Medicaid reimbursement for school nursing services: a position paper of the National Association of State School Nurse Consultants.
School nursing services are currently provided to all students in order to support and sustain their school attendance and to maximize their learning potential. The need for these services has increased dramatically in recent years due to changing student populations, not only among students with disabilities, but also among the general student population. Because of federal legislation related to the education of children with disabilities and the access rights of persons with handicaps, previously homebound or institutionalized children now attend public school in their neighborhood. Furthermore, advances in medical science and technology have enabled children with complex medical conditions, chronic diseases and other physical and mental health impairments to function more freely and participate more actively in school programs. Among the general population of students, other factors have contributed to the increased demand for school nursing services. For example, working parents frequently have limited opportunities to seek preventive health care for children and expect school nurses to assist them by providing nursing assessment and triage for potential or existing health problems. Similarly, the risk-taking behavior of adolescents in a changing and challenging society increases the need and demands for health services by qualified professional school nurses. Finally, promoting the health and safety of students during the hours of mandatory school attendance is an inherent responsibility of the school.
Despite this increased demand, there are no federally designated funds for school nursing services. Thus, funding is a challenge for school districts nationwide. The creative school district must rely on a combination of local, state and federal categorical funds to provide services allowed within the parameters of the designated funding program. Most recently, states have begun claiming Medicaid funds to provide needed health services for Medicaid eligible students. A number of states are currently reimbursing school districts with Medicaid funds to provide physical and occupational therapy, and audiological, nursing, psychological, and speech services for students with disabilities. Nursing services should be included in all state plans.
The school district that provides school nursing services to a student who is eligible for Medicaid should be reimbursed at a unit rate for the services provided. For quality assurance purposes, reimbursement should be restricted to services which are provided by qualified registered nurses or which are delegated by them to other licensed or unlicensed personnel based on:
* the nurse's assessment of the student's health status;
* the complexity of the procedure;
* the education and ability of the LPN/LVN or unlicensed paraprofessional;
* availability of the RN to provide adequate supervision; and
* applicable requirements of state laws and regulations governing nursing practice.
Medicaid: A federal/state medical assistance program for low-income families through Title XIX of the Social Security Act. The state is required to match federal funds to benefit from the program. Children with low income can receive comprehensive and interim screening, diagnosis and medically necessary treatments through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) preventive program. Medicaid will also pay for therapeutic treatments and procedures to Medicaid eligible children with disabling conditions or chronic illness.
Service Units: Segments of service time that are reimbursable by Medicaid. Reimbursement for school nursing services can be based on designated school nurse-student encounters or on increments of time (service units) anticipated for the designated service. For example, service units for school nursing might be defined according to the following terms: Brief Visit, 15 minutes, limited nursing assessment/intervention; Intermediate Visit, 30 minutes, extended nursing assessment/intervention; and Comprehensive Visit, 45 minutes for in-depth nursing assessment/intervention.
CATEGORIES OF SCHOOL NURSING SERVICES
The following list of potentially reimbursable school nursing services is not intended to be all inclusive. Documentation and quality assurance mechanisms, while not included on the list, are essential components of all service delivery.
1. Nursing assessment of applicants registering for early child development programs.
2. Pre-school health appraisals for kindergarten children and periodic assessment of eligible students who have not had a comprehensive health appraisal in the past year (EPSDT).
3. Health appraisal with middle school entrants who have not had a comprehensive health appraisal in the past two years (EPSDT).
4. Health assessment of students referred for special education eligibility evaluation.
5. Case-finding screening activities including health history review, developmental maturation/milestones, vision acuity status, hearing acuity status, speech development, dental deviations, spinal deviations, blood pressure abnormalities, growth and nutritional disorders.
6. Nursing assessment of new or previously identified medical/health problems based on student initiated or teacher/staff referral to nurse, including substance use assessment, child abuse assessment, pregnancy confirmation, etc.
7. Home visit for comprehensive health, developmental and/or environmental assessment.
Nursing Care Procedures
1. Administration of immunizations to students not in compliance with state immunization law.
2. Medication assessment, monitoring and/or administration.
3. Nursing assessment and interventions related to the Individualized Health Care Plan.
4. Nursing procedures required for specialized health care, including but not limited to: Feeding: Nutritional assessment, Naso-gastric feeding, Gastrostomy feeding, Jejunostomy tube feeding, Parenteral feeding (IV), Nasogastric tube insertion or removal, and Gastrostomy tube reinsertion; Catheterization: Clean intermittent catheterization and Sterile catheterization; Ostomies: Ostomy care and Ostomy irrigation; Respiratory: Postural drainage, Percussion, Pharyngeal suctioning, Tracheostomy suctioning, Tracheostomy tube replacement, and Tracheostomy care; Medical Support Systems: Ventricular peritoneal shunt monitoring, Mechanical Ventilator monitoring and emergency care, Oxygen administration, Hickman/ Broviac/IVAC/IMED, Peritoneal dialysis, and Apnea monitor; Medications: Administration of medications (oral, injection, inhalation, rectal, bladder instillation, eye/ear drops, topical, intravenous, and spirometer); Specimen Collecting: Blood glucose, Urine glucose, and Pregnancy testing; Other Nursing Procedures: Dressings, sterile, and Soaks; and Development of Protocols: Health care procedures, Emergency protocols, Health objectives for Individualized Education Program (IEP), Health objectives for Individualized Health Care Plan (IHCP), and Health objectives for Individualized Family Service Plan (IFSP).
1. Outreach to identify children who are eligible for Medicaid.
2. Follow-up on referrals made for further evaluation, diagnosis and treatment.
3. Home visit for follow-up, coordination or home environment assessment of students with health impairments.
4. Interim prenatal or family planning monitoring visit.
5. Visit for arranging transportation of Medicaid eligible students to medical, dental or other authorized appointments.
Student Health Counseling and Instruction
1. Limited nursing assessment, health counseling, instruction and anticipatory guidance for an identified health problem or developmental concern.
2. Extended nursing assessment and/or health counseling, instruction and anticipatory guidance for identified health problem(s) or concern(s).
3. In-depth nursing assessment and health counseling, instruction and anticipatory guidance for complex or multiple health problems.
1. Assessment, planning and intervention for emergency management of a student with chronic or debilitating health impairment.
2. Provision of urgent emergency care, to include nursing assessment and emergency response treatment, such as CPR, oxygen administration, seizure care, administration of emergency medication, and triage.
3. Post emergency assessment, and development of preventive action plan.
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|Publication:||Journal of School Health|
|Date:||Mar 1, 1996|
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