School Health and Related Services

The School Health and Related Services (SHARS) program allows Texas local educational agencies (LEAs) and shared service arrangements (SSAs) to request reimbursement for Medicaid health-related services. The admission, review, and dismissal (ARD) committee determines SHARS services. Services must be medically necessary and reasonable to ensure that children with disabilities are able to participate in the educational program.

SHARS reimbursement is available for students with parental consent to release identifying information to Medicaid and who meet all of the following requirements:

• 20 years of age and younger
• currently eligible for Medicaid
• enrolled in a public school's special education program
• meet requirements for special education described in the Individuals with Disabilities Education Act (IDEA)
• May current individualized education program (IEP) that prescribes the needed services.

Services covered by SHARS include:

• audiology services
• counseling
• nursing services
• occupational therapy
• personal care services
• physical therapy
• physician services
• psychological services, including assessments
• speech therapy
• specialized transportation as defined by the Health and Human Services Commission (HHSC)

Medicaid Policy Changes Effective Oct. 2022 through Jan. 2023

After inviting stakeholder input, the Texas Medicaid & Healthcare Partnership (TMHP) has posted revisions to SHARS policy. 

Major policy changes include:

• SHARS coding is updated;
• Telehealth expansion continues;
• Providers eligible to submit claims for SHARS speech therapy is limited:
  •  licensed speech-language pathologists (SLPs) certified by American Speech-Language-Hearing Association (ASHA);
  • SLP's supervised interns and assistants.
•  Personal Care Services (PCS) continues to be limited to non-educational support.

A list of these changes is on the TMHP website.

Major Texas Administrative Code (1TAC §355.8443) changes include:

SHARS providers must submit interim claims as designed below:

• interim claims for all personal care services that an eligible student receives within the cost report period
  • only 1 claim per PCS service code can be submitted to Medicaid per day;
• interim claims for all eligible specialized transportation trips provided within the cost report period; and
• at least one interim claim for other direct medical services that an eligible student receives within the cost report period.

Provider Service Documentation - Individualized Logs

SHARS providers are required to document service through 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) document. 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.

If providers are not able to meet this requirement, the service should not be billed for SHARS reimbursement. Medicaid has an expectation that once providers are aware of the need to modify local practices, those changes should be made. As always, TEA is available to support LEAs as they make this transition.

A district must enroll as an active Medicaid provider for SHARS to become eligible to submit claims and receive reimbursement for SHARS Medicaid services.  Additional information about becoming a SHARS Medicaid provider is located on the Health and Human Services Commission website.

Written Notification Required Prior to Consent and Annually

LEAs and SSAs must provide written parental notification prior to requesting consent and accessing benefits for the first time and annually thereafter.  Minimally, it must include all of the following:  §34 CFR300.154(d)(2) 

1. A statement of the parental consent to access public benefits:

•  specifies the personally identifiable information that may be disclosed (e.g., information about the services),
•  describes the purpose of the disclosure (e.g., billing for specific IEP services), and
•  identifies the agency to which the disclosure may be made (e.g., Medicaid).

2. A statement of "no cost" provisions. The LEA may not:

• require parents to sign up for or enroll in public benefits or insurance programs in order for their child to receive a free appropriate public education (FAPE);
• require parents to incur an out-of-pocket expense such as the payment of a deductible or co-pay amount incurred in filing a claim for SHARS services, the state or LEA may be required to pay the cost that the parents otherwise would be required to pay;
• use a child’s benefits under a public benefits or insurance program if that use would—
  • decrease available lifetime coverage or any other insured benefit;
  • result in the family paying for services that would otherwise be covered by the public benefits or insurance program and that are required for the child outside of the time the child is in school;
  • increase premiums or lead to the discontinuation of benefits or insurance; or
  • risk loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

3. A statement that the parents have the right to withdraw their consent at any time.

4. A statement that the withdrawal of consent or refusal to provide consent does not relieve the public agency of its responsibility to ensure that all required services are provided at no cost to the parents.

The notification must be written in language understandable to the general public. It must be in the native language or other mode of communication used by the parent, unless it is clearly not feasible to do so.  §34 CFR300.503(c)

Written Consent

LEAs and SAAs must obtain parental consent before releasing a child's personally identifiable information for billing purposes to a public benefits or insurance program for the first time.  Minimally, it must include the following:  §34 CFR300.154(d)(2) 

1. A statement of the parental consent to access public benefits:

• specifies the personally identifiable information that may be disclosed (e.g., information about the services),
• describes the purpose of the disclosure (e.g., billing for specific IEP services), and
• identifies the agency to which the disclosure may be made (e.g., Medicaid).

2. A statement indicating that the parent understands and agrees that the public agency may access the child’s or parent’s public benefits or insurance to pay for specific services identified in the child's IEP.

Annual Cost Report Requirements

Participating agencies are required to submit an annual cost report documenting the provider's Medicaid-allowable costs for all SHARS delivered during the federal fiscal year. This is used to reconcile interim payments to total Medicaid-allowable costs based on approved cost allocation methodology procedures. 

TEA does not dictate this process. HHSC determines these procedures and has clarified the use of parental consent it relates to the cost report . Questions regarding this process can be directed to HHSC PFD SHARS (ProviderFinanceSHARS@hhs.texas.gov).

TEA support includes:

• monitoring compliance with documentation guidelines,
• performing regular desk reviews and field audits,
• providing policy clarifications to districts,
• validating data submitted for SHARS billing,
• working to minimize exposure to provider waste, program abuse, and fraud.

The SHARS Self-Monitoring Tool is an instrument that can be used to assess a LEA's compliance with SHARS standards.  It is relevant to SHARS policy prior to November 2021.

The SHARS Self-Monitoring Tool - Nov. 2021 is an updated instrument that can be used to assess compliance with the revised SHARS policy. 

The SHARS Self-Monitoring Tool - Nov. 2022 is an updated instrument that can be used to assess compliance with the revised SHARS policy.

Additional Resources and Training

• Texas Medicaid Provider Procedures Manual (TMPPM)
  • Vol 1 Provider Enrollment and Responsibilities
  • School Health and Related Services (SHARS) Handbook
• Personal Care Services: What It Is and What It Is NOT
• Payment Rates - Interim Billing
• SHARS Update: Electronic Bulletin Registration
• Office of Inspector General (US Department of Health and Human Services): Centers for Medicare and Medicaid Services (CMS)