MEDICAID AND SCHOOL HEALTH

TABLE OF CONTENTS

Purpose of this Guide . 5

Overview of Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Forging A Relationship with the State Medicaid Agency. . . . . . . . . . . . . . . . . . 9

COVERAGE OF SCHOOL HEALTH SERVICES (SHS) 11

Requirements for Coverage of Medicaid Services 13

EPSDT 14

Medical Services Under IDEA 17

Medicaid Provider Qualifications 19

Provider Agreements 20

Freedom of Choice 22

MEDICAID MANAGED CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Types of Medicaid Managed Care Entities 33

Medicaid Managed Care Enrollment 34

Section 1915(b) and 1115 Waivers 34

Issues for School Providers and Medicaid Managed Care. . . . . . . . . . . 38

Examples of Relationships 39

Recommended Publications and Resources . . . . . . . . . . . . . . . . . . . . . 42

PAYMENT 45

Payment Requirements 47

Establishing Payment Rates 49

The Role of Medicaid Providers in Billing 51

Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

FREE CARE AND THIRD PARTY LIABILITY 55

Free Care 57

Exceptions to Free Care 58

Impact of Free Care on SHS 59

Third Party Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Payment of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Cost Avoidance 61

Pay and Chase 61

Prenatal and Preventive Pediatric Services 62

Exceptions to Medicaid as the Payer of Last Resort 63

Impact of the TPL Requirements on School-Based Providers 63

ADMINISTRATIVE CLAIMING 67

Guiding Principles of Administrative Claiming 69

General Administrative Services 72

Percentage of Allowable Activities 73

TRANSPORTATION 75

Transportation as an Optional Medical Service 77

Transportation as an Administrative Expense 78

Medicaid Coverage of Transportation to SHS 78

CASE MANAGEMENT 81

Administrative Case Management 85

Case Management as a Medical Service . . . . . . . . . . . . . . . . . . . . . . . . 86

Case Management Under Medicaid Waivers 87

Targeted Case Management 88

CONFIDENTIALITY 91

Administration of the Plan 93

EPSDT 93

Standards of Confidentiality 94

Releases of Information 95

Confidentiality and SHS 96

State Examples 97

CONCLUDING REMARKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

MEDICAID DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103

HCFA REGIONAL OFFICE AND STATE MEDICAID OFFICE . . . . . . 105

PURPOSE OF THIS GUIDE

School health services play an important role in the health care of adolescents and children. Whether implemented for children with special needs under the Individuals with Disabilities Education Act (IDEA), or for routine preventive care, on-going primary care and treatment in the form of a school-based or linked health clinic, school-centered programs are often able to provide medical care efficiently and easily without extended absences from school. Recognizing the important role school health services can play, the Medicaid program has been supportive of school-centered health care as an effective method of providing access to essential medical care to eligible children.

There are, however, challenges in the collaboration between the Medicaid program and the schools. Federal Medicaid requirements are complex and the implementation of Medicaid varies by state. Because many schools are unaccustomed to these requirements and the complexity of operating in the “medical services world,” understanding and negotiating Medicaid in order to receive reimbursement often has the effect of placing a considerable administrative burden on schools.

The purpose of this guide is to provide information and technical assistance regarding the specific Federal Medicaid requirements associated with implementing a school health services program and seeking Medicaid funding for school health services. Because of the numerous types of school-based arrangements in existence throughout the country, in this guide, “school health and school-based services” refers to any type of Medicaid-covered school-based health services provided by or within a school system, whether in the school, through a school-based or school-linked clinic or through the IDEA.

The following is a brief summary of each section of this guide:

Coverage of School Health Services - This section details the requirements for coverage of services under the Federal Medicaid statute and regulations, the Federal Medicaid requirements for coverage of services under the IDEA and the Federal Medicaid requirements for providers furnishing services to Medicaid beneficiaries.

Medicaid Managed Care and School Health Services - This section discusses the waivers of the Medicaid statute needed by states to implement mandatory managed care and the implications of mandatory implementation of Medicaid managed care on school-based health providers. This section also provides examples of coordination as a guide for schools whose state is moving toward implementation of Medicaid managed care.

Medicaid Payment for School Health Services - This section discusses the Federal Medicaid payment requirements, including the state plan process as it pertains to school health services, Medicaid provider responsibilities, allowable payment methodologies and necessary documentation.

Third Party Liability and Free Care - This section details the Medicaid free care and third party liability requirements and their impact on schools seeking payment for school health services.

Administrative Claiming - This section discusses the Medicaid requirements associated with schools/school districts claiming administrative costs for activities performed related to the administration of the Medicaid program.

Transportation - This section explains Federal Medicaid policy regarding schools seeking payment for transportation of Medicaid beneficiaries to school-health services.

Case Management - This section defines the provision of case management for Medicaid-eligible children and the requirements for schools seeking payment for these services.

Confidentiality - This section explains the Medicaid confidentiality requirements, in addition to providing examples of how the provision of Medicaid-covered school health services has been achieved within these requirements.

The document concludes with a page of definitions for referencing complex terminology used in this guide and a list of Medicaid regional office and state Medicaid agency contacts.

Because Medicaid policy often changes and evolves, this guide should not be considered an authoritative source in itself. The guide is intended to be a general reference summarizing current applicable law and policy and not intended to supplant the Medicaid statute, regulations, manuals or other official policy guidance. As noted throughout this guide, Federal Medicaid guidelines provide only a framework for state Medicaid programs. Therefore, in order to determine specific state requirements, schools should contact their state Medicaid agency.

OVERVIEW OF MEDICAID

Title XIX of the Social Security Act (the Act) established a Federal-state matching entitlement program which provides medical assistance for certain low-income individuals. The program, known as Medicaid, was enacted in 1965. Within broad Federal guidelines, the Medicaid program is jointly funded by the Federal and state governments and is administered by each individual state to assist in the provision of medical care to pregnant women and children and to needy individuals who are aged, blind, or disabled. Medicaid is the largest program financing medical and health-related services to the nation’s poor.

States operate their Medicaid programs within the broad parameters of Federal Medicaid laws and regulations. Within this framework, each state establishes its own eligibility standards; determines the type, amount, duration, and scope of services; sets the rate of payment for services; and administers its own program. Each state describes its program in a state plan. On the Federal side, the Health Care Financing Administration (HCFA) reviews each state’s proposed state plan for conformity with Federal requirements, including the requirements to provide a basic core package of federally mandated services to certain eligible populations in each state. The structure of HCFA is that there are 10 regional offices located throughout the country that are responsible for direct oversight of the state Medicaid programs. The central office of HCFA, located in Baltimore, Maryland, serves as the focal point for Medicaid policy considerations, and works closely with the regional offices on issues regarding state Medicaid policy and administration. HCFA also determines which expenditures by a state Medicaid agency are necessary and proper for carrying out the requirements of the Medicaid program; approves state agency estimates of expenditures on a quarterly basis; conducts financial management studies and survey and certification reviews; provides leadership in special program initiatives; conducts research and demonstration projects and studies as directed by Congress; and provides technical assistance and policy guidance to the states in the development of their individual Medicaid programs.

Funding for the Medicaid program is shared by the state and the Federal governments, and the amount of total Federal payment to states for Medicaid has no set limit. Federal Financial Participation (FFP), which is the Federal government’s share for states’ Medicaid program expenditures, are generally claimed under two categories, administration and medical assistance payments.

FFP for administrative expenditures for functions such as outreach, follow-up, eligibility determination, and provider relations, are usually Federally matched at a fixed rate of 50%. This means the Federal government will provide funds equal to the sum the state contributes toward total administrative expenditures. However, higher matching rates of 75%, 90% or even 100% are authorized by law for certain administrative functions and activities. For expenditures for those activities, the Federal government will provide funds in a higher proportion than the state’s contribution.

State expenditures for the cost of medical assistance is Federally matched at varying percentage rates. FFP matching rates for medical services expenditures are determined annually for each state by a formula that is based on the relationship of the state’s average per capita income level with the national per capita income. Called the Federal Medical Assistance Percentage (FMAP), this matching rate by law, is limited to a minimum of 50% and a maximum of 83%, with poorer states receiving a higher match and wealthier states receiving a lower match. Some services provided by the state Medicaid programs, such as transportation and case management, may be treated as either administrative or medical assistance payments; and under some circumstances may be divided between the two categories.

As mentioned earlier, in order to receive Federal matching dollars for medical services under the Medicaid program, each state maintains a state plan. This state plan details the scope of the Medicaid program in a particular state by listing the eligibility groups and standards, the services provided, any applicable service requirements, and payment rates for those services. While states generally have flexibility in forming their Medicaid programs, Medicaid state plans must include certain elements of information, and must be consistent with mandates detailed in Federal statutes. Broad Federal coverage and reimbursement guidelines give structure to the state plans and promote some consistency among the many state Medicaid programs. Within Federal Medicaid statutory and regulatory guidelines, states have the flexibility to change their state plans in terms of the services covered and payment rates offered by submitting a state plan amendment (SPA) to HCFA. While formulating a state plan is a specific function of the state agency, schools or local education agencies (LEAs) can be involved in helping develop the state plan language pertaining to school health services. In the provision of such covered services and payment rates, LEAs or schools will also be responsible for fulfilling specific state requirements. Therefore, it is imperative that those entities involved work closely with the state Medicaid agency to ensure that all requirements are satisfied.

FORGING A RELATIONSHIP WITH THE STATE MEDICAID AGENCY

Because state Medicaid agencies are responsible for the operation of their Medicaid program, it is imperative the education agencies, LEAs, etc. attempt a concerted effort to formulate a relationship with the state Medicaid agency. Education agencies interested in Medicaid should request applicable sections of the state plan and become familiar with this document as a first step. In this manner, the education agency can work with the state Medicaid agency in developing or augmenting existing Medicaid services. If both parties can make an effort to establish a working relationship, communication will decrease confusion and foster understanding, thereby improving the provision of services to children.

In some states, the state Department of Education (DOE) will take a leadership role in working with the state Medicaid agency. If not, it is essential for LEAs and local school districts to look to contact the state Medicaid agency. However, in other states, LEAs or the state Department of Education choose to involve private consultants as an intermediary or to facilitate the process. Although consultants are helpful in that they can provide advice on the requirements associated with seeking Medicaid payment, the Medicaid agency is the authority of the specific requirements associated with seeking Medicaid reimbursement in the state. In addition, consultants can be costly, as they can charge up to 20 percent on the amount of Medicaid payment they acquire. We recommend that any LEA or education agency considering the use of private consultants check out the consultants’ references and conduct a realistic assessment of what the consultants are offering to deliver. This will ensure that the proposals formulated by the consultants for the state will meet the necessary Federal standards when submitted by the state, which can facilitate Federal approval of the proposal.

In addition, using consultants should not substitute for educational agencies establishing a close working relationship with the state Medicaid agency. The state Medicaid agency can coordinate program planning and reimbursement, provide technical assistance to schools and expedite problem solving with Medicaid on policy issues for LEAs.

Title XIX of the Act requires states must cover certain basic services to certain categories of eligible individuals. Examples of mandatory services a state must cover are physician services, family planning services and supplies, rural health clinic services and federally qualified health center (FQHC) services and early and periodic screening, diagnostic and treatment services (EPSDT) for individuals under the age of 21.

States may also elect to cover optional services. Currently, there are over 30 optional services states can choose to cover in their state plan. Some of the most common optional services states choose to cover are clinic services and prescription drugs.

In their state plans, states also specify the populations covered, and the amount, duration and scope of services to be covered for both mandatory and optional services in their state plan. The purpose of this section is to explain the requirements for coverage of services under the Medicaid statute and regulations, the Federal Medicaid requirements for coverage of the health-related services under IDEA and the Federal Medicaid requirements for providers (in particular school-based providers) furnishing services to Medicaid beneficiaries.

Requirements for Coverage of Medicaid Services

Section 1905(a) of the Act lists the mandatory and optional services a state can cover in its Medicaid program. Federal Medicaid law requires that the amount, duration and scope of each service must be sufficient to achieve its purpose. In addition, the Federal Medicaid comparability provisions (42 CFR 440.240), require that, with certain exceptions, all individuals within an eligibility group must be offered comparable amount, duration and scope of services. And, for mandatory services, a state cannot place arbitrary limitations, such as diagnosis, on who may receive covered services.

States may place appropriate limits on the coverage of Medicaid services based on such criteria as medical necessity or utilization control. For example, states may place a reasonable limit on the number of covered physician visits or may require prior authorization to be obtained before service delivery to ensure that the provision of the services is warranted. Medical necessity refers to the appropriateness of medical intervention and treatment for certain medical conditions. States themselves define what medical necessity means for the purposes of covering services under their Medicaid programs. Furthermore, unless waivers of the Federal Medicaid statute are obtained (discussed in more detail in the section of this guide on Medicaid Managed Care), the state plan must allow beneficiaries freedom of choice among health care providers participating in the Medicaid program. This means that within reasonable limits, beneficiaries are allowed to choose among all available qualified providers who are willing to furnish services to them.

In order for Medicaid to reimburse for health services provided in the schools, the services must be included among those listed in the Medicaid statute (section 1905(a) of the Act) and included in the state’s Medicaid plan or be available under the Early and Periodic Screening, Diagnostic and Treatment benefit (EPSDT, described below). There is no benefit category in the Medicaid statute titled “school health services” or “early intervention services.” Consequently, a state must describe its school health services in terms of the specific section 1905(a) services which will be provided. Except for services furnished under EPSDT, a service must be specifically identified in the state’s Medicaid plan to make Medicaid payment available for it.

Typically, schools which provide medical services provide a number of different Medicaid-covered services. Some Medicaid coverage categories in the regulations are more specific, in that the services are described along with the providers who can furnish those services. Other Medicaid service categories are more general, (such as the rehabilitation benefit), which is more broadly defined in terms of the services as well as the providers of the services. The end of this section contains a chart describing the various Medicaid service categories that could generally be provided by or within the school health system.

EPSDT

In addition to being eligible for the Medicaid services offered under a state Medicaid program, children under the age of 21 are entitled to the mandatory Federal Medicaid benefit known as Early and Periodic Screening, Diagnostic and Treatment (EPSDT). EPSDT is Medicaid’s comprehensive and preventive children’s health care program geared toward early assessment of children’s health care needs through periodic examinations. The goal is to assure that health problems are diagnosed and treated as early as possible, before the problems become complex and treatment more costly. States must develop periodicity schedules for each service after consultations with organizations involved in child health care.

Many states call the EPSDT program in their state “catchy” names other than EPSDT, to emphasize the importance of child health and to “market” the benefit to eligible beneficiaries. Examples of such names include KIDMED (Louisiana); KAN BE HEALTHY (Kansas); Health Check (North Carolina, Wisconsin, Georgia, Wyoming and Nebraska); Health Kids Club (South Dakota) and Well Child Care (New Jersey).

The following are required EPSDT services (under Section 1905(r) of the Act):

Screening services, which must contain the following 5 elements:

(1) Comprehensive health and developmental history, including assessment of both physical and mental health development;

(2) Comprehensive unclothed physical exam;

(3) Appropriate immunizations according to the ACIP (Advisory Committee on Immunization Practice) schedule;

(4) Laboratory tests, including blood lead level assessment, and

(5) Health education, including anticipatory guidance.

Vision services, which at a minimum must include diagnosis and treatment for defects in vision, including eyeglasses.

Dental services, which at a minimum must include relief of pain and infection, restoration of teeth, and maintenance of dental health.

Hearing services, which at a minimum must include diagnosis and treatment for defects in hearing, including hearing aids.

Other necessary health care, diagnostic services and treatment services. As with all Medicaid services, any limitation that the state imposes on EPSDT services must be reasonable and the benefit provided must be sufficient to achieve its purpose. In addition, states must provide other necessary health care, diagnostic services, treatment and other measures described that are listed under the Medicaid statute, to correct and ameliorate defects and physical and mental illnesses and conditions discovered by screening services, whether or not covered in a particular state Medicaid plan. This means that if the state does not cover an optional service under its state plan, such as occupational therapy, the State would have to make medical assistance available for the service when furnished to a child eligible for EPSDT if occupational therapy is medically necessary. As such, EPSDT constitutes an exception to the comparability requirements in that the state does not have to make comparable services to all Medicaid beneficiaries. This is an important point because this means that if medically necessary, a Medicaid eligible child is entitled to any Medicaid-coverable service, regardless of whether the state covers it in the state plan or not. However, a state may still subject these services to prior authorization for purposes of utilization control.

Provision of medically necessary interperiodic screening. Interperiodic screenings, outside of the state’s established periodicity schedule, must be made available to EPSDT beneficiaries when an illness or condition is suspected that was not present during the regular scheduled periodic screening. Referrals for interperiodic screens may be made by a physician, school nurse, parent or by self-referral. The provider performs the necessary screening components, which need not include all five elements of the required periodic screening, and provides or refers for any additional diagnostic or treatment services.

The referral for interperiodic screening can be made by any health or developmental education personnel who comes in contact with the child, within or outside of the health care system. The purpose of the interperiodic screening is to assure that children are assessed as soon as a problem is suspected even if they are not scheduled for a complete screening for many months. For example, a teacher might suspect a speech delay in a child based on the child’s performance in the classroom. The child could have already received his or her periodic screen. The teacher can refer the child to a speech pathologist (either through or outside the school system) for an interperiodic exam to determine if the child does indeed have a speech delay needing treatment. State Medicaid agencies cannot require prior authorization for either periodic or interperiodic screens as this would be an inappropriate limitation on the very service which is needed to determine that a medical or mental health problem exists.

Because of the proximity of schools to the target population, HCFA has always encouraged the participation of schools in the Medicaid program as they can play a particularly useful role in providing EPSDT services. School-based health services can represent an effective tool which can be used to bring more Medicaid-eligible children into preventive and appropriate follow-up care.

In addition, schools present a wonderful opportunity for Medicaid outreach. That is, because schools are by definition “in the business of serving children,” they can be a catalyst for encouraging otherwise eligible Medicaid children to obtain primary and preventive services, as well as other necessary treatment services. Even if a school does not directly furnish medical services, we encourage efforts to inform potential eligibles about the Medicaid program and the EPSDT benefit. Examples of how schools can get reimbursed for activities such as outreach are discussed in the section of the guide on administrative claiming.

Medical Services Under IDEA

The Medicaid program can pay for certain medically necessary services which are specified in Medicaid law when provided to individuals eligible under the state plan for medical assistance. The Individuals with Disabilities Education Act (IDEA), formerly called the Education of the Handicapped Act, authorized Federal funding to states for two programs that impact Medicaid payment for services provided in schools. Section 411(k)(13) of the Medicare Catastrophic Coverage Act of 1988 (P.L. 100-360) amended section 1903(c) of the Act to permit Medicaid payment for medical services provided to children under IDEA through a child’s Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP). This amendment was enacted to ensure that Medicaid would cover the health-related services under IDEA.

Part B of IDEA was designed to ensure that children with special education needs receive a free appropriate public education. Part H of IDEA provided for financial assistance to the states to develop and implement comprehensive, interagency early

intervention programs for infants and toddlers with disabilities. Implementation of Section 411(k)(13) of the Medicare Catastrophic Coverage Act of 1988 has resulted in the expansion of many state Medicaid programs to include payment for services provided in accordance with an IEP or IFSP of a Medicaid-eligible child.

As schools and school districts are aware, under Part B of IDEA, school districts must prepare an IEP for each child which specifies all special education and “related services” needed by the child. The Medicaid program can pay for some of the “health related services” required by Part B of IDEA in an IEP, if they are among the services specified in Medicaid law. In addition, the services must be included in the state’s Medicaid plan or available through the EPSDT benefit. Examples of such services include physical therapy, speech pathology services, occupational therapy, psychological services and medical screening and assessment services. Within Federal and state Medicaid program requirements regarding allowable services and providers, the Medicaid program can pay for some or all of the cost of these health-related services when provided to children eligible for Medicaid. The 1997 reauthorization of IDEA strengthened the expectation that schools work closely with the state Medicaid agency to coordinate provision of services to disabled children in schools.

Part H of IDEA provides for early intervention programs that include all of the available developmental services needed by the infant or toddler with special health needs and the development of an IFSP. Many of the health services included in IFSPs can be covered by Medicaid as well.

In addition, if medical evaluations or assessments are conducted to determine a child’s health-related needs for purposes of the IEP/IFSP, payment for some or all of the costs may be available under Medicaid. However, if the evaluations or assessments are for educational purposes, Medicaid reimbursement is not available. Medicaid payment is only available for the part of the assessment that is medical in nature and provided by qualified Medicaid providers. In addition, reimbursement for non-medical services, such as special instruction, is not covered.

Health-related services coverable under an IEP/IFSP are still subject to the Medicaid requirements for coverage of services including amount, duration and scope, comparability, medical necessity and prior authorization. Often the medical necessity criteria as well as the prior authorization requirement places a cumbersome burden for schools in claiming reimbursement for health-related services in an IEP/IFSP. For example, a school provider might have to go through the process of obtaining prior authorization for a Medicaid-covered service in an IEP/IFSP from the state Medicaid agency before rendering the service. Some states (such as Louisiana), in an effort to alleviate the administrative burden on schools in this area, deem prior authorization to be based on the IEP/IFSP and also use the IEP/IFSP to establish medical necessity. However, a state must determine that these services meet all of the requirements for Medicaid coverage.

In summary, HCFA policy is that health-related services included in a child’s IEP or IFSP can be covered under Medicaid if all relevant statutory and regulatory requirements are met. A state may cover services often included in an IEP or IFSP as long as: 1) the services are medically necessary and coverable under a Medicaid coverage category (speech therapy, physical therapy, etc.), 2) all other Federal and state regulations are followed, including those for provider qualifications, comparability of services and the amount, duration and scope provisions; and 3) the services are included in the state’s plan or available under EPSDT.

Medicaid Provider Qualifications

In order for schools or school providers to participate in the Medicaid program and receive Medicaid reimbursement, they must meet the Medicaid provider qualifications. It is not sufficient for a state to use Department of Education provider qualifications for reimbursement of Medicaid-covered school health services.

After determining which specific Medicaid service or services the school will provide, it then becomes necessary to specify what entity will become a provider of each service, and whether it is qualified to enroll to provide those services. Federal Medicaid regulations (42 CFR 431.107) require that there be a provider agreement between the state Medicaid agency and the provider furnishing the service. Any entity wishing to become a provider of Medicaid services, including schools or school districts, must be qualified to enroll to provide those services. Some Medicaid provider qualifications are dictated by the Federal Medicaid program by regulation, while other provider qualifications are established by the state. Where states have established provider qualifications, the requirements must be applied consistently among all entities seeking provider status. Where a school or school district provides a variety of Medicaid covered services, the school must meet all Federal and state provider qualifications associated with each service it provides.

Further, Medicaid regulations require that provider qualifications be uniform and standard. This means that states cannot have one set of provider qualifications for school providers and another set of provider qualifications for all other providers. Schools should check with the state Medicaid agency to determine specific state requirements regarding provider qualifications for participation in the Medicaid program.

Provider Agreements

In order for a school or school district to participate in the Medicaid program and receive Medicaid reimbursement, there must be a provider agreement between the state Medicaid agency and the actual health care provider. Schools may enroll as Medicaid providers, either by qualifying to provide services directly, or, under certain conditions, by contracting with independent practitioners to provide the services. There are several arrangements schools may choose to provide Medicaid services.

MODEL 1, Direct Employment of Health Professionals The school (or school district) itself employs health professionals such as physicians, nurse practitioners and nurses, or operates a clinic, i.e., has direct supervision and control over the clinic activities. The arrangement between schools and providers governs how and by whom Medicaid is billed for services and to whom payment may be made. Where the school employs the staff which provides the health services (or operates a clinic), the school can enter a provider agreement with the Medicaid program and receive Medicaid payments for the covered services provided.

MODEL 2, Contracting with Health Practitioners or Clinics The school (or school district) contracts with health practitioners or clinics to furnish services. Under this type of arrangement, the health practitioner or the clinic (not the school) is the provider of services, and payments under Medicaid must be made, with limited exception, only to the provider of the services.

However, Federal Medicaid requirements permit Medicaid providers to voluntarily reassign their right to payment to a governmental entity, such as a school district. Consequently, if the school and the provider are willing to work out an agreement under which the provider reassigns payment to the school, the school may both bill and receive payment directly from the state Medicaid agency. Under these circumstances, the provider must be separately qualified and enrolled as a Medicaid provider and must have a separate provider number. In addition, assignment to the school must be accomplished in a way that satisfies all applicable Federal requirements. For example, in accepting assignment of Medicaid claims, the school is also accepting the providers’ responsibility for collection of probable third party liability, unless the state has been granted a waiver from cost-avoidance methods of seeking third party liability in accordance with Federal regulations (42 CFR 433.139) or the services provided are preventive pediatric services (see the Third Party Liability section of this guide for more information on these requirements).

MODEL 3, Combination of Direct Employing and Contracting The school (or school district) uses a combination of employed health professionals and contract health professionals to furnish services. In general, when a school provides a service through employed staff and contracts with additional health professionals to supplement the care and services being provided by its own employees, the school can qualify as the provider and receive payment from the state Medicaid agency for the services being provided by both the employed and contract health staff. A key element in making the determination that the school is the provider is that the school itself provides the service through its own employees and includes certain contract health professionals only to supplement that which it is already providing. For example, the school may employ one physical therapist and contract with other physical therapists to supplement the services provided. No additional provider agreements are required for contracted providers under this type of arrangement.[1]

MODEL 4, Mix of Employed and Contracted Providers : This model is similar to model 3 in which the school (or school district) uses a mix of employed and contracted providers. This model is used where the school provides some services directly but wishes to contract out entire service types without directly employing even a single practitioner in a service category. The school may establish itself as an organized health care delivery system under which it provides at least one service directly, such as case management, but provides additional services solely under contract. Under this model, payment may be made to the school on behalf of those contracted providers who have voluntarily agreed to enter into this arrangement with the school.

It is also important that the service being provided by the school or school district employees is the same service that the contract health professionals provide. In other words, if a school or school district operates a clinic and employs most of the necessary health professional to provide clinic services but contracts with a physician to provide services and direction of the clinic, in order for the school to be considered the provider of the services, the services furnished by the physician could not be billed to the Medicaid agency as physician services but must be billed as clinic services. That is, the contract physician is simply supplementing the service that the school/school district is providing. Under section 1902(x) of the Act, every physician used or employed by the school must have a unique physician identifier which appears on Medicaid claims for services under the direction of that physician. This is true whether or not the physician practices independently or in a clinic setting, and whether or not the physician is a Medicaid provider.

Under any model for school-based providers for services, the school must meet a number of basic requirements. A school provider, like all providers, must meet Medicaid service provider requirements, including any Federal and any state requirements in place for the specific services provided. For those schools which seek to provide administrative services, the school must either have an interagency agreement or a contract setting out the responsibilities which the single state agency is delegating to it, as well as providing a reimbursement methodology for those functions as an administrative cost. The school would not need a Medicaid provider number simply to perform administrative functions. If schools wish to coordinate other Medicaid activities with local health or education agencies, interagency agreements should also be in place to delineate these activities. (See the section of this guide on Administrative Claiming for more specific information on this subject).

Because of the different types of provider agreements available for school health services, and depending on the provider types employed and the specific agreement in place, the services provided by and within schools and school districts can be diverse. For example, some schools have a clinic onsite or are linked to a clinic which generally provides primary and preventive health services, including EPSDT screening services. Medicaid-covered IDEA services are generally provided separately in the school by licensed practitioners employed by the school/school district or contracted by the school/school district. Many schools do not have a school-based or school-linked clinic and just provide the Medicaid-covered IDEA services under one of the models listed above. Other schools have both a school-based or school-linked clinic which provides primary and preventive services, in addition to providing Medicaid-covered IDEA services in the school by providers who are employed by the school, through a contract with the school or another arrangement. Depending on the specific health services a school provides and the type of model a school uses to provide these health services, different issues regarding coverage of services, provider qualifications and provider arrangements apply in order to seek Medicaid payment for these services.

Freedom of Choice

Federal Medicaid regulations at 42 CFR 431.51 and section 1902(a)(23) of the Act require Medicaid beneficiaries to have the freedom to choose from among all qualified providers. Therefore, Medicaid-eligible children cannot be limited to school health providers for Medicaid covered services. In the absence of a Federal Medicaid waiver (described under the section of the guide on Managed Care), states can encourage, but may not require, Medicaid children to receive Medicaid-covered services through or at the school. Medicaid recipients must be permitted to obtain services outside the school health services system if they wish.

In addition, unless operating under a waiver, states must allow all willing qualified providers to participate in Medicaid. States must permit whatever types of providers which furnish school health services to also furnish those services independently of the school system. For example, if a state covers independently practicing physical therapists through school-based programs, it cannot limit participation of physical therapists to those who provide school health services.

The Medicaid service categories that could be typically provided by school providers, along with the Federal Medicaid regulatory citation (or statutory citation) are listed below. This list is an illustration of Medicaid services that could be provided in a school setting. Potentially, health-related services provided by schools may fit into one or more of the Federal service categories. This chart is not necessarily all-inclusive, and while it indicates the general Federal Medicaid regulatory requirements, schools should check with their state Medicaid agency to determine any additional or specific state requirements.

FEDERAL CITATION	SERVICE	DESCRIPTION
42 CFR 440.50	physicians’ services and medical and surgical services of a dentist	services furnished by a physician (or a doctor of dental medicine or surgery for a dentist) within the scope of practice of medicine or osteopathy as defined by state law and by or under the personal supervision of an individual licensed under state law to practice medicine or osteopathy.
42 CFR 440.60	medical or other remedial care provided by licensed practitioners	“any medical or remedial care or services provided by licensed practitioners within the scope of practice under state law.” This category is used by states to cover such services as psychologist services and nursing services other than those nursing services specifically identified in the Medicaid statute and regulations (such as private duty nursing, home health nurses or nurse practitioners).
42 CFR 440.90	clinic services	“preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished by a facility that is not a part of a hospital but is organized and operated to provide medical care to outpatients.” The services must be furnished under the supervision of a physician or dentist, in a facility which meets the state’s definition of a clinic.
42 CFR 440.100	dental services	“diagnostic, preventive or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession.”
42 CFR 440.110	physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders.	Physical and occupational therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under the state’s law and must be provided by or under the direction of a qualified licensed physical therapist or occupational therapist. Services for individuals with speech, hearing or language disorders means diagnostic, screening, preventive or corrective services provided by or under the direction of a speech pathologist or audiologist, for which the patient is referred by a physician or other licensed practitioner of the healing arts. It includes any necessary supplies or equipment.
42 CFR 440.130(a)	diagnostic services	“any medical procedures or supplies recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under state law, to enable him or her to identify the existence, nature or extent of illness, injury or other health deviation in a recipient.”
42 CFR 440.130(c)	preventive services	“provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability, and other health conditions or their progression; to prolong life and promote physical and mental health and efficiency.”
42 CFR 440.130(d)	rehabilitative services*	“any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his or her best possible functional level.” This optional benefit category is used to cover both mental health and substance abuse services and may include assessments, individual, group and family counseling, therapies, psychosocial rehabilitation services, living skills training, drug abuse treatment, medication monitoring and crisis intervention.
42 CFR 440.170(a)	transportation services	(Please see the Transportation section of the guide for more specific information on transportation and school-based services).
42 CFR 440.166	nurse practitioner services	“furnished by a registered professional nurse who meets the state’s advanced educational and clinical requirements, if any, beyond the 2 to 4 years of basic nursing education required.”
42 CFR 440.166	Private duty nursing services	“for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or skilled nursing facility.” These services are provided by a registered nurse or licensed practical nurse under the direction of a physician, usually in the beneficiary’s home. However, the nurse is permitted to be taken into the community (such as when the child attends school) with the beneficiary if his or her normal life activities take the beneficiary out of the home and the services have been prescribed by the physician for primary use in the home.
Section 1905(a)(24) of the Act (soon to be published ate 42 CFR 440.167)	personal care services	These services are authorized for an individual by a physician in accordance with a plan of treatment or otherwise authorized by the state in accordance with a service plan approved by the state, and may be provided in a home or other location (however, not in a Medicaid-funded inpatient facility) by an individual qualified to provide such services, who is not a member of the individual’s family.
Section 1905(a)(4) (c) of the Act and 42 CFR 441.20	family planning services	“supplies for children who are of childbearing age, including minors who can be considered to be sexually active and desire such services and supplies. These include services to aid those who voluntarily choose not to risk an individual pregnancy or who wish to control family size. Federal Medicaid law limits coverage of abortion. In general, family planning services are matched at a higher FFP rate of 90%.

* HCFA has historically differentiated between habilitation and rehabilitation services and does not allow for the inclusion of habilitation services under the rehabilitation benefit category. Habilitation services, which are services to assist an individual in obtaining a skill, are not included in the section 1905(a) list of services and are only available in an institution for the mentally retarded or under a home and community based services waiver. Habilitation services cannot be covered as “rehabilitative” when they are furnished to individuals, for example, suffering from mental retardation or to children experiencing developmental delays, because the services are assisting the child in obtaining a skill rather than restoring lost capabilities. However, because occupational therapy, physical therapy and speech therapy do not have the same requirement to restore lost capabilities, habilitation services are not precluded from coverage under those service categories.

In addition, Federally Qualified Health Center (FQHC) services is a mandatory benefit required under the Medicaid program. A FQHC is statutorily defined as an entity which is receiving a grant under the Public Health Services Act or based on the recommendation of the Health Resources and Services Administration (HRSA) (section 1861(4) of the Act). Some school-based clinics receive grants from HRSA or are associated with larger community health centers that receive grants from HRSA. Either arrangement would result in the school-based clinic being recognized as a FQHC. These clinics are reimbursed differently from other school-based health clinics. They receive an encounter rate that is based on their reasonable costs and are not limited to the standard Medicaid fee schedule (see the Payment section for more information on reimbursement). There are many specific requirements and limited opportunities for any clinic to become an FQHC.

Managed care is a health care system that combines the delivery and financing of health care services. Managed care organizations (MCOs) offer a wide variety of medical specialities and services for their members. Managed care has the potential to offer increased access to preventive and primary care as each patient is assigned to a primary caregiver who coordinates his/her care. Managed care providers are responsible for informing enrolled patients what services are available through the plan and what services are not.

While there are many different types of managed care arrangements, there are general characteristics regarding the delivery and financing of services. For delivery of services, patients must be enrolled with a primary care physician who is responsible for coordinating their care. Primary care physicians provide patients with access to a selected provider network in which services are coordinated with a focus on prevention and early detection of illnesses and conditions.

Managed care plans are generally paid a capitated, prepaid premium for the provision of an agreed upon package of services. In exchange for the prepaid premium, the managed care entities assume financial risk for the provision of an agreed upon package of services. The managed care entities also pay providers, establish a provider network and educate providers and enrollees about the covered services available under the plan.

Types of Medicaid Managed Care Entities

There are many types of managed care arrangements available. Medicaid managed care programs are arranged either with the state paying certain providers a fee to furnish case management services, or the state contracting with managed care organizations and paying them on a pre-paid full risk or partially capitated basis to provide or arrange for a range of services. These basic models of Medicaid managed care (full-risk capitation, primary care case management and partial capitation) are described in more detail below.

(1) Full-Risk Capitation- In this model, states contract with an entity, such as an HMO or Federally qualified health center, to provide all health care to enrolled beneficiaries for a fixed amount per member per month. Beneficiaries enrolled receive a comprehensive set of services from providers employed by or affiliated with the MCO and the entity assumes full risk for the services provided.

(2) Primary Care Case Management- A state contracts directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid beneficiaries under their care. Generally, these providers receive a case management fee in addition to their fee-for-service reimbursement.

(3) Partial Capitation- In this model, the state reimburses providers for a limited number of services on a fixed per member per month basis and pays for all other services on a fee-for-service basis.

Medicaid Managed Care Enrollment

State efforts to enroll their Medicaid beneficiaries into managed care has dramatically increased over the past few years. States are facing fiscal pressure due to increasing Medicaid growth and state budget restrictions and are responding to these fiscal pressures by developing Medicaid managed care programs. The growth in managed care programs is the result of a desire of states to improve access to services while decreasing unnecessary care, enhancing the quality of care and containing health care costs.

Section 1915(b) and 1115 Waivers States can test new approaches to providing services to their Medicaid populations by obtaining waivers of statutory requirements and limitations from the Secretary of the Department of Health and Human Services. Section 1915(b) waivers permit states flexibility from the Federal Medicaid statutory and regulatory requirements that cannot be altered through the Medicaid state plan amendment process. In obtaining waivers of Medicaid program requirements, many states mandate managed care delivery systems to Medicaid beneficiaries. There are two types of waivers that states use to institute mandatory Medicaid managed care programs, section 1915 (b) waivers and section 1115 waivers.

(1) Section 1915 (b) Waivers

Section 1915(b) waivers provide limited waiver authority. Section 1915(b)(1) waivers permit variations from the Medicaid law to allow states to restrict the providers from whom a recipient receives Medicaid services. Furthermore, these waivers permit states to waive such Medicaid requirements as comparability of services ( allowing different benefits to be provided to one group and not another) and statewideness (facilitating variations in the Medicaid program in different areas of the state). These waivers are limited in scope and flexibility. For example, 1915(b)(1) waivers do not allow states to: