Shenandoah County Public Schools strongly opposes the proposed DMAS changes to the policy manual for nurses, personal care assistants, and psychological services.  We are heavily dependent on Medicaid reimbursements for meeting the needs of our most vulnerable population and in a community that is already under-served in terms of health related services. These proposed changes would impact funding to the school division due to loss of billable time waiting for the physician to sign and return the Plan of Care, potential doctor fees for completing additional paperwork, and loss of funding for transportation for these lost billable services.  These changes would also result in increased staff time in following up on the required information and tracking data for students who have multiple physicians that would result in a Plan of Care for each physician. School divisions would have to submit claims per physician.  If a student had asthma, diabetes, and tube feeding all ordered by different specialists, three claims would be submitted instead of one.  This would also be an additional cost to school divisions.  Nurses and Personal Care Assistants will be tracking more data, billing for possibly less services and will be taking time away from other students.  The proposed changes to psychology will also result in increased time tracking data and documentation.