Skip Maine state header navigation

Agencies | Online Services | Help

 

 

 

 

 

 

 

ADMINISTRATIVE LETTER NO.:  5

 

POLICY CODE:  IHBA

 

 

TO:                  Superintendents of Schools and Directors of Special Education

 

FROM:            J. Duke Albanese, Commissioner

                        Department of Education

 

DATE:             September 14, 2001

 

SUBJECT:       EF-S-04A, State Agency Client Admission/Discharge Notice

                        EF-S-04B, State Agency Client Billing Form

 

Enclosed with this Administrative Letter are copies of the EF-S-04A and EF-S-04B.  These two forms are to be used to report the admission or discharge of state agency clients to/from each school administrative unit and when billing the Department of Education for special education and related services provided to state agency clients by either a school administrative unit or a private special purpose school.  These forms will provide verification that a student is a state agency client in the school administrative unit and authorize payment for special education and related services provided to special education children only.  The forms are available by e-mail or on the department’s web page at www.maine.gov/education/forms.htm.  The enclosed tables have been changed to reflect changes in the Maine Special Education Regulations, Chapter 101.

 

The EF-S-04A, State Agency Client Admission/Discharge Notice, should be completed and mailed by each school administrative unit to the Department of Education, Office of Special Services, no later than October 1, 2001, for all state agency clients enrolled as of the start of the school year.  If you have no state agency clients, it is not necessary to send in this form until the end of the month when a state agency client enrolls in your unit.

 

The EF-S-04B, State Agency Client Billing Form, should be sent to the Department of Education, Office of Special Services, on a monthly basis, for services provided to eligible students by your unit.  BILLS FOR SEPTEMBER WILL BE DUE ON OCTOBER 18, 2001.  Any bill received more than thirty (30) days after the due date will be returned to the billing party and will not be paid.  An amendment was made to the statute during the 1989 Legislative session which allows for transportation to be billed as a related service to state agency clients when this is specified in the student's IEP.  (Table 4, Code 38)


ADMINISTRATIVE LETTER NO: 5

Page 2

 

The enclosed instructions provide specific information as to when the EF-S-04B is due.  The Office of Special Services will verify that the students reported for billing were reported on the EF-S-04A prior to authorizing payment and will notify the school administrative unit or private school of any problems with processing the payment.

 

The initial submission of the EF-S-04A will verify enrollment of all state agency clients as of the beginning of the school year.  The EF-S-04A should be amended any time a change occurs in the status of any state agency client included in the original report and a copy of the amended form sent to the Office of Special Services at the end of the month in which any changes occur.  If no changes occur during the month, you do not have to send an amended EF-S-04A.

 

Students who are eligible state agency clients are defined as follows:

 

     A.  Department of Human Services - Any student who is in the care or custody of DHS, residing in a foster home, group home, or emergency shelter in the unit, and for whom special education and/or related services are being provided;

 

     B.  Department of Behavioral and Developmental Services (formerly Department of Mental Health and Mental Retardation and Substance Abuse Services. - Any student who is placed in a facility or with a person other than the child's parent, legal guardian, or relative, with the approval of designated employee of Department of Behavioral and Developmental Services, whose placement was made for other than educational reasons and for whom special education and/or related services are being provided; *

 

     C.  Department of Corrections – Any student who is in the custody or under the supervision of the Department of Corrections, including, but not limited to, a juvenile on conditional release, an informally adjusted juvenile, a probationer or a juvenile on aftercare status from the Maine Youth Center and who is placed, for reasons other than educational reasons, pursuant to a court order or with the agreement of an authorized agent of the Department of Corrections, outside the juvenile’s home; and

 

     D.  Residents of state institutions - Any student residing in a state institution who is attending either a public school or a private special purpose day school, and for whom special education and/or related services are being provided.

 

If there is a question about the eligibility status of any student, school administrative units should contact the appropriate state agency to determine whether the student qualifies as a State Agency Client within the meaning of this statute.  For further assistance, please contact Christine Bartlett, Office of Special Services, at 624-6650.

 

JDA/CBB/pwo

 

* Reflects changes in Department of Mental Health and Mental Retardation and Substance Abuse Services name and their policy regarding what is an eligible state agency client.


ADMINISTRATIVE LETTER NO.:  5

Page 3

 

GENERAL INSTRUCTIONS FOR EF-S-04A

 

The EF-S-04A State Agency Clients Admission/Discharge Notice is to be used for reporting all eligible state agency clients who are residing in a school administrative unit (SAU).  Required data includes each student's name, birthdate (month, day, year), gender, disability, state agency, if state ward name and address of surrogate parent and yes or no to the automatic foster parent appointment, educational placement, date of entry into the SAU, discharge date upon leaving, and the SAU to which the student transferred, if known.  Amendments should be submitted at the end of any month in which there is a change of status for any state agency client included in the initial report or if a new state agency client enters the SAU.

 

PAGE NUMBERING

 

If more than one page is necessary, please duplicate the original form, number sequentially, and indicate the total number of pages.

 

AMENDMENTS

 

When a state agency client changes programs, or moves from one SAU to another, the EF-S-04A should be amended to reflect the change which has occurred.  If a new state agency client moves into the SAU, all appropriate information must be added to the original report.  For either of these events, provide all appropriate information, check Amended Report in the upper left hand corner, and submit a copy of the amended report to the Office of Special Services at the end of the month in which the change occurred.

 

SPECIFIC INSTRUCTIONS FOR EF-S-04A

 

Indicate the name of the administrative unit, name of the person completing the form, and the telephone number where that individual can be reached.

 

STUDENT INFORMATION

 

Identify each state agency client using last name, first name, date of birth (month, day, year), gender (M/F), exceptionality and the state agency(ies) with which the client is affiliated, using the appropriate columns.  Table 1 provides the codes to be used for identifying exceptionality;  Table 2 provides the codes to be used for identifying the State Agency(ies).

 

EDUCATIONAL PLACEMENT OF THE STUDENT

 

Identify the name and level (Elem., Middle, or Secondary) of the school attended, the type of placement (see codes from Table 3), and any related services being provided (use codes from Table 4) for each state agency client listed.  Whenever the student's placement or program changes, this must be noted on the form and an amended copy submitted to the Office of Special Services as directed above, see AMENDMENTS.

 


 

ADMINISTRATIVE LETTER NO.:  5

Page 4

 

DATE ENTERED/DATE DISCHARGED

 

Enter the date on which the state agency client first enrolled in the SAU in the Date Entered column.  Whenever a new state agency client enters the SAU, all of the above information must be added to the form and the date the student entered noted.

 

Whenever a state agency client moves from one SAU to another, the date on which the client left the SAU must be noted in the Date Discharged column and the SAU to which the client moved noted in the last column, if known.

 

A copy of the amended form must be submitted to the Office of Special Services at the last school day of the month during which any changes in the status of state agency clients occurred.

 

SIGNATURE AND DATE

 

Each copy submitted must be signed by the Superintendent of the SAU and dated.  If more than one page is necessary, each page should be signed and dated.

 


ADMINISTRATIVE LETTER NO.:

Page 5

 

GENERAL INSTRUCTIONS FOR EF-S-04B

 

The EF-S-04B State Agency Clients Billing is to be used for billing the Office of Special Services, Department of Education, for special education and related services provided to eligible state agency clients by a school administrative unit or a private special purpose school, in accordance with the student's IEP.  Required data includes each student's name, birthdate, gender, exceptionality, state agency, educational placement, dates of service provided, related service charges and corresponding information, total related services, tuition, and total of the two charges.  The EF-S-04B should be mailed to the Office of Special Services by Friday of the first full week of the month following provision of special education and related services.  Any bill received more than thirty (30) days after the service was provided will be returned to the billing party and will not be paid.  Amendments must be submitted if there is an error in the information provided on the original mailing of the form.

 

PAGE NUMBERING

 

If more than one page is necessary, please duplicate the original form, number sequentially, and indicate the total the number pages.  Record the total of all charges at the end of the final page.

 

AMENDMENTS

 

If an error is made in any of the information provided, the EF-S-04B must be amended to reflect the correct information and a copy of the amended EF-S-04B submitted to the Office of Special Services.  Please check the Amended Report box in the upper left hand corner of the form.  Amended reports must be received in the Division no later than June 15 for the fiscal year being billed.  Amended reports received after this date will not be paid.

 

SPECIFIC INSTRUCTIONS FOR EF-S-04B

 

Indicate the name of the administrative unit or private special purpose school, name of the person completing the form, and the telephone number where that individual can be reached.

 

STUDENT INFORMATION

 

Identify each state agency client using last name, first name, date of birth (month, day, year), gender (M/F), exceptionality and the state agency(ies) with which the client is affiliated, using the appropriate columns.  Table 1 provides the codes to be used for identifying the exceptionality; Table 2 provides the codes to be used for identifying the State Agency(ies).

 

EDUCATIONAL PLACEMENT OF STUDENT

 

Identify the name and level (Elem., Middle, Secondary) of the school attended, the type of placement (use codes from Table 3), and any related services being provided including transportation, if included in the student's IEP (use codes from Table 4).  List all services for which a charge will be made for each state agency client listed.  If the student's placement changes, note on the next form submitted.


ADMINISTRATIVE LETTER NO.:  5

Page 6

 

DATES OF SERVICE PROVIDED

 

Provide the dates (month, day, year) when service began and ended during the month for which the bill is being submitted for each eligible state agency client listed.  For students who were enrolled in the program for the entire month, use beginning and ending dates for the billing period.  For students who either entered after the start of the billing period, or left prior to the end of the billing period, provide the date the student actually entered as the first date, or the date the student actually left as the last date entered.

 

RELATED SERVICES

 

Enter separately the actual monthly cost of each related service provided to each eligible student.  The cost/student should be determined by dividing the total cost of the service by the total number of units of service provided (e.g., hours of therapy). Multiply the cost/unit by the actual number of units of service provided to the eligible student during that billing period, and enter this amount in the column Related Services.  Transportation is considered for billing purposes as a related service, if specified as such in the student's IEP.

 

TUITION CHARGE

 

Enter the actual monthly cost for each client's special education classroom placement in the column marked tuition.  Private schools should enter the approved monthly rate as established by the Department, pro-rated to reflect the actual number of days served, if the client entered or was discharged without attending for the full month being billed.  School administrative units should determine the actual tuition cost according to Title 20-A, M.R.S.A., sub-Chapter III, ss 7302, and Maine Special Education Regulations, C.101.19. 3. (or 19.4., if a new program).

 

TOTAL OF TUITION AND RELATED SERVICES

 

For each student, add the tuition column and the total related service(s) charge column and enter the total in this column.

 

TOTALS

 

For each page submitted, total all tuition charges at the bottom in the appropriate column, all related service charges, and the total of all costs.  If more than one page is submitted, total all pages and enter this figure at the bottom of the last page submitted.

 

SIGNATURE AND DATE

 

Each copy submitted must be signed by the Superintendent of the school administrative unit or the Director of the private school submitting the bill.  Each page must also be dated.

 

 

 

 

TABLE 1

 

EXCEPTIONALITY

 

(USE ONE CODE ONLY)

 

CODE:

            1.  Mental Retardation

            2.  Hearing Impairment

            3.  Deafness

            4.  Speech and Language Impairment

            5.  Visual Impairment including blindness

            6.  Emotional Disability

            7.  Orthopedic Impairment

            8.  Other Health Impairment

            9.  Specific Learning Disability

            10.  Deaf/Blindness

            11.  Multiple Disabilities

            13.  Autism

            14. Traumatic Brain Injury

            15.  Non-Special Education

 


TABLE 2

 

STATE AGENCY CODES

 

(USE AS MANY CODES AS NECESSARY)

 

CODE:

20.  Department of Behavioral and Developmental Services (formerly Department of Mental Health, Mental Retardation and Substance Abuse Services), student with Mental Illness/Behavior Impairment

 

21.    Department of Behavioral and Developmental Services (formerly Department of Mental Health, Mental Retardation and Substance Abuse Services, student with Mental Retardation

 

22.    Department of Human Services

 

23.    Department of Corrections

 

24.  Residents of State Institutions

 

 

REPORT OF SERVICES TO EXCEPTIONAL STUDENTS

 

 

TABLE 3

 

CONTINUM OF SPECIAL EDUCATION PLACEMENTS

 

NOTE: THIS TERMINOLOGY IS DERIVED FROM FEDERAL REPORTING REQUIREMENTS AND DOES NOT IMPLY A CHANGE IN MAINE REGULATIONS OR DEFINITIONS

 

CODE:

 

21.  Regular Class                        where a student with a disability receives a majority of his/her

Placement:                        educational program with non-disabled students, receiving special

education and related services OUTSIDE THAT CLASSROOM for less than 21 percent of the school day. This may include students with disabilities placed in:  regular class with special education/related services provided within the regular class, or regular class with instruction within the regular class and with special education/related services provided outside the regular class.  Students receiving monitoring services should also be included in this category.

 

 

 

 

 

 

22. Resource Room                        where a student with a disability receives special education and

      Placement:            related services OUTSIDE THE REGULAR CLASSROOM for 60 percent or less of the school day and at least 21 percent of the school day.  This may include students with disabilities placed in:  resource rooms with special education/related services provided within the resource room, or resource rooms with part-time instruction in a regular class.

 

23. Self-Contained            where a student with a disability receives special education and related

      Placement:                        services OUTSIDE THE REGULAR CLASSROOM for more than

60 percent of the school day in a self-contained program.  This may include students with disabilities placed in: self-contained special classrooms with part-time instruction in a regular class, or self-contained special classrooms full-time.

 

24. Public                     where a student with a disability receives special education and related

      Separate Day      services for greater than 50 percent of the school day in public separate

      School                    day school facilities.

      Placement:

 

25. Private                    where a student with a disability receives special education and related

      Separate Day      services for greater than 50 percent of the school day in private separate

      School                    day school facilities.

      Placement:

 

26. Public                     where a student with a disability resides and receives special education

      Residential            and related services for greater than 50 percent of the school day in

      Placement:              public residential facilities.

 

27. Private                    where a student with a disability resides and receives special education

      Residential            and related services for greater than 50 percent of the school day

      Placement:              in private residential facilities.

 

28. Homebound            where a student with a disability receives special education and

      Hospital                  related services in a medical treatment facility or at home.

      Placement:

 


TABLE 4

 

SUPPORTIVE SERVICES

 

 

(USE AS MANY CODES AS NECESSARY)

 

 

Definitions of these related services can be found in 34 CFR 300.16.

 

Diagnostic Services should be reported under the appropriate related service code.

 

 

 

CODE:

 

            31.  Psychological Services

 

            32.  School Social Work Services

 

            33.  Occupational Therapy

 

            34.  Speech and Language Services

NOTE:  Do not use this code for

students with speech/language

impairment (Table I, Code 4)

as their primary exceptionality.

 

            35.  Audiological Services

 

            36.  Recreational Services

 

            37.  Physical Therapy

 

            38.  Transportation Services (special transportation arrangements)

 

            39.  School Health Services

 

            40.  Counseling Services

 

41.    Other Related Services (please specify)