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Governor Phil Murphy • Lt. Governor Tahesha Way

New Jersey School-Based Health Services

Special Education Medicaid Initiative (SEMI)

SEMI LEA Interim Reimbursement Rates

Interim Rate Tiers Gross Claim Rate Federal Share
50%		 State Share
32.5%		 School Share
17.5%
0 $15.00 $7.50 $4.88 $2.63
1 $22.50 $11.25 $7.31 $3.94
2 $40.00 $20.00 $13.00 $7.00
3 $55.00 $27.50 $17.88 $9.63
4 $70.00 $35.00 $22.75 $12.25
5 $85.00 $42.50 $27.63 $14.88
6 $97.50 $48.75 $31.69 $17.06
Warning Tier $15.00 $7.50 $4.88 $2.63

*Please Note: Gross Claim Rates include the following: Direct Medical Services, Evaluations, and Transportation.

SEMI Documentation
  • NJ SBHS Service Log - Psychology Services and Social Work
  • NJ SBHS Service Log - Speech Therapy Services
  • Semi Parental Consent Form
  • Semi Parental Notification Form
  • Arabic Parental Consent Form
  • Arabic Parental Notification Form
  • Chinese Cantonese Parental Consent Form
  • Chinese Cantonese Notification Form
  • Chinese Mandarin Parental Consent Form
  • Chinese Mandarin Parental Notification Form
  • Haitian Creole Parental Consent Form
  • Haitian Creole Parental Notification Form
    • Accountability Regulation

    In accordance with New Jersey Statutes Annotated 18A:55-3 school districts are required to maximize their participation in the Special Education Medicaid Initiative (SEMI). The newly adopted Accountability Regulations specified in New Jersey Administrative Code (N.J.A.C. 6A:2A-5.3). include programmatic guidelines and standards for local school districts to maximize participation in SEMI.

    Memos:
    Percentage Shares
    Effective for all services rendered July 1, 2006 and forward, the district share for SEMI and MAC is 35% of net revenue.
    Agency Responsibilities

    • Researches and resolves fiscal issues for LEAs
    • Provides assistance with SEMI and Medicaid Administrative Claiming (MAC) payments
    • Facilitates signing of Memorandum of Understanding (MOU) for SEMI/MAC program by all parties
    • Provides policy guidance
    • Maintains SEMI/MAC public website
    • Serves as Contract Manager on behalf of the State of New Jersey

    • Provides policy and guidance
    • Coordinates the process and maintains documentation (LEA Statement of Assurances and Approved Board Minutes) for Board of Education approval for participation by LEA
    • Facilitates pre-enrollment process by the LEA for participation in the SEMI program

    • Conducts Medicaid provider enrollment, including issuing Electronic Data Interchange (EDI) Agreement to LEAs for their signature
    • Issues Medicaid provider numbers to LEAs
    • Provides Medicaid technical assistance
    • Communicates requirements of program specifics to ensure that Federal Medicaid regulations are followed
    • Processes and adjudicates claims
    • Provides policy guidance

    • Conducts Office of Education evaluations
    • Provides Medicaid technical assistance and transportation to DCF Campuses
    • Appoints a SEMI Coordinator to coordinate with PCG in fulfilling the operational responsibilities for SEMI
    • Verifies that student health-related services submitted to PCG for Medicaid claiming are included in the student’s IEP which is valid for the dates of service
    • Verifies that service providers have the appropriate qualifications or credentials for Medicaid billing

    • Pre-enrolls with the Department of Education to certify LEA status by submitting board approval and assurances for program implementation related to participation in SEMI program
    • Completes the Medicaid Provider Application package to enroll as a Medicaid provider with the Medicaid program and receives a unique seven-digit Medicaid provider number which will be used for billing purposes
      • Obtains assistance, as needed, from the Medicaid office to complete the various forms included in the application package
    • Designates PCG as the LEA’s Medicaid billing agent by completing the State of New Jersey Submitter/Provider Relationship EDI and Electronic Remittance Advice (ERA) agreements
    • Appoints a SEMI Coordinator to coordinate with PCG in fulfilling the LEA’s operational responsibilities for SEMI
    • Verifies that student health-related services submitted to PCG for Medicaid claiming are included in the student’s IEP which is valid for the dates of service
    • Verifies that service providers have the appropriate qualifications or credentials for Medicaid billing
    • Verifies that signed written positive parental consent to bill Medicaid has been obtained prior to submitting service records to PCG for Medicaid billing
    • Verifies that transportation services billed to Medicaid are: (1) for transportation on specialized vehicles; (2) included in the student’s IEP; (3) for a student who received another Medicaid covered service on the day for which round-trip transportation is billed; and (4) for a student who actually used the transportation service
    • Monitors service documentation compliance by related service providers and conducts necessary follow-up
    • Complies with New Jersey DOE’s Fiscal Accountability Regulations and record retention responsibilities

    • Receives and processes Billing Agreements (Electronic Data Interchange) from newly Medicaid enrolled LEAs
    • Provides a toll-free Help Desk telephone hotline and email address to provide technical assistance to LEAs regarding SEMI service documentation issues
    • Manages and hosts EdPlan™ for LEA’s electronic service documentation and compliance for the fee-for-service program component of the State’s program
      • Conducts Medicaid eligibility verification activities for New Jersey students
      • Provides initial user names and passwords for LEA providers documenting services within EdPlan
      • Provides training to providers for service documentation using EdPlan (see Appendix A)
    • Maintains and hosts PCG Claiming System in supporting various MAC and Cost Settlement program requirements
      • Provides initial user names and passwords for SEMI administrators at LEA
      • Provides training to administrators for reporting and certifying data
    • Prepares and submits claims for FFS Medicaid reimbursement, MAC, and Cost Settlement, based on LEA service and compliance documentation, consistent with Medicaid billing requirements
    • Supports the State in administering aspects of on-going Medicaid legal and regulatory compliance monitoring and facilitates best-practice sharing across districts
    • Complies with all responsibilities outlined in the State Contract


    Last Updated: Thursday, 11/13/25