I am writing to express my concerns over the substantive proposed changes to the LEA Medicaid manual. I have serious concerns regarding the changes to the nursing and personal care services, which now require physicians' orders and signatures. The proposed changes will likely have a negative effect on school districts' abilities to bill in a timely fashion. In addition, many doctors' offices charge fees for paperwork, and this will also negatively impact school districts' costs to bill Medicaid. Compounding these changes are the potential negative impact to transportation billing as well. Finally, school psychologists in our district have reviewed the changes to school psychological services, and they have reported to me that the proposed changes are confusing and hard to understand.