Every New Jersey school district, with the exception of any district that obtains a waiver of the requirements of N.J.A.C. 6A:23A-5.3 pursuant to the procedures set forth at N.J.A.C. 6A:23A-5.3(b), shall take appropriate steps to maximize its revenue from the Special Education Medicaid Initiative (SEMI) Program by following policies and procedures to maximize participation in the program as set forth in N.J.A.C. 6A:23A-5.3(d) and to comply with all program requirements as set forth in N.J.A.C. 6A:23A-5.3(e).
1. The school district may seek, in the prebudget year, a waiver of the requirements of N.J.A.C. 6A:23A-5.3 upon demonstration that for the subsequent school year:
a. The district projects, based on reliable evidence, that it will have forty or fewer Medicaid eligible classified pupils; or
b. The district demonstrates that efforts to participate in SEMI would not provide a cost benefit to the district, based on the projection of the district’s available SEMI reimbursement for the budget year as set forth in N.J.A.C. 6A:23A-5.3 (c) and B. below.
2. The application for a waiver of the requirements of N.J.A.C. 6A:23A-5.3 shall be made to the Executive County Superintendent no less than forty-five days prior to the submission of the district’s proposed budget for the school year to which the waiver request applies. The Executive County Superintendent shall notify the district of the decision on the waiver application within twenty days of receipt of the waiver request. If the waiver is not granted, the district shall submit a SEMI action plan to the Executive County Superintendent as required by N.J.A.C. 6A:23A-5.3(f) as part of its annual school district budget submission or demonstrate to the Executive County Superintendent the district has achieved maximum participation in the SEMI program in the prebudget year.
B. Projection of Available SEMI Reimbursement
1. As part of the annual budget information, the New Jersey Department of Education shall provide each school district with a projection of available SEMI reimbursement for the budget year, as determined by the State Department of Treasury’s third party administrator for SEMI. The projection shall be based on the following:
a. Number of Medicaid eligible pupils;
b. Assumption of twenty services per eligible pupils per year;
c. One IEP meeting per eligible pupil per year; and
d. Applicable SEMI reimbursement rates.
2. Beginning with the 2009-2010 school year, the school district shall recognize as revenue in its annual school district budget no less than ninety percent of the projection of available SEMI reimbursement. The district may seek approval from the Executive County Superintendent to use its own projection of SEMI reimbursement upon demonstration that the numbers it used in calculating the projection are more accurate than the projection provided.
C. SEMI Program Requirements
1. The school district shall strive to achieve maximum participation in the SEMI program. “Maximum participation” means obtaining a ninety percent return rate of parental consent forms for all SEMI eligible pupils. Districts shall enter all pupils following their evaluations into the third-party system to identify the district’s universe of eligible pupils. This can be done without parental consent.
2. Districts participating in the SEMI reimbursement program shall comply with program requirements as follows:
a. The school district shall implement Policy and Regulation 6111 concerning the effective and efficient administration of the SEMI reimbursement program consistent with the requirements of N.J.A.C. 6A:23A-5.3.
b. Any service submitted to Medicaid for reimbursement shall be rendered by a Medicaid qualified practitioner, or rendered by a provider under the supervision of a Medicaid qualified practitioner. The following outlines the required documentation for each related service provider:
(1) Nurses – copy of license (DOE certification is not required for SEMI);
(2) Occupational Therapist – copy of license and DOE certification;
(3) Physical Therapist – copy of license and DOE certification;
(4) Psychologist – copy of DOE certification;
(5) Social Worker – copy of DOE certification;
(6) Speech Therapist – Copy of DOE certification and American Speech-Language-Hearing Association (ASHA) Certification or Copy of DOE certification and past or present license (on or after January 1, 1993); or copy of DOE certification and documentation that the equivalent educational requirements and work experience necessary for ASHA certification have been met.
3. Practitioners who are not Medicaid qualified can deliver services under the direction of Medicaid qualified practitioners. These include certified occupational therapist assistants (COTAs), physical therapist assistants (PTAs) and speech correctionists.
4. Any direct therapy or other related service shall be prescribed in the related services section of the pupil’s IEP prior to submitting a claim to Medicaid for reimbursement. Delivery of nursing services and dispensing of medication must be referenced in the IEP and supported by physicians’ orders or prescriptions. These documents must be maintained on file. The supporting documentation to be maintained by the school district shall be the cover/signature page, related services section of the IEP, therapy logs, and the evaluations and assessments conducted by the Medicaid-qualified practitioners.
5. Entities where the school district has placed SEMI eligible pupils shall take steps to enable school districts to maximize participation, including either logging the eligible services provided directly through the vendor or the sending school district, as mutually agreed upon with the school district, and obtaining SEMI provider qualification certifications. Every out-of-district placement must provide copies of SEMI provider qualifications, certifications and licenses. This provision applies to the following out-of-district placement options:
a. Approved private schools for pupils with disabilities;
b. Educational services commissions;
c. Jointure commissions;
d. Vocational half-time programs;
e. Department of Education Regional Day Schools; and
f. Special Service School Districts.
6. All supporting documentation for a Medicaid claim shall be maintained on file and available for audit or State review for at least seven years from the date of service. Supporting documentation shall include provider certification (current and historical for each provider), provider service logs, licenses and certifications, physician authorizations for nursing services, parental consent forms, attendance records, and copies of the pupil’s IEP.
D. SEMI Action Plan
1. Each school district that has less than ninety percent participation of SEMI eligible pupils in the 2007-2008 school year or has failed to comply with all program requirements set forth in C. above, shall demonstrate a good faith effort to achieve maximum participation and to maximize available SEMI revenue during the 2008-2009 school year by submitting a SEMI action plan to the Executive County Superintendent for review and approval by September 1, 2008. In subsequent years, each school district that has less than ninety percent participation of SEMI eligible pupils in the prebudget year or that has failed to comply with all program requirements set forth in C. above shall submit a SEMI action plan to the Executive County Superintendent for review and approval as part of the school district’s proposed budget submission.
2. The SEMI action plan shall include the following components:
a. Procedures for obtaining parental consent forms including the Parental Consent Best Practices which are available from the New Jersey Department of Education.
b. Establishment of a benchmark for the 2008-2009 school year or for the first year the district does not have an approved waiver pursuant to the provisions of N.J.A.C. 6A:23A-5.3(b), whichever is applicable, for obtaining maximum participation of all SEMI eligible pupils by the start of the subsequent school year:
(1) The benchmarks for the 2008-2009 school year or for the first year that the district does not have an approved waiver pursuant to N.J.A.C. 6A:23A-5.3(b), whichever is applicable, for achieving maximum participation shall at a minimum close the gap between current participation and maximum participation by fifty percent by the beginning of the subsequent school year; and
(2) The benchmarks shall be based on the percentage of parental consent forms collected from eligible pupils. The number of parental consent forms shall reflect one parental consent form for each eligible pupil. This should include documentation of parental refusal to give consent.
c. Procedures to ensure that all IEP meetings are documented in the third-party administrator’s system. IEPs are only claimable if a Medicaid qualified practitioner is present.
d. Procedures to ensure that all SEMI eligible services, including services provided by entities where the school district has placed SEMI eligible pupils, are documented in the third-party administrator’s system.
e. Procedures to ensure that a valid IEP is on file and the IEP date is on file in the third-party administrator’s system for each SEMI eligible pupil for whom parental consent has been obtained.
f. Procedures to ensure that service providers used by the school district and entities where the school district has placed SEMI eligible pupils have valid licenses and certifications documenting SEMI provider qualifications on file in the third-party administrator’s system.
E. Districts that did not achieve ninety percent participation or achieve their approved benchmarks in the SEMI program for a given budget year and cannot demonstrate they fully implemented their New Jersey Department of Education approved SEMI action plan required above shall be subject to review for the withholding of State aid by the Commissioner pursuant to N.J.S.A. 18A:55-3 in an amount equal to the SEMI revenue projection based on their approved benchmark for the budget year, if applicable, less actual SEMI reimbursements for the budget year. The State aid deduction shall be made in the second subsequent year after the budget year.
Issued: September 2008
Revised: October 2012