SHARS Benefits to Change for Texas Medicaid

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SHARS Benefits to Change for Texas Medicaid

As we approach the beginning of the 2023 FFY (October 1, 2022) as well as the November 1, 2022 deadline for Speech Pathology policy changes, ONWARD wishes to remind you of these prior notifications.  Starting in August 13, 2021 ONWARD began releasing training information and guidelines as notifications were issued by the Health and Human Services Commission (HHSC) and the Texas Education Agency (TEA) outlining new policies and regulations for SHARS.  Beginning November 1, 2021, the following changes were made to the Texas SHARS program:

Reminder: Speech Therapy providers will have 365-days or one year-long grace period for the new referring or prescribing provider NPI requirement.

Overview of Benefit Changes

Major changes to this medical benefit include the following:

  • New billable procedure codes for audiology evaluation and management services
  • Clarification for occupational therapy (OT), physical therapy (PT), speech therapy (ST), and audiology services
  • New documentation requirements for all SHARS services
  • New documentation requirements for special transportation
Audiology Services

The following information about provider referrals for audiology services have been added:

  • A referral from a physician or another eligible referring provider is required for audiology services. The referral must be signed and dated within three calendar years before the initiation of services and must be updated a minimum of once every three calendar years.
  • Audiologists whose evaluations serve as the referral must be enrolled in Medicaid as individual practitioners and must use their individual National Provider Identifier (NPI) for claim submission.
  • The school district must maintain the referral in the client’s record.
Physical Therapy, Occupational Therapy, and Speech Therapy Therapy

The following information about care coordination for PT, OT, and ST services will be added:

Care coordination between SHARS PT, OT, and ST providers and non-SHARS PT, OT, and ST providers is strongly encouraged to reduce or avoid duplication of services. Care coordination requires parental consent and must be carried out in a manner that complies with privacy and confidentiality requirements in accordance with state and federal law and regulations including Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA).

Physical and Occupational Therapy

The following information about prescriptions for PT and OT services will be added:

  • A prescription from a physician or other eligible prescribing provider is required for PT and OT services. The prescription must be signed and dated within three calendar years before the initiation of services and must be updated a minimum of once every three calendar years.
  • A prescription is defined as a written order for services from the ordering physician or other eligible prescribing provider.
  • PT and OT services may be reimbursed up to (but not to exceed) the amount designated in the prescription.
  • The Local Education Agency (LEA) must maintain the prescription in the client’s record.
Speech Therapy

The following information about provider referrals for ST services will be added:

  • A referral from a physician or other eligible referring provider is required for ST services. The referral must be signed and dated within three calendar years before the initiation of services and must be updated a minimum of once every three calendar years.
  • A referral is defined as a written document requesting evaluation for services (such as ST or audiology) from the referring physician or other eligible referring provider.
  • Speech therapists whose evaluations serve as the referral must be enrolled in Medicaid as individual practitioners and must use their individual NPI for claim submission.
  • The school district must maintain the referral in the client’s record.
TEA Certified SLPs and Grandfathered SLPs

Also, as of October 1, 2022 TEA certified speech therapists will no longer be an approved speech therapy provider for SHARS reimbursements.

Co-Treatment

The following information about co-treatment for PT, OT, and ST services will be added:

  • PT, OT, or ST services that are prescribed in the student’s Individualized Education Program (IEP) may be reimbursed when delivered as co-treatment. Providers should document in the session notes the reason for co-treatment. Multi-disciplinary team evaluations performed collaboratively with any combination of PT, OT, or ST, and psychology may be billed by each provider when performed during overlapping time periods.
  • Co-treatment is defined as two different therapy disciplines performing therapy on the same client at the same time by a licensed therapist and rendered in accordance with the Executive Council of Physical Therapy and Occupational Therapy Examiners, and Texas Department of Licensing and Regulation.
Re-Evaluations

The following information about re-evaluation requirements for SHARS services will be added:

  • Individuals with Disabilities Education Act (IDEA) requires that a student receiving SHARS services must have a re-evaluation every three years, which requires current information, unless the parent and the LEA agree that a re-evaluation is unnecessary (IDEA §1414 (a)(2)(B)). The need for a re-evaluation should be determined by the student’s Admission, Review, and Dismissal (ARD) committee.
  • A physician’s prescription or referral is not required specifically for a re-evaluation, provided the prescription or referral for services has occurred in the previous 3 years.
Documentation Requirements

The following documentation requirements will be added:

Documentation of services should be generated at the time of service, or shortly thereafter, to maintain an accurate medical record. Documentation of services must occur within 1 week (7 calendar- days) of the time the service is rendered.

The following service log documentation is required for all SHARS services:

  • Student’s name
  • Student’s date of birth
  • Student’s Medicaid identification number on every page of the chart/record/note
  • Date of service, including the following for each date of service:
    • Billable start and stop time
    • Total billable minutes
    • Student observation
    • Procedure code(s)
    • Activity performed; documentation of service provided must support the services billed
  • The SHARS provider’s printed name, title, and original handwritten or electronic signature

Service providers are expected to perform and document evaluations in accordance with discipline-specific standards of practice and retain records in the student’s file.

Session notes are required for therapy (audiology, OT, PT, ST, and counseling), and must include all elements of a service log in addition to the following:

  • Student’s progress towards goals (if applicable)
  • Note whether the service was provided individually or in a group
  • The related IEP objective

Note: Any electronic signature technologies that are used must comply with all federal and state statutes and administrative rules.

Special Transportation

Transportation services in a school setting may be reimbursed when they are provided on a specially adapted vehicle and if the following criteria are met:

• Provided to or from a Medicaid-covered service on the day for which the claim is made
• A child requires transportation in a specially adapted vehicle to serve the needs of the disabled
• A child resides in an area that does not have school bus transportation, such as those in close proximity to a school
• The Medicaid services covered by SHARS are included in the student’s IEP
• The special transportation service is included in the student’s IEP

Transportation services are provided on a specially adapted school bus to or from the location where the school-based service is provided.

A specially adapted vehicle is one that has been physically modified (e.g., addition of a wheelchair lift, addition of seatbelts or harnesses, addition of child protective seating, or addition of air conditioning). If an LEA already provides a modification for all students, then the modification is not considered a special adaption. For example, if air conditioning is already provided to all students, then air conditioning is not considered a specially adapted modification.

Bus monitor or other personnel accompanying children on the bus is not considered an allowable special adaptive enhancement for Medicaid reimbursement under SHARS specialized transportation.

The student’s IEP must document the need for transportation to be provided on a specially adapted vehicle.

Specialized transportation services reimbursable under SHARS requires the Medicaid-eligible special education student has the following documented in his or her IEP:

• The student requires a specific physical adaptation or adaptations of a vehicle in order to be transported
• The reason the student needs the specialized transportation

If a SHARS student rides the regular school bus to and from school with other nondisabled students, then that student is not required to have specialized transportation services listed in their IEP.

Covered transportation services from a child’s residence to school and return are not reimbursable if, on the day the child is transported, the child does not receive Medicaid services covered by SHARS (other than transportation). This service must not be billed by default simply because the student is transported on a specially adapted bus.
Transportation services is limited to a total of four one-way trips per day.

The following requirements for special transportation trip logs will be added:

Trip logs must be maintained daily to record one-way specialized transportation trips. This documentation must include the number of one-way trips per day and the time for each trip (can be indicated using AM/PM). At a minimum, trip logs should also include the following:

  • Name of the LEA
  • Route name or number
  • Bus driver’s name
  • Bus aid or bus monitor aide name (if applicable) and initials for each one-way trip
  • Date of service and day of the week
    • If a service is not provided on a school day, Monday-Friday, mark the student as absent
  • Copy of the school district’s calendar (to be submitted once during the annual desk review)
  • Indication if a bus aide or monitor was needed
    • Schools may only bill for a bus aid/monitor if this service is prescribed in the child’s IEP
  • If personal care services are provided on the bus, documentation of the type of personal care service (type of activity and group/individual) that was performed must be included
  • Student’s full name, and Medicaid number
    • If the Medicaid number is not in the log, a separate ledger detailing student name, date of birth, and Medicaid status and number must be provided
  • Dated signature of the bus driver and bus aide/monitor (if applicable)
    • Dated signatures should be captured after all trips have been documented

Reminder: LEAs must adhere to all HIPAA and FERPA guidelines when documenting and submitting special transportation logs.

Record Retention

The following additional documents must be collected and maintained by the LEA:

  • Assessments/evaluations
  • Written agreements (contracts) for contracted service providers
  • Copies of signed Certification of Funds (COF) letters and supporting documentation, including quarterly COF reports
  • E-signature authorization forms, if applicable

Refer to: The current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsection 3.4.1, “Record Retention,” for a list of additional documents that must be collected and maintained.

Personal Care

Personal care services are provided to help a child with a disability or chronic condition benefit from special education. Personal care services include a range of human assistance provided to persons with disabilities or chronic conditions which enables them to accomplish tasks that they would normally do for themselves if they did not have a disability.

An individual may be physically capable of performing Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) but may have limitations in performing these activities because of a functional, cognitive, or behavioral impairment. PCS include direct intervention (assisting the client in performing a task) or indirect intervention (cueing or redirecting the client to perform a task).

Students must be enrolled in special education, under the age of 21, Medicaid eligible, have the activities outlined in the IEP and be required based on the direct need of the student’s disability or chronic condition.

SHARS PCS activities may include:

  • Bathing, Dressing, Eating, Locomotion or Mobility, Personal Hygiene, Positioning, Toileting/Diapering, Transferring, Hand-over-hand support when completing PCS activities and/or Functional Curriculum tasks, Grocery Shopping, Housework/Chores, Meal Prep/Cooking, Escorting, Medication Assistance, Money Management, Telephone use or other communication tools, and Orientation & Mobility Services.
  • Redirecting, cueing, prompting any of the Activities for Daily Living (ADL) or Instrumental Activities (IADL) for Daily living may qualify as a SHARS PCS activity.

Personal Care Services (PCS) does not include the following:

  • ADLs, IADLs, or HMAs that a typically developing child of the same chronological age could not safely and independently perform without adult supervision (i.e. potty training)
  • Services that provide direct intervention when the client has the physical, behavioral, and cognitive abilities to perform an ADL, IADL, or health-related function without adult supervision
  • Services used for or intended to provide respite care, childcare, or restraint of a client
  • Braille instruction
  • Sign language interpreter (or interpreting)
  • Stand-by observation/supervision related to safety
  • Teaching a life skills curriculum
  • Cueing educational tasks

Functional curriculum is NOT Personal Care

To be reimbursed for Personal Care Services, services provided mut not be delivered solely for the purpose of education, such as Reading, English, Language Ats, Writing, Mathematics, Science, Social Studies, Physical Education, Functional Curriculum or Electives.

Personal Care Documentation for SHARS Reimbursement

Personal care service (PCS) providers are required to complete timely service logs.  Guidance for this requirement comes from the Texas Medicaid Provider Procedures Manual (TMPPM). As clarification was requested in the past, the Health and Human Services Commission (HHSC) developed and distributed a Frequently Asked Questions (FAQ) documents. The FAQ specifies, “Service log for PCS must include the signature of the individual that provided the PCS. In cases where more than one person provided PCS throughout the day, only one person needs to sign the service log.” TEA audits confirm that districts have implemented this guidance in self-contained classrooms.  One staff member is chosen to document PCS provided by the classroom staff throughout the day.

The FAQ expired on October 31, 2021. HHSC reminds us that the current guidance document is the November 2021 TMPPM SHARS Handbook. In subsection 2.4, it includes new language regarding documentation requirements:

The SHARS provider’s printed name, title, and original handwritten or electronic signature are required components of the service log for all SHARS services, including PCS.

Therefore, there is an expectation that all service providers, including staff in self-contained classrooms, must document their own service.  TEA will enforce this expectation for documents created on or after November 1, 2021, when the FAQ expired.