1. (a) The enrolled school provider shall provide documentation annually regarding all services rendered pursuant to these rules.

2. (b) Such documentation shall:

   1. (1) Demonstrate that:

      1. a. The percentage of federal medical assistance reimbursed, as required by section 1905(b) of the Social Security Act, does not exceed 50% of the actual cost of covered services claimed under medicaid; and
      2. b. Services that are reimbursable under medicaid, but paid by other federal funding, are not claimed by the enrolled school provider under NH medicaid;
   2. (2) Be reviewed and signed by the enrolled school provider’s superintendent;
   3. (3) Be submitted to the department no later than October 30 of each year for the preceding fiscal year period; and

   4. (4) Be accompanied by a completed form “Documentation of Expenditure of Non-Federal Funds” (November 2025) for a specific July 1 through June 30 time period which includes an attestation signed and dated by the superintendent stating:

      “I hereby certify that all Medicaid funds paid to the above named districts under He-W 589.08, Medical Assistance Services Provided by Educational Agencies for the period July 1, xxxx through June 30, xxxx have been supplemented with LEA/SAU and/or non-federal funds to total 100% of the cost of services rendered and that the Medicaid reimbursement does not exceed 50% of the total cost of the services rendered.”

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98 New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99 New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07 New. #9035, eff 11-22-07; amd by #10278, eff 2-23-13; EXPIRED: 11-22-15 in paras. (a), (b)(1), and (b)(2); amd by #11045-A, INTERIM, eff 2-25-16, EXPIRES: 8-23-16; ss by #11165, eff 8-23-16; renumbered by #12607, EMERGENCY RULE, (formerly He-M 1301.07) (renumbered as He-M 1301.07 again pursuant to RSA 541-A:18, V upon expiration 2-16-19 of #12607); ss by #12861, EMERGENCY RULE, eff 8-28-19 (formerly He-M 1301.07) New. #12994, eff 2-21-20 (formerly He-M 1301.08) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35