HHS Appellate Decision on Texas Health and Human Services 2009

8/8/2019 HHS Appellate Decision on Texas Health and Human Services 2009

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Department of Health and Human Services DEPARTMENTAL APPEALS BOARD

Appellate Division SUBJECT: Texas Health & Human Serv ices DATE: March 19, 2009CommissionDocket No. A-08-87Decis ion No. 2235

DECISIONThe Texas Heal th & Human Serv ices Commission (Texas) appealed th edec i s ion o f th e Centers fo r Medicare & Medicaid Services (CMS) todisa l low f edera l f inanc ia l pa r t i c ipa t ion (FFP) in th e amount o f$7,846,951 c la imed under the Medicaid program as cos t s i ncur redfo r school-based hea l th s e rv ices . CMS based th e disal lowance onan HHS Office o f t he Inspec to r General (OIG) au d i t t ha t revieweda 330-un i t sample o f cla ims made fo r s e rv ices provided in e levenTexas school d i s t r i c t s from September I , 1999 through August 31,2000 ( s t a t e f i s c a l year 2000). Each sample u n i t cons i s ted o f a l lclaims fo r se rv ices provided to one s tuden t in a one-month per iodduring t h a t f i s c a l year . Based on th e sample . r e su l t s , th e OIGes t imated t h a t Texas was overpaid $8,749,158 FFP, o f which Texassubsequen t ly refunded $902,197.Texas appealed th e f u l l amount disal lowed but l a t e r withdrew itsappeal wi th r espec t to some of th e c la ims. Texas a l so ind ica tedin its r ep ly b r i e f t ha t it was not pursuing its i n i t i a l argumentt h a t th e s t a t i s t i c a l methodology used by th e OIG was i nva l id . Inadd i t ion , while t h i s appeal was pending, CMS withdrew th edisal lowance wi th r espec t to some o f th e c la ims. Most of thec la ims still a t i s sue a re fo r counsel ing, assessments , andnurs ing se rv ices th e OIG found were provided by unl icensedprov ider s . The OIG a l so found t ha t th e assessments werenonmedical assessments no t covered by Medicaid. Also remainingin d ispu te a re cla ims fo r speech therapy se rv ices th e OIG foundl acked th e r e qu i s i t e r e f e r r a l .As exp la ined below, we con,clude t ha t Texas has documented t h a tone o f t he p rov ide rs found unl icensed by th e OIG was in f a c tl i censed , and we reverse the disa l lowance with r espec t to th eclaims fo r th e d i r e c t se rv ices she provided as wel l as th e


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2 r e l a t ed c la ims fo r th e s tuden t ' s t r anspor t a t ion . However, weconclude t h a t Texas has no t met its burden of documenting thea l l owab i l i t y of th e remaining disputed cla ims fo r d i rec tse rv ices , and we uphold th e disa l lowance with r e spec t to thosec la ims as wel l as th e r e l a t ed cla ims for the s tudent s 't r a ns po r t a t i on on the da tes on which no o the r d i rec t se rv iceswere provided . 1Legal BackgroundThe f ede ra l Medicaid s t a t u t e , title XIX of the Socia l Secur i ty. Act (Act), au tho r izes a program t h a t fu rn i shes medica l ass i s t anceto low-income ind iv idua l s and f ami l i e s as wel l a s to bl ind andd isab led persons . Act 1901. Each s t a t e opera t es its own.Medicaid program in accordance with broad f ede ra l requirementsand th e terms of its approved Medicaid s t a t e p lan . Act 1902(a) (10), 1905(a ) . A s t a t e r ece ives f ede ra l reimbursementfo r a share of its Medicaid program expendi tures . Act 1903 (a) , 1905 (a ) .In o rder fo r Medicaid to re imburse s t a t e s fo r the cos t of hea l thse rv ices provided in schools , th e se rv ices must be among thosel i s t e d in sec t ion 1905(a) of the Act . Fur ther , the se rv ices muste i t h e r be inc luded in the s t a t e ' s Medicaid plan o r be ava i l ab leas an Ear ly and Per iodic Screening , Diagnos t ic and Treatment(EPSDT) bene f i t . The Act requi re s s t a t e s to provide EPSDTbene f i t s - which inc lude comprehensive d iagnos t i c , prevent ion ,and t r ea tmen t se rv ices - to Medicaid-e l ig ib le ch i ld ren under age21. Act 1905(a) (4) (B), 1905(r ) . The ob jec t ive i s to ensure

1 A cha r t i den t i fy ing the disa l lowed cla ims or ig ina l lyappealed by Texas appears a t Texas Exhib i t 2. Texas withdrew itsappea l wi th r e spec t to c la ims fo r speech the rapy se rv ices and ther e l a t ed t r anspor t a t ion c la ims in th e fol lowing sample cases : #16(Center ISD) , #24 (La Marque ISD) , #6 (Texarkana ISD) , #25(Texarkana ISD) , #11 (Texarkana ISD) , #2 1 (Texarkana ISD) , #7(Texarkana ISD) , and #29 (Texarkana ISD). See TX Reply Br. a t 8,10. We do no t di s turb th e disa l lowance with r e spec t to e i t h e rthese c la ims o r the cla ims no t or ig ina l l y appealed. CMS withdrewthe disa l lowance wi th r e spec t to cla ims fo r d i rec t se rv ices andth e r e l a t ed t r anspor t a t ion cla ims in th e fol lowing sample cases :#12 (Houston ISD)-speech the rapy, #1 8 (Dal las ISD)-nursing, #21(Houston ISD)-nursing, #30 (Houston ISD)-nurs ing , #12 (HoustonISD)-speech therapy , #9 (La Marque ISD)-occupa t iona l therapy , #1(Texarkana I S D ) ~ p h y s i c a l the rapy, and #27 (Texarkana ISD)phys ica l therapy ahd occupa t iona l the rapy. See CMS Br. a t 11,14-15.


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3 t h a t an e l i g i b l e c h i l d ' s hea l th needs a re i de n t i f i e d , assessed ,and t r e a t e d ear ly , before they become more complex and cos t ly tot r e a t . I l l i n o i s Dept . o f Publ ic Aid, DAB No. 2022 (2006) , a f f ' d ,Sta te o f I l l i n o i s Dep ' t o f Heal thcare & Family Servs. v . Leav i t t ,No.06-C-6412, 2008 WL877976 (N.D. Ill. Mar. 28, 2008) .In add i t ion to meeting the medical needs o f Medica id -e l ig ib l es tuden ts , school-based hea l th s e rv ices may f u l f i l l requirementso f the Ind iv idua l s with D i s a b i l i t i e s Educat ion Act (IDEA), 20U.S.C. 1400. The IDEA r equ i res s t a t e s to ensure t h a t a l lch i ld r en with d i s a b i l i t i e s ( regardless o f Medicaid e l i g i b i l i t y )"have ava i l ab le to them a f ree appropr i a t e pub l i c educa t ion t h a temphasizes s p ec i a l educa t ion arid r e l a t e d se rv ices designed tomeet t h e i r unique needs [ . ] " 20 U.S.C. 1400{d) (1 ) (A). For eachc h i l d t h r ee y ea r s and o lder i de n t i f i e d as di sab led , a schoo l mustdevelop an " ind iv idua l i zed educat ion program" ( IEP), whichi d e n t i f i e s th e " spec ia l educa t ion and r e l a t e d se rv ices andsupplementary a ids and se rv ices to be provided to th e c h i ld . " 20U.S.C. 1414 (d) . eMS's guidance s t a t e s t h a t u [h ]e a l t h - r e l a t e ds e r v i ce s included in a c h i l d ' s IEP may be covered under MedicaidUas long as : 1) th e se rv ices a re medical ly necessary andcoverab le under a Medicaid coverage ca tegory (speech therapy ,phys ica l therapy , e t c . ) , 2) a l l o ther Federa l and s t a t er egu la t ions a re fo l lowed, inc lud ing those fo r p rov ide rqua l i f i c a t i ons . . . ; and 3) the serv ices a re included in th es t a t e ' s plan or ava i lab le under EPSDT." August 1997 Medicaid andSchool Heal th : A Techn ica l Assi s tance Guide a t 15 (CMS Ex. 1 ) .The r egu la t ions a t 42 C.F.R. Par t 440 conta in the genera lp rov i s ions r e l a t i ng to se rv ices re imbursable by Medicaid. Wec i t e to those r egu la t ions as appropr i a t e below.Texas ' S t a t e Medicaid plan approved fo r t he pe r iod in ques t ionhere inc luded school h ea l t h and re l a t ed se rv ices (SHRS) coveredby EPSDT. TX Exs. 4, 6. As re l evan t here , the p lan includedspeech therapy , school hea l th serv ices (provided by a schoo lnurse o r o th e r s i m i l a r l y q u a l i f ie d person) , assessment , andcounse l ing , as wel l as t ranspor t a t ion to hea l th r e l a t e d se rv ices .TX Ex. 6, s ec t i o n 4.b.A. o f Appendix 1 to Attachment 3 . I -A .Sec t ion 4 .b .B. o f the p lan , t i t l ed uProvider Def in i t ion andCondit ions fo r P a r t i c i p a t i o n , " s t a t e s in pa r t :

A q u a l i f i e d prov ide r o f SHRS i s a person who meets s t a t eeduca t ion agency approved o r recognized c e r t i f i c a t i o n ,l i c en s in g , r e g i s t r a t i on , o r o ther comparable requirementswhich apply to th e SHRS he/ she i s prov id ing . Suchrequirements must be cons i s ten t with s t a t e / f e d e r a l laws and


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4 r egu la t ions and are sub jec t to approval by th e s ing le s t a t eagency.

TX Ex. 4, sec t ion 4 . b . B . l . a . Sec t ion 4 .b .B . l . b . of the plans t a t e s :Providers must meet appl icable Federa l Medicaid requirementsand in accordance with Federa l r egu la t ions a t 42 CFR431.107(b) , the providers must mainta in records and mustsubmit any documentat ion requi red by th e s ing le s t a t eagency.

S e c ~ i o n 4 .b .B .3 . of the plan also s t a t e s in r e levan t pa r t t ha t"[a] prov ide r m u s t . comply with a l l app l icab le f edera l ,s t a t e and l o c a l laws and r egu la t ions regarding th e se rv icesprovided [ . ] "The uniform admin is t r a t ive requirements fo r g ran t s to s t a t e sp lace on a s t a t e the burden of documenting the a l lowab i l i ty anda l l o c a b i l i t y o f cos t s fo r which reimbursement i s cla imed. See 45C.F.R. 74.50-74.53 (1999) ( repor t ing and record re t en t ionrequirements) ; see also Oklahoma Health Care Author i ty , RulingNo. 2008-4, a t 4 (2008) , c i t i ng Cal i fo rn ia Dept . o f HealthServices , DAB No. 1606 (1996) ( " I t i s a fundamental pr inc ip l e t h a ta s t a t e has th e i n i t i a l burden to document i t s cos t s and to showt h a t i t s . cla im fo r reimbursement i s proper ." ) .AnalysisBelow, we discuss each of th e ca tegor ies of disputed cla ims int u rn .1 . Claims fo r counse l ing se rv ices th e OIG found were provided byunl icensed prov ide rsThe OIG ques t ioned cla ims fo r counse l ing se rv ices rendered byschool counse lors on th e ground t ha t th e counse lors d id no t havea l i cense from th e appl icable Sta te l i cens ing agency. The OIGfound t h a t the s e rv ices rendered by th e school counse lors weret he re fo re n o t provided within the scope o f t h e i r prac t ice underSta t e law, as requi red by 42 C.F.R. 440.60(a) . TX Ex. I , a t20. CMS asse r t s , and Texas does not dispute , t h a t counse l ingse rv ices may be covered by Medicaid only as "medical or o therremedia l care provided by l icensed pra c t i t i one r s , " which i sdef ined in sec t ion 440.60(a) a s -
http:///reader/full/74.50-74.53http:///reader/full/74.50-74.53


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5 Any medical o r remedial care or se rv ices , o ther thanphys ic ians ' s e rv ices , provided by l i c ensed pra c t i t i one r swi th in the scope of prac t i ce as def ined under Sta te law.

The Texas Occupat ions Code (TOC) provides fo r l i cens ing o fp r o f e s s io n a l counselors by th e Texas S ta t e Board o f Examiners o fProfe s s iona l Counse lors (TSBEPC) and s t a t e s t ha t "[a] person mayno t engage in th e prac t i ce o f profes s iona l counsel ing unle s s theperson i s : (1) l i censed under t h i s chapte r ; or (2) exempt fromt h i s chap te r under Subchapter B." TOC 503.301 (access ib l e a th t t p : / / t l o 2 . t l c . s t a t e . t x . u s / s t a t u t e s / d o c s / O C / c o n t e n t / h t m / o c . 0 0 3 . 00.000503.00 .h tm); see a l so TOC 503.002(4) (de f in i t ion o f" l i censed p ro fes s iona l counse lor") .On appeal , Texas does not di spu te t ha t th e school counse lo rs weren o t l i censed by th e TSBEPC pursuant to chapte r 50 3 o f th e TexasOccupat ions Code. Texas t akes the p o s i t i o n , however, t h a t th eschool counse lo rs were l i c ensed as requi red by St a t e law becausethey were c e r t i f i e d as counselors by th e Texas Educat ion Agency(TEA) o r by the Sta te Board fo r Educator Ce r t i f i c a t i on (SBEC),which took over t h i s func t ion in 1996. Texas po in t s out t h a tchap te r 50 3 o f the Texas Occupations Code s pe c i f i c a l l y exemptsfrom its l i cens ing requirements "a person employed as a counse lo rby a . . . pub l ic o r pr iva te educa t iona l i n s t i t u t i o n if th eperson i s performing counsel ing or counse l ing- re l a t ed a c t i v i t i e swi th in th e scope o f the person ' s employment." Sect ion 503.051.Texas argues t h a t " [ t ]h e ind iv idua l s who provided the counse l ingse rv ices were thus no t sub jec t to th e l i cens ing prov i s ions o f th eTSBEPC because they were prac t i c ing within th e scope o f t h e i remployment in a publ i c educa t iona l i n s t i t u t i o n and, the re fo re ,were sub jec t to th e r egu la t ions and qua l i f i c a t i on requirements o fanother s t a t e e n t i t y , th e TEA" o r th e SBEC. TX Br. a t 10. Texasa l so argues t ha t the school counselors were q u a l i f i e d as Medicaidprov ide rs under th e Sta te Medicaid plan because they "met th erequirement , s t a t e educat ion ce r t i f i ca t i on , fo r t he SHARS theyprov ided . , ,2 TX Reply Br. a t 4.Texas ' arguments do no t address th e s a l i e n t ques t ion : whetherth e school counse lo rs who were c e r t i f i e d by the Sta te educa t ionagency may be considered " l i censed p ra c t i t i o n e r s " fo r purposes o fproviding medical o r remedial se rv ices under Medicaid. We agreet h a t th e approved S ta t e Medicaid plan a t sec t ion 4 .B.b . canreasonab ly be read as t r ea t ing c e r t i f i c a t i o n as equ iva len t tol i cens ing within th e meaning o f 42 C.F.R. 440.60(a) where th e

2 We assume t h a t , by "SHARS," Texas i s r e f e r r i n g to "schoolhea l th and r e l a t e d se rv ices , " abbrev ia ted in th e Sta te Medicaidp lan as "SHRS."
http://tlo2.tlc.state.tx.us/statutes/docs/OC/content/htm/oc.003.0http://tlo2.tlc.state.tx.us/statutes/docs/OC/content/htm/oc.003.0


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6 c e r t i f i c a t i o n permi t s an i nd iv idua l to provide remedial care andse rv ices covered by Medicaid . As we di scuss below, however, th erequirements fo r c e r t i f i c a t i o n o f school counselors in th e TexasAdminis t ra t ive Code are much narrower in scope than th erequirements fo r l i cens ing o f profes s iona l counselors in th eTexas occupat ions Code. In add i t ion , t he requ i rements fo rc e r t i f i c a t i o n o f school counselors do not appear t o qua l i fy t he secounse lo rs to perform the comprehensive the rapeu t ic counsel ingdescr ibed in th e de f in i t i on of "prac t ice o f profes s iona lcounse l ing" in th e Texas Occupations Code. Moreover, th e f a c tt h a t a counse lo r who i s c e r t i f i e d only by the Sta te educa t ionagency i s n o t permi t ted to provide counse l ing se rv ices out s ide o fa school s e t t i ng i s fu r the r evidence t h a t th e scope o f p ra c t i c eo f such school counselors was l imi ted to educa t iona l counse l ing .Accordingly , whi le th e school counselors c e r t i f i e d by th e Sta teeduca t ion agency were l i c ensed to provide counsel ing se rv iceswi th in the scope o f t h e i r employment, Texas has not es tab l i shedt h a t it was wi th in the scope o f t h e i r prac t i ce to provide medicalo r remedia l se rv ices reimbursable by Medicaid.For Sta te educa t ion agency c e r t i f i c a t i o n as a counse lo r , anind iv idua l must meet th e fo l lowing requirements in add i t ion tosp e c i f i e d undergraduate c r i t e r i a r e l a t i ng to c e r t i f i c a t i o n o fclassroom t e ache rs and o ther more genera l ly app l i cab lerequ i rements :

(1) The guidance program (a t l e a s t th ree semes ter hours) .This area prov ides an unders tand ing o f the p r i n c i p l e s ,phi losophy , organ iza t ion , and se rv ices o f th e guidanceprogram.

(2 ) The pup i l served (a t l e a s t s ix semes ter hours ) . Thisarea i s devoted to in tens ive s tudy t ha t develops anunderstanding o f t he phys ica l , i n t e l l ec t ua l , so c i a l , andemotional development o f chi ldren and youth, and th ein f luences o f th e school program on development.

(3) Resource areas (a t l e a s t 21 semes ter hours) .(A) The prepara t ion program s ha l l help t he p rospec t ivecounse lo r ach ieve a balanced program o f t e ache reduca t ion by giving a t t e n t i o n to r e l a t e d resourceareas .(B) These advanced l eve l s tud ies a re not necessa r i lyrepresented by a sequence of semester hour courses .They a re planned programs to meet th e needs of theind iv idua l s tuden t . They a re in tended to ensureprofes s iona l competence.(C) Upon complet ion of th e program, the prospec t ivecounse lo r s ha l l have developed s k i l l s in guidancet echn iques t ha t assure an a b i l i t y to use th e ins t ruments


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o f measurement and eva lua t ion necessary fo runderstanding, appra is ing , and counsel ing ind iv idua l sand groups . The s tudent s ha l l be s k i l l e d in th e use o foccupat iona l and educa t iona l informat ion and mate r i a l sappropr i a t e fo r th e guidance o f youths . Also, th es tuden t s h a l l have developed, through s tudy andsuperv i sed p ra c t i c e , an a b i l i t y to work with groups o fyouths and ad u l t s and to counsel with ind iv idua l s .

TX Ex. 3, a t 11-12 (unnumbered) (TOC 137.307) . In add i t ion , ava l id prov is iona l t each ing c e r t i f i c a t e and th ree yea rs o fclassroom t eaching exper ience a re requ i red fo r t he "pro fes s iona lcounse lo r c e r t i f i c a t e . " Id .These c e r t i f i c a t i o n requirements are focused on t e ache r educa t iongenera l ly and in any even t do not require e i t h e r a sp e c i f i cprogram o f s tudy o r supervised exper ience s pe c i f i c a l l y i ncounse l ing . On t h e i r face, they appear merely to prepare ani n d iv id u a l to provide th e educa t iona l counsel ing normal lyprovided by a schoo l guidance counselor .In c o n t r a s t , the requirements fo r a l i c ensed profes s iona lcounse lo r a t s ec t i o n 503.202 o f th e Texas Occupat ions Codeinc lude a mas te r ' s o r doc to ra l degree in counsel ing o r a r e l a t e df i e l d ; complet ion o f a graduate degree a t a r eg iona l ly accred i tedi n s t i t u t i o n of h ighe r educat ion wi th not l e s s than 48 graduatesemester hours and 300 "clock hours of superv i sed pract icum" t h a tare p r imar i ly counsel ing in na tu re ; completion o f no t l e s s than3,000 hours of superv i sed exper ience hours in a counsel ingse t t i ng a f t e r th e completion o f the graduate program; and pass inga l i cense examinat ion and a ju r i sp rudence examinat ion . Anind iv idua l meet ing these requirements may engage in th e "p rac t i ceo f profes s iona l counsel ing" as def ined in sec t ion 503.003 o f th eTexas Occupat ions Code. Sect ion 503.003(a) de f ines t h i s term a s -

The app l i ca t ion o f mental hea l th , psycho therapeu t ic , andhuman development pr inc ip les to :(1) F a c i l i t a t e human development and adjus tment throughoutl i f e ;(2) Prevent , as ses s , eva lua te , and t r e a t menta l , emotional ,o r behaviora l d iso rder s and as soc ia ted d i s t r e s s e s t ha ti n t e r f e r e with mental hea l th ;(3) Conduct assessments and eva lua t ions to e s t a b l i s ht rea tment goa ls and ob jec t ives ; and(4) Plan, implement, and eva lua te t rea tment plans us ingcounse l ing t rea tment in te rven t ions t ha t inc lude :(A) counsel ing


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8 (B) assessment;(C) consu l t ing ; and(D) r e f e r r a l .

The term "counsel ing t rea tment i n t e rven t ions" i s def ined toi nc lude , among o ther th ings , "the assessment , eva lua t ion , andt rea tment of a person wi th a mental , emotional , o r behaviora ld i so rder , " and " the use of func t iona l assessment and counsel ingfo r a person reques t ing ass i s t ance in adjus tment to a d i s a b i l i t yo r handicapping condi t ion [ .] " TOC 503.003 (b) (4 ) (C), (E).Texas does n ot exp la in how th e r e l a t i ve l y minimal requirementsfo r c e r t i f i c a t i o n in the Texas Admin is t ra t ive Code qua l i f i e dschool counse lo rs to perform the profes s iona l counse l ing se rv icesdescr ibed in th e Texas Occupat ions Code.Thus, we conclude t ha t ind iv idua l s who d id not hold aprofes s iona l counse lo rs l i cense from th e TSBEPC d id not meet th erequi rements of 42 C.F.R. 440.60(a) and t ha t th e cla ims fo rse rv ices provided by t he se ind iv idua l s were the re fo reuna l lowable .2. Claims fo r assessments the OIG found were provided byunl i censed p rov ide rs and were nonmedical assessmentsThe OIG ques t ioned cla ims fo r assessments provided by educa t iona ld iag n o s t i c i an s . According to th e OIG, th e se rv ices cons i s ted of"educa t iona l t e s t ing" and "ass i s t [ ing ] in summarizing o th e rmedical prov ider s ' assessments /eva lua t ions fo r IEP se rv ices . " TXEx. I , a t 20. The OIG found Medicaid reimbursement was n otava i l ab le fo r these se rv ices because they were nonmedical inna tu re . As an ad d i t i o n a l bas i s fo r ques t ioning th e c la ims , th eOIG found t h a t th e educa t iona l d iagnos t ic ians could not q u a l i fyas providers under th e approved Sta te Medicaid plan s ince ,according to th e OIG, the re i s no prov i s ion in Sta te law fo rl i cens ing educa t iona l d iagnos t ic ians . Id .Texas t akes the pos i t ion t ha t educa t iona l d iagnos t ic iansconducted assessments of the type covered by th e approved Sta teMedicaid plan , which de f ines "assessment" as " [ a ] c t i v i t i e sr e l a t e d t o the evaluat ion of the func t ion ing of a s tuden t fo r thepurpose of determining th e needs fo r spec i f i c school hea l th o rr e l a t e d se rv ices , th e e f f e c t of de l ivered se rv ices on IEP goalsand the rev i s ion of IEP plans and goa ls . " TX Ex. 6, a t 5. Inad d i t i o n , Texas argues t ha t the educa t iona l d iagnos t ic ians werequa l i f i e d prov ide rs under th e Sta te Medicaid plan because theywere c e r t i f i e d by th e Sta te educat ion agency pursuan t t o sec t ion137.425 of th e Texas Admin is t ra t ive Code and met a l l .o ther


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9 app l icab le requirements in the p lan (such as th e requirement t h a ta SHRS prov ide r be enro l led and approved fo r pa r t i c ipa t ion inMedicaid and s ign a wri t t en provider agreement with th e s ing les t a t e agency) . According to Texas, moreover , th e Sta te educa t ionagency ce r t i f i ca t ion sa t i s f i ed th e requirement in 42 C.F.R. 440.60(a) t h a t medical o r remedial care or s e rv ices o ther thanphys ic ians ' s e rv ices be provided by l icensed pra c t i t i one r s withinthe scope o f prac t ice as def ined under Sta te law.For c e r t i f i c a t i o n as an "Educat ional Diagnos t ic ian (Specia lEducation) ," sec t ion 137.425 of th e Texas Adminis t ra t ive Coder equ i res "an earned mas te r ' s degree," and sp e c i f i e s th e number ofsemes ter hours fo r each of f ive major a reas o f profes s iona lcompetence. TX Ex. 3, a t 16-17 (unnumbered). According toTexas, the a rea of competence t ha t i s r e levan t here i s"[k]nowledge of th e except iona l ch i ld , " which th e Code s t a t e s"should provide the prospec t ive educa t iona l d iagnos t ic ian withknowledge o f the l ea rn ing c ha ra c t e r i s t i c s of those ch i ld rende f i c i e n t i n bas ic i n t eg r i t i e s which can be ca tegor ized in toper iphera l nervous system dysfunct ion, c e n t r a l nervous systemdysfunc t ions , and behaviora l d iso rder s . " Id . The Code fu r t h e rs t a t e s t h a t l ea rn ing c ha ra c t e r i s t i c s "may inc lude d iso rder s insensory func t ioning, percept ion , conceptua l iza t ion , memory,language, a t t e n t ion , neuromuscular coordina t ion , emotional s oc i a lbehav ior , read ing , wri t ing , a r i thmet ic , spe l l ing , and anydevelopmental d i s pa r i t y in the phys io log ica l and psychologica lprocesses re la ted to educa t ion ." Id . Texas argues t h a t " [ t ]h e ses k i l l s would c e r t a in ly al low the educa t iona l d iagnos t ic ian toperform th e assessment se rv ices descr ibed in th e Sta te Plan." TXBr. a t 15.The requirements fo r c e r t i f i c a t i o n on which Texas r e l i e s appearto be designed to provide an educa t iona l d iagnos t ic ian with th eknowledge and s k i l l s to as ses s how a c h i l d ' s d i s a b i l i t i e s maya f f e c t o r have af fec ted th e c h i l d ' s a b i l i t y to meet va r iouseduca t iona l goa ls . We a re not persuaded, however, t h a t theserequi rements qua l i fy an educa t iona l d iagnos t ic ian to conduct th etype of assessments descr ibed in th e approved Sta te Medicaidp lan . The f i r s t pa r t of th e de f in i t i on o f "assessment" r e f e r s t o" [ a ] c t i v i t i e s re la ted to the eva lua t ion of the func t ioning of as tuden t fo r th e purpose of determining th e needs fo r spec i f icschool hea l th o r re la ted se rv ices [ . ] " (Emphasis added.) Therei s noth ing in the c e r t i f i c a t i o n requirements t h a t would inform aneduca t iona l d iagnos t ic ian about a ch i l d ' s needs fo r spec i f icschool hea l th o r re la ted se rv ices . Moreover, while th e Sta teMedicaid plan desc r ip t ion of "assessment" re fe r s genera l ly to" the e f f e c t of de l ivered se rv ices on IEP goal s and th e rev i s iono f IEP plans and goa ls , " t h i s language must be read as r e f e r r ing


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10 to th e e f f e c t o f de l ivered hea l th s e rv ices on IEP goal s and tothe r ev i s ion o f IEP plans and goal s r e l a t e d to h ea l t h . Any o th e rread ing would c onf l i c t with fede ra l law, which prov ides fo rMedicaid coverage o f hea l th se rv ices , not educa t iona l se rv ices ,au thor i zed by an IEP.

3

Even if the educa t iona l d iagnos t ic ians were qua l i f i ed to conductth e type o f assessment descr ibed in th e approved Sta te Medicaidplan , t h e r e i s no bas i s in the record fo r f inding t h a t th eassessments they ac tua l ly conducted were o f t h i s type . As notedabove, th e OIG descr ibed th e assessments conducted by th eeduca t iona l d iagnos t ic ians as 1) "educa t iona l t e s t ing" and 2)" a s s i s t [ ing] in summarizing o t h e r medical prov ider s 'assessments /eva lua t ions fo r IEP se rv ices . " "Educat ional t e s t ing"i s n ot necessa r i ly d i rec ted a t eva lua t ing " the func t ioning o f as tuden t fo r the purpose o f determining th e needs fo r spec i f icschoo l hea l th o r re la ted se rvices" as provided in the Sta teMedicaid plan . Moreover, s ince some IEP se rv ices a re educa t iona ls e r v i ce s r a the r than hea l th - re l a t ed se rv ices , th e"assessments /eva lua t ions fo r IEP se rvices" with which theeduca t iona l d iagnos t ic ians a s s i s t e d did not necessa r i ly qua l i fyas assessments within the meaning o f th e S ta t e Medicaid plan .Thus, it i s imposs ib le to conclude t h a t any o f th e assessmentsf e l l wi th in the d es c r ip t i o n in th e S ta t e Medicaid plan withouts pe c i f i c in fo rmat ion about the na ture of each of the assessments .Texas , however, provided no documentat ion o f th e assessmen tsthemselves.Ins t ead , Texas fu r the r a s s e r t s i n suppor t o f its pos i t ion t h a tboth educa t iona l d i agnos t i c i ans and l i c ensed spec i a l i s t s inschool psychology ( ~ h o were presumably qua l i f i ed as Medicaid

3 Texas a s s e r t s t ha t " i t s i n t e rp r e t a t i on o f th equa l i f i c a t i ons o f its educa t iona l diagnos t i c i ans i s reasonable"and sugges t s t ha t t h i s i n t e rp r e t a t i on i s e n t i t l e d to deference .TX Br. a t 15, c i t i ng Colorado Dept . of Health Care and Pol icyFinancing, DAB No. 2057, a t 2 (2006) ( s t a t ing t h a t " [ g ] en e r a l l y ,th e Board gives deference to a s t a t e ' s i n t e rp r e t a t i on o f its ownS t a t e plan , so long as t ha t i n t e rp r e t a t i on i s an o f f i c i a li n t e rp r e t a t i on and i s reasonable in l i g h t o f th e language o f th ep lan as a whole and t he app l i cab le fede ra l r equ i rem ent s . " ). Toth e ex t en t t h a t Texas i s arguing t h a t th e descr ip t ion o fassessments in th e S ta t e Medicaid plan should be read in such away t h a t educa t iona l d i agnos t i c i ans c e r t i f i e d by th e Sta teeduca t ion agency were qua l i f i ed to conduct th e assessments , t h a targument has no meri t s ince such a reading c onf l i c t s with f edera llaw.


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11 providers ) use th e same procedure code fo r assessments and mayuse th e same t e s t i ng inst ruments in conduct ing t he se assessments .According to Texas , t h i s " re fu tes CMS's argument t h a t th eeva lua t ions o r assessments were fo r educa t iona l purposes only ."TX Br. a t 16. This argument ignores , however, th e p o s s i b i l i t i e st h a t th e educa t iona l d iagnos t i c i ans used th e wrong procedure codeo r used th e same t e s t i ng inst ruments as th e l i censed s p e c i a l i s t sin school psychology b ut fo r d i f f e r e n t purposes.Texas a l so sugges t s t ha t an assessment conducted by aneduca t iona l d iagnos t ic ian qua l i f i ed as a "developmentalassessment , " which CMS's Sta te Medicaid Manual (SMM) i nd ica tes i scovered by Medicaid as an EPSDT benef i t . 4 TX Br. a t 16-17,c i t i ng SMM 5123.2 . Sect ion 5123.2 s t a t e s t ha t a developmentalassessment " inc ludes a range o f a c t i v i t i e s to determine whetheran i nd iv idua l ' s developmental processes f a l ~ within a normal~ a n g e o f achievement according to age group and c u l tu r a lbackground." TX Ex. 8, a t 9. It con t inues : "Screening fo rdevelopmental assessment i s a pa r t of every rout ine i n i t i a l andp e r io d i c examinat ion." Id . Texas a l so a s s e r t s t ha t th e Sta teMedicaid Manual does not " l i m i t th e t e s t i ng to a c e r t a in type o fprov ider , " presumably to make t he po in t t h a t educa t iona ld iagnos t ic ians a re not precluded from conduct ing suchassessments . TX Br. a t 17.While th e Sta te Medicaid Manual does s t a t e t h a t " [ t ] he use o f a l ltypes o f prov ide rs i s encouraged," t h i s sta tement read in contextdoes n o t au thor i ze the use of educa t iona l d iagnos t ic ians toconduct developmenta l assessments . Th e preceding paragraphs t a t e s in p e r t i n e n t pa r t t h a t "[e]xaminat ions are performed by,o r under the supervis ion o f , a c e r t i f i e d Medicaid phys ic ian ,den t i s t , o r o th e r prov ide r qua l i f i ed under S ta t e law to fu rn i shprimary medical and hea l th s e rv ices . " TX Ex. 8, a t 9 (emphasisadded) . The requirements fo r c e r t i f i c a t i o n as an educa t iona ld iagnos t ic ian do n o t purpor t to q u a l i f y ind iv idua l s to fu rn i shpr imary medical and hea l th s e rv ices , nor does Texas provide anyevidence t h a t the educa t iona l d iagnos t i c i ans p e ~ f o r m e d t h e i r"examinat ions" under the supervis ion o f such a prov ide r .Thus, we conclude t ha t educa t iona l diagnos t i c i ans were notqua l i f i e d to provide th e type of assessment descr ibed in th eSta te Medicaid plan o r in the S ta t e Medicaid Manual prov i s ions onEPSDT b e n e f i t s and t ha t the re i s no bas i s in th e record fo r

4 As ind ica ted above, if se rv ices requi red to be provided asp a r t o f EPSDT benef i t s are l i s t e d under sec t ion 1905(a) of theAct , they are re imbursable by Medicaid even if they a re n otincluded in an approved s t a t e plan .


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12 concluding t h a t , the assessments ac tua l ly conducted were o th e rthan educa t iona l assessments . Accordingly , we conclude t h a t th ec la ims fo r t he se assessments were unal lowable .3 . Claims fo r speech therapy se rv ices th e OIG found were renderedby unl icensed providersThe cla ims a t i s sue here a re fo r speech the rapy se rv ices providedin sample cases #20, #1, #27, #25, #21, and #7 ( a l l in TexarkanaIndependent School D i s t r i c t (ISD by one ind iv idua l we i de n t i f yhere as Ms. S. Sect ion 440.110(c) (1) of 42 C.F.R. prov ides inr e l ev an t pa r t t ha t " [s]erv ices fo r ind iv idua ls with speech,hearing, and language d i sorders means d iagnos t ic , sc reening,preven t ive , o r cor rec t ive se rv ices provided by o r under th ed i r e c t ion of a speech pa tho log is t o r aud io log i s t .... "( I t a l i c s in o r ig ina l . ) There i s no dispute t ha t Ms. S providedth e se rv ices under th e d i rec t ion of a speech pa tho log i s t . SeeCMS Br. a t 11. Never the less , th e OIG ques t ioned th e cla ims onth e ground t h a t Ms. S (and o ther providers no longer a t i s sue)d id n ot meet St a t e l i cens ing requi rements . TX Ex. 1, a t 8. Asind ica ted above, th e approved Sta te Medicaid plan requi red t h a t aqua l i f i e d prov ide r meet the Sta te educat ion agency l i cens ingrequi rements appl icable to th e SHRS provided . CMS t akes th epos i t i on t h a t Ms. S was requi red by Sta te law to have an " i n t e rnl i cense" s ince she "was acqui r ing supervised work experience( in te rnship) dur ing the per iod in ques t ion . " CMS Br. a t 11,c i t i ng sec t ion 401.301 of the Texas occupa t ions Code, sec t ion741.62 of th e Texas Admin is t ra t ive Code, and 1999 Texas MedicaidProv ider Procedures Manual, Chapter 38-7 (TX Ex. 7, a t 7 (unnumbered) ) . Sect ion 401.301 of the Texas Occupations Code s t a t e s t h a t "[a]person may not p ra c t i c e speech-language pa thology o r audio logy o rrepresen t t h a t th e person i s a speech-language pa tho log i s t o raud io log i s t in t h i s s t a t e unless th e person holds a l i cense undert h i s chap te r . " Texas argues t ha t Ms. S was exempt from t h i srequirement s ince sec t ion 401.054 of the Code conta ins an. except ion fo r persons ce r t i f i ed in speech-language pa thology bythe Texas Educat ion Agency " i f th e person only performs speechlanguage pa thology o r audiology se rv ices as pa r t of the person ' sdu t i es within an agency, i n s t i t u t i on , o r organ iza t ion under th ej u r i sd i c t i on of the Texas Education Agency." Texas a l so asse r t st h a t Ms. S had a " teach ing c e r t i f i c a t e i s sued by th e SBEC, ad iv i s ion of the TEA." Texas Reply Br. a t 8. In suppor t of itsargument , Texas provided a copy of a "Texas Educator Ce r t i f i c a t e "which was va l id fo r the per iod in ques t ion and which s t a t e s t h a tMs. S "has fu l f i l l e d requirements of s t a t e law and r egu la t ions o fthe St a t e Board fo r Educator Cer t i f i ca t ion and i s hereby


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13 author ized to perform Speech and Language Therapy (GradesPK-12) ." TX Ex. 11.Texas ' argument ignores o the r prov i s ions of Sta t e law, however.Spec i f i ca l l y , sec t ion 741.62 of th e Texas Adminis t ra t ive Code, asin e f f e c t dur ing th e per iod in ques t ion , requ i red t h a t anappl i can t fo r a speech-language pathology l i cense must havecompleted 36 weeks of fu l l - t ime , o r i t s par t - t ime equivalen t , o fsuperv ised pro fess iona l exper ience , and t h a t an app l ican t "mustbe l i censed as an i n t e r n i n order to commence th e superv isedprofess iona l exper ience ." Sect ions 741.62(q) , 741.62(a)( repealed 12/24/00) (access ib le a th t tp : // in fo .sos . s t a te . tx .u s /p l s /pub / read tac$ex t .TacPage?s l=R& app =3&p_dir=&p_rloc=2028&P_tloc=&p-ploc=&pg=1&p_tac=2028&ti=22&pt=32&ch=741&rl=61&dt=01/02/1999) . Consis ten t with t hese requi rements ,th e 1999 Texas Medicaid Provider Procedures Manual s t a t ed i nre l evant pa r t :

Ind iv iduals acqui r ing superv ised work exper ience may a l sode l i ve r speech-language therapy se rv ices . These i nd iv idua l smust have an in te rn l i cense and may de l i ve r speech- languagetherapy se rv ices under the supe rv is ion of an ind iv idua l whoi s ASHA-cert i f ied o r ASHA-equivalent qual i f i ed .

TX Ex. 7, a t 7 (unnumbered).Texas does not chal lenge CMS's asse r t ion , which i s suppor ted byTexas ' own documentation, t h a t Ms. S was acqui r ing superv isedprofess iona l exper ience a t the t ime she provided th e se rv ices inquest ion here . See TX Ex. 2, a t Tex-1a and Tex-1k (Report ofCompleted In te rnsh ip Form and Cl in ica l Fel lowship Report , bothshowing beginning date o f 8/16/99 and ending date of 5/26/00) .Thus, she was c lea r ly requi red by Sta t e law to have an i n t e r nl i cens e . The "Texas Educator Cer t i f i ca te" does no t on its faceappear to be an in te rn l i cense , however, nor does Texas contendt h a t it cons t i t u t e s such a l i cense . Since Texas f a i l ed t odocument t ha t Ms. S was l i censed as requ i red by Sta t e law, thecla ims for se rv ices she provided a re unal lowable .4 . Claims fo r nurs ing se rv ices th e OIG found were rendered byun l i censed providersThe OIG ques t ioned cla ims fo r nurs ing se rv ices on the ground t h a tthey were rendered by unl icensed providers . TX Ex. 1, a t 20,c i t i n g sec t ion 301.251 o f the Texas Occupat ions Code (providingt h a t a person may no t prac t i ce pro fess iona l o r vocat ional nurs ingin the Sta t e unless th e person i s l i censed pursuan t to chapter301) . The cla ims a t i s sue here are fo r se rv ices provided in
http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&apphttp://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app


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14 sample case #19 (Dal las ISD) by one ind iv idua l , who wasapparen t ly i den t i f i ed by Texas on th e cla ims documenta t ion as"Kathy Duncan." The only dispute here i s whether Texas hasdocumented t h a t t h i s ind iv idual was l i censed pursuant to chap te r301.Texas submit ted wi th its appeal a pr i n t ou t from the Texas Boardof Nurse Examiners records showing t ha t "Kathlyn Duncan" of GulfBreez'e, Flo r ida was i n i t i a l l y l icensed on 12/15/93 and t ha t h erl i censure was cu r ren t as of 1/31/08 . TX Ex. 2, a t DAL-1. CMSfound t ha t th e documenta t ion " is i n s u f f i c i en t to demonstra te t ha tt h a t 'Kathy Duncan' and 'Kath lyn Duncan' (a re s iden t of Flor ida)a re the same person ." CMS Br. a t 14. According toCMS, " theSta t e Board of Nurse Examiners a lso has in format ion on a 'KathyDuncan' [who] was not l i censed u n t i l . . . a f t e r th e da te of th ese rv ices in ques t ion , " . as wel l a s "severa l l i s t i n g s fo r personswith th e same o r va r i a t i ons of the name 'Kathy Duncan. '" Id .Texas subsequent ly submit ted a pr i n t ou t from the Texas Board ofNurse Examiners records showing Kathlyn Duncan's s oc i a l s ecu r i t ynumber and a pr i n t ou t from i t s Department of Human Resourcesr eco rds showing th e same s oc i a l secur i ty number fo r th e "KathyDuncan" who provided th e se rv ices . 5 TX Ex. 13, a t 1-5 . Based ont h i s documenta t ion , we conclude t h a t the cla ims were al lowable .5 . Claims fo r speech therapy se rv ices fo r which th e OIG foundt he re was no r e f e r r a lThe OIG ques t ioned cla ims fo r speech the rapy se rv ices on theground t h a t they lacked th e r e f e r r a l requi red by 42 C.F.R. 440.110 (c) (1) . TX Ex. 1, a t 18. Sect ion 440.110 (c) (1)r equ i r es a r e f e r r a l "by a phys ic ian or o the r l i censedp r a c t i t i o n e r of th e heal ing a r t s with in the scope of h is o r herpr ac t i ce under Sta t e law."The cla ims a t i s sue here a re fo r se rv ices provided to twos tuden t s , sample case #12 and sample case #18 (both La MarqueISD). For each s tuden t , Texas provided a form capt ioned"Phys ic ian ' s Presc r ip t ion fo r Speech/Language Therapy." TX Ex.2, a t LAM-2 and LAM-5. One sec t ion of th e form, capt ioned"Phys ic ian ' s Opinion ," conta ins the fo l lowing pre -p r i n t e dlanguage:

5 This in format ion wi l l be redacted on any copy of th erecord t h a t i s r e leased in response to a Freedom of Informat ionAct r eques t .


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15 The s tuden t i de n t i f i e d he re in has been re fe r red to meregard ing th e need fo r Speech/Language Therapy.

I recommend t ha t t h i s s tudent rece ive therapy , from ac e r t i f i e d Speech Therapis t o r Speech Patho log is t , aspresc r ibed in th e t rea tment schedule o f t he Ind iv idua l i zedEducat ion Plan (IEP). . . .

I do not recommend t h i s s tudent for Speech/LanguageTherapy fo r th e fol lowing reason(s) :Nei the r box i s checked on th e form fo r e i t h e r sample case ,a l though th e phys ic ian s igned and dated both forms.CMS t akes the pos i t ion t ha t th e cla ims should be disal lowed onth e ground t h a t " [ t ]h e phys ic ian d id not recommend t ha t t he ses tuden ts rece ive speech therapy se rv ices . " CMS Br. a t 12. Texaspo in t s ou t t ha t i n ano ther sec t ion of th e form, under t he cap t ion"Documents Reviewed," the re a re checkmarks showing t h a t th ephys ic i an reviewed th e s t u d e n t ' s IEP. Texas provided a copy o fth e each s tude n t ' s IEP, which Texas a s s e r t s shows t ha t th es tuden t "requ i red" speech therapy se rv ices . TX Reply B r. a t 9,c i t i ng TX Ex. 2, a t LAM-2A and LAM-5A. Texas argues t h a t s incet he phys ic i an signed th e form a f t e r not ing t h a t he had reviewedthese documents , " [ t ]h e p h y s i c i an ' s i n t e ~ t to recommend th espeech se rv ices i s apparent when the form i s considered in itsen t i r e t y . " TX Reply Br. a t 9. Texas presented no evidence fromt he phys ic i an confi rming t ha t t h i s was h is or he r i n t e n t .Texas ' argument appears to be pred ica t ed on th e assumption t h a tt he phys ic i an would always r e f e r the s tudent for speech therapyse rv ices if th e IEP team had determined t ha t such se rv ices wererequ i red . Such an assumption makes th e requirement fo r ar e f e r r a l meaningless , however.6 Moreover, on its face , th e formgives the phys ic ian the opt ion o f no t r e f e r r i n g t he s tuden t fo rspeech therapy se rv ices , without regard to what documents thephys ic i an has reviewed (or t h e i r con ten t ) . Thus, while one couldi n f e r from th e f a c t t ha t the phys ic ian reviewed th e IEP t h a t th ephys ic i an was consider ing whether to make a r e f e r r a l , we dec l ineto i n f e r on t h i s bas i s a lone t ha t the physic ian in tended to make

6 A d i f f e r e n t s i t ua t ion might have been presented if th ephys ic i an had been a member o f th e IEP team, in which case th esigned IEP might have su f f iced as the r e f e r r a l . Cf. OklahomaHeal th Care Author i ty , DAB No. 2140 (2007); Ruling on Request fo rP a r t i a l Reconsiderat ion , Ruling No. 2008-4 (2008) .


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16 th e r e f e r r a l when th e physic ian d id not t ake th e minimal s tep o fi nd ica t ing by a checkmark which opt ion he o r she was se lec t ing .?ConclusionBased on th e foregoing ana lys i s , '. we reverse the disal lowance wi thr espec t to th e d i r e c t serv ices and r e l a t e d t ranspor t a t ion cla imsfo r sample case #19 (Dal las ISD). We uphold the disal lowance o fth e remaining disputed claims fo r d i r e c t se rv ices and th e r e l a t e dt ranspor t a t ion c la ims.

/ s /Jud i th A. Bal la rd

/ s /Constance B. Tobias

/ s /Les l ie A. Sussanpres id ing Board Member

7 In view o f t h i s conclusion, we need not cons ider CMS'sargument t h a t the da te on the r e f e r r a l form fo r sample case #12,a t Texas Exhibi t 2, LAM-5, "appears to be a l te red" to show a da tep r i o r to t he da te the se rv ices were prov ided . CMS Br. a t 12.

HHS Appellate Decision on Texas Health and Human Services 2009

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