Official Site of The State of New Jersey

Below is an overview of the district’s final Fiscal Year (FY) 2025 SEMI (NJ SBHS) program performance. Per N.J.A.C. 6A:23A-5.3(f), an action plan is required for those school districts that did not meet at least 90 percent parental consent response and/or 100 percent of budgeted reimbursement revenue by June 30, 2025. If the district did not meet one or both benchmarks listed in the “Action Plan Triggers” section below, the district must complete and submit an action plan to the County Office, due with the district’s FY 2027 budget.

Additional financial deadline performance metrics are listed below for districts to identify those areas for improvement, but do not trigger the need for an action plan.

The NJ Department of Education (NJ DOE) will provide a template for the required action plan including contextual language to explain the challenges and contributing factors that impacted FY 2025 revenue benchmark performance. This is available online on the NJ SBHS Website for the district’s use. Suggested activities for consideration in the action plan are available upon request through the County Office and/or Public Consulting Group (PCG); contact information for PCG is: The NJ SBHS Team, (609) 275-0250, extension 2 and njsemi@pcgus.com .

New Jersey is a Cost Settlement state, and all Fee-For-Service (FFS) reimbursement is interim reimbursement. For interim FFS reimbursement to be retained by the school district, it must be supported by eligible, reported allowable costs in the Annual Cost Report submission and Annual Cost Settlement process. The State of New Jersey has implemented an updated Cost-Based Interim Rates calculation effective for FY 2026, which also drives the FY 2027 Reimbursement Revenue Projection calculations.

Notes:

• District Projected Reimbursement Revenue: FY 2027 reimbursement revenue calculations and assumptions are listed immediately below. 
• District Budgeted Reimbursement Revenue Requirement: District shall recognize no less than 90 percent of the SEMI (NJ SBHS) reimbursement revenue projection.

For school districts with FY 2025 SEMI (NJ SBHS) claiming data, the FY 2027 Reimbursement Revenue Projection is calculated as follows:

For school districts that did not participate in the SEMI (NJ SBHS) Program in FY25 or failed to claim direct medical services in FY25, the FY 2027 Reimbursement Revenue Projection will be based on the following calculation:

Apply Fee-for-Service (FFS) interim reimbursement rates to district-specific, health-related direct service average count, as outlined within each district’s individual FY 2027 reimbursement revenue projection, which are disseminated by the County Offices.

Cost-based interim reimbursement tiered bill rates are located on the State’s NJ SBHS Website.

The Medicaid-Eligible Student Count is calculated as follows:

• The Medicaid-Eligible Student Count is derived by comparing the list of special education students (reported by the district to NJDOE via NJSLEDS) to a list of Medicaid-eligible students (provided by the Department of Human Services, per the October 2025 match).
  • For the FY 2027 reimbursement revenue projections, the October 15, 2025 NJSLEDS Special Education Submission snapshot will be used.
• Students identified as a match are included in the count to determine the total number of Medicaid-eligible students from the October 15 snapshot.
• Note: The count of eligible students is based on district reported data at the October 15 snapshot. Disputing the number of Medicaid-eligible students will not be considered reliable evidence for a waiver.

• 100 percent positive parental consent rate for Medicaid-eligible students.
• All health-related direct services and health-related evaluation services must be documented in EDPlan.
• Next steps after reviewing your district reimbursement revenue projection are indicated below.

Reimbursement Revenue Projection: More than 40 Medicaid-Eligible Students

If the reimbursement revenue projection has a count of more than 40 Medicaid-Eligible Students:

• Districts projected to have more than 40 Medicaid-Eligible Special Education students for the 2026-2027 school year must participate in the SEMI (NJ SBHS) program, per N.J.A.C. 6A:23A-5.3.
  • These districts must include the district budgeted reimbursement revenue projection in the FY 2027 district budget (recorded on revenue line 540 “Medicaid Reimbursement”).
• Per N.J.A.C. 6A:23A-5.3, districts projected to have over 40 Medicaid-Eligible Special Education students who have reliable evidence to seek an alternate reimbursement revenue projection must submit all supporting information to the County Office for approval.
  • An alternate reimbursement revenue projection is not a waiver and districts with an approved alternate reimbursement revenue projection are still required to fully participate in SEMI (NJ SBHS) program requirements. Please refer to Attachment B for a list of items to consider when developing the alternate reimbursement revenue projection.

Reimbursement Revenue Projection: 40 or Fewer Medicaid-Eligible Students

If the reimbursement revenue projection has a count of 40 or fewer Medicaid-Eligible Students:

• Districts that are eligible for a SEMI (NJ SBHS) waiver, excluding those with a projected reimbursement revenue of $0, are required to submit a formal written request to the Executive County Superintendent in order to seek an exemption from the SEMI (NJ SBHS) program requirements. If a formal request is not submitted and approved, the district will be expected to maximize its participation in the SEMI (NJ SBHS) program.
• Districts that are in receipt of an approved waiver and choose to participate are required to provide written notification of their election to participate to the County Office.