is receiving PCA services for toileting who also has a history of elopement during unstructured activities, PCA services that include observation and redirection of behavior would be billable during passing time, recess, and/or lunch.
Resisting care and verbal aggression that cause care to take longer than normally expected (while receiving another PCA services (i.e., ADLs)). For example, for a student who is receiving PCA services for eating, PCA services that include observation and redirection of behavior would be billable when the student swears at staff and pushes eating materials off their table.
Examples of non-billable/non-covered services include redirection when students are: not staying on task with the lesson plan, not listening to the teacher, speaking out of turn, making comments out loud, or grabbing for other children’s property.
School personnel who would be qualified to supervise PCAs in this area include, but are not limited to: school social workers, school psychologists, and some special education teachers (e.g., EBD-licensed teachers for Level 1 behaviors and DD/DCD-licensed teachers for the other categories described above).
**For specific information and resources related to documenting PCA services (i.e. time studies), refer to the section further down this page, titled "Service Documentation", under PCA Services, under Logging Services.
Special Transportation
Covered services include getting a student to and from the vehicle, waiting for the vehicle with the child, and transporting the child. Services are only covered when all of the following requirements are met:
Services are provided in a district owned vehicle or a contracted school transportation agency vehicle.
The student has a physical or mental impairment that prevents them from safely accessing and using a common carrier (taxi, bus, car, van).
The student requires at least one of the following while being transported:
A special adaptation (e.g., wheelchair lift, special harness, safety vest, or special car seat).
An aide, nurse, or PCA. The aide/nurse/PCA cannot also be the driver, and for the service to be billable, the ratio of aide/nurse/PCA-to-student(s) must be 1-to-3 or below.
The student is transported to another MA covered IEP service on the same day. Note that sign language interpreter services do not count for this requirement.
Only trips from home-to-school and school-to-home are billable. Trips in the middle of the day (e.g., transportation from the school building to a job site and back) are not billable.
Mental Health Services
Covered services include:
administering assessments face-to-face,
interpreting assessments results, and
writing reports. Evaluation review meetings are not covered. The evaluation does not need to result in an IEP/IFSP to be covered.
Covered providers include: School Psychologists when completing the specified IEP evaluation activities.
Speech/Language Pathology and Audiology
Covered services include: Individual and group therapy, specialized maintenance therapy as provided by a speech and language pathologist, telemedicine, and IEP evaluations.
Covered providers include: Educational speech & language pathologists (Masters in speech/language pathology, licensed by MN Board of Teaching, and either a Certificate of Clinical Competence (CCC) or has completed the required education and work experience to obtain the CCC), Speech & language pathologist (Masters and CCC), Audiologists, clinical fellowship licensees (Master’s degree and completing the supervised clinical fellowship under MN Statutes 148.511-148-5196).
Physical Therapy (PT) or Occupational Therapy (OT)
Covered services include: Individual and group therapy, specialized maintenance therapy, and IEP evaluations (provided by a physical therapist or occupational therapist).
Covered providers include: Physical Therapists, Occupational Therapists, and Physical Therapy Assistants or Certified Occupational Therapy Assistants (COTA) working under the direction of a PT or OT at least every sixth treatment session.
Assistive Technology Devices
Covered devices may be purchased or rented, and repairs are also covered. Before billing, the device must be purchased/rented and delivered to the student. It must belong to the student (i.e., it cannot be purchased for ownership and exclusive use by a school program).
Covered devices include:
Augmentative and Alternative Communication (AAC) devices
Hearing amplification devices
Mobility devices
Positioning devices
Hardware/software essential to a covered device
Nursing Services
Covered services include:
Face-to-face nursing care or medication administration
Medication management
IEP evaluations
Covered providers include: Licensed School Nurses (LSN), Licensed Practical Nurses (LPN), Registered Nurses (RN), or Public Health Nurses (PHN).
Oral Language & Sign Language Interpreter Services
Covered services include:
Services provided to a student with limited English proficiency in conjunction with another covered IEP service
Services provided to a parent in order to obtain and relay information regarding the student during a covered IEP service or evaluation. Note that meetings are not covered. The most common covered interpreter service is assisting with a parent interview during an evaluation. Additional examples of possible covered interpreter services include Part C parent-consultation services for early childhood students and consultation with a parent for a student receiving home-based or homebound services.
Covered providers must speak the language (or sign) and must be employed by or have a contract with the district to provide language interpreter services.
After billable services have been identified, case managers (or a district-assigned MA billing point person) send an ICD-10-CM Code Checklist for MA Billing to the appropriate service providers, who then assign codes and return the form to the case manager or MA billing point person.
Case managers do not assign ICD-10 codes. For most MA billable services, the person responsible for assigning the ICD-10 code(s) is the same person who provides the service. For example, a school nurse assigns the ICD-10 code(s) for nursing services, a Physical Therapist assigns the code(s) for PT services, etc.
For PCA and special transportation services, an OT, PT, school nurse, or school psychologist assigns the ICD-10 code(s) — depending on who is qualified to supervise the service. For example:
If the student is receiving special transportation for a health-related reason, the school nurse would assign the ICD-10 code.
If the student is receiving special transportation due to behavior, a school psychologist would assign the ICD-10 code.
For mental health services, school psychologists assign the ICD-10 code(s).
ICD-10-CM Code Checklist for MA Billing: Case managers often print a hard copy of the form and use that hard copy to collect ICD-10 codes from staff. However, if you would prefer to make a digital copy that can be emailed or shared in Google Drive, click the link.
To set up an ICD-10 code in SpEd Forms, click the "MA Forms" tab and then the "ICD-10 Code Setup" module.
Click "Add New Code" and then "Edit." At the top of the setup page, SpEd Forms includes a link to a helpful tutorial document. An index of current ICD-10-CM codes can be accessed at ICD10Data.com.
Service providers, case managers, and/or MA Billing Site Contacts complete the ongoing task of filling out activity logs and data collection forms. These forms are submitted to an assigned person in each district on a monthly basis.
Remember that billable services should be documented for all MA eligible students regardless of whether parental consent has been obtained (A) because this is a DHS requirement and also (B) because we can back-bill for services if we receive consent at a later date.
Read below for descriptions of unique documentation requirements regarding specific covered services.
PCA Services
PCA Plans of Care
What is it?: PCA Plans of Care (POC) are written descriptions of each of the medically necessary services a student needs during the school day that will be delivered by a PCA.
Who develops it?: A POC is developed by the qualified professional (QP) responsible for supervising the PCA service. If the student is receiving more than one MA billable PCA service and multiple QPs are supervising, the QPs work together to develop a single POC rather than maintaining multiple POC documents.
When is it developed?: A POC must be developed within the first week of the student receiving MA billable PCA services. Update the POC if/when there is a change in the student’s need for PCA services. The POC must be reviewed and revised (if necessary) annually.
Where does it live?: Case managers have three options for the location of a student's PCA Plan of Care (see below). Regardless of which option is chosen, a statement describing where the PCA Plan of Care is located must be included in the IEP. It is recommended this statement be included either on the Services page where the need for 1:1 para support is described, or, if the student does not have a need for 1:1 para support, in the accommodations section. See examples of these linking statements under each option below.
PCA Plan of Care Template in SpEd Forms.pdfOption 1: PCA Plan of Care Template in SpEd Forms
A tutorial on how to access this template in SpEd Forms is available. When completed initially and when updated, this form can simply be finalized in the same way that PWNs, evaluation reports, etc. are finalized in SpEd Forms.
Example linking statement: "George's Personal Care Assistance (PCA) Plan of Care will be maintained as a separate document."
PCA Plan of Care with Help Text - Master CopyOption 2: PCA Plan of Care Template in Google Docs
A tutorial on how to upload Google Docs to a student's SpEd Forms history page is available.
Example linking statement: "David's Personal Care Assistance (PCA) Plan of Care will be maintained as a separate document."
BSP Template - SpEd Forms.pdfOption 3**: BSP Template in SpEd Forms
**A Behavior Support Plan (BSP) can function as a student's PCA POC only for Level 1 behaviors.** If the student is also receiving PCA services based on ADLs, health-related tasks, vulnerability, etc. (see above), they will need a separate PCA Plan of Care.
Example linking statement: "Chelsea's Personal Care Assistance (PCA) Plan of Care will be maintained as a separate document. Her Behavior Support Plan will function as her PCA Plan of Care."
Logging PCA Services
There are two options:
Continuous Logging: Document the face-to-face time spent with the child according to the Plan of Care for that child for each task provided per day.
Time Study: Conduct a 10 day time study to determine the average time per day, per child for the specific PCA tasks identified in the Plan of Care for that child. The time study must be current and meet the MA IEP PCA Time Study requirements.
Form requirements, regardless of documentation method:
Must include start and end times.
Must include a statement indicating it is a federal crime to provide false information on personal care services billings for medical assistance.
If the form you are using does not meet both of these requirements, connect with your School Psychologist, Special Services Supervisor, or the Director of Special Education for guidance and assistance.
When completing logging or time study forms:
Complete one record per student even if there are multiple paras; multiple paras can use the same record.
Make only one entry for the total time served.
Make separate entries when the group size changes.
SCRED PCA Time Study MasterExample option 1: SCRED Time Study Form
MA Billing Time Study FormExample option 2: North Branch Time Study Form
Special Transportation
A special education transportation trip log is completed for eligible students (see criteria above) per trip from home-to-school and school-to-home each day that the eligible student receives another billable service.
For example if the student with a special adaptation, such as a 1:1 aide on the bus, receives speech therapy twice a week, we can bill for transportation on those two days, but not on days when the student is not receiving billable services (assuming that speech is their only other billable service).
If a student with a special adaptation on the bus, such as a wheelchair lift, receives MA billable PCA services every day, then transportation could be billed each day, so long that they meet the other eligibility criteria.
Nursing Services
For all nursing services that—per the nurse’s license—require a physician’s order or prescription, the nurse must obtain an order or prescription at least annually or following IEP amendments where billable nursing services are changed. The orders/prescriptions must be obtained from a physician, nurse practitioner, or physician assistant; must include dated signatures; and must be in place at the time the service is billed.
The case manager explains the district's request to access MA to bill for services and then obtains parental consent using the MA Parental Consent Form. For the sake of convenience, this often occurs during IEP meetings but can occur at any point.
After initial consent is obtained, annually providing parents with procedural safeguards is the only ongoing requirement.
Script for Explaining MA Billing:
"By law, schools are mandated to bill Medical Assistance or MinnesotaCare for certain health-related special education services that students receive."
"The state has reserved a funding source specifically for schools to support these health-related special education services, and there will not be any changes to your Medical Assistance coverage as a result of us billing."
"Before billing for the first time, the district must provide you with information regarding the billing process and obtain your consent. Every year after, you will be provided with a copy of your Procedural Safeguards. This document will serve as notice to you that the district intends to continue billing for the services, unless you choose to withdraw your consent."
"We appreciate your support with this process! If you have any further questions, please feel free to contact our Special Services Supervisor."
After the MA Parental Consent Form is signed:
Send the signed hard copy to the assigned MA billing clerk in your district (i.e., the individual who periodically e-mails you a list of MA eligible students on your caseload).
From there, the MA billing clerk:
Scans the MA Parental Consent Form and uploads it to SpEd Forms under the student's History tab.
Sends the scanned copy to Heather Guzik at SCRED (hguzik@scred.k12.mn.us).
Files the hard copy of the form in the student's SpEd file.
✋ Frequently Asked Questions
Can you MA bill for time spent on an initial evaluation if it doesn't result in qualification and an IEP?
Yes, you can bill. Per the DHS Manual:
"Medical Assistance (MA), Minnesota’s Medicaid, will reimburse the federal share of the cost of covered health-related evaluations and assessments under the Individuals with Disabilities Education Act (IDEA) when conducted for the sole purpose of identifying the health-related needs for a child’s IEP or Individualized Family Service Plan (IFSP) or to determine the need for continued coverage. That is, if the school is evaluating a child for the sole purpose of identifying the health related needs of that child for the child’s IEP or IFSP, MA will cover the time spent performing that evaluation or assessment even if the service does not get added to the IEP or IFSP or result in an IEP or IFSP."