School-Based Medicaid FAQs
What are Medicaid School Based Services?
Medicaid School Based Services (MSBS) refer to a range of healthcare services or health-related services that are provided to eligible students in a school setting and that are funded in whole or in part by the federal Medicaid program. MSBS are intended to ensure that students have access to necessary health services that may impact their ability to succeed in school.
MSBS may include a variety of services, such as diagnostic and evaluative services, health-related services, specialized transportation, and targeted case management services. Examples of specific services that may be covered under MSBS include speech and language therapy, occupational therapy, physical therapy, nursing services, counseling and mental health services, and specialized transportation for students with disabilities.
To be eligible for MSBS, students must meet certain criteria, including being enrolled in a Medicaid program and having a medical or developmental need for the services. Schools that provide MSBS must also meet certain requirements, including having a Medicaid provider agreement, ensuring that services are provided by qualified professionals, and following specific documentation and billing requirements.
Overall, MSBS play an important role in increasing health equity by ensuring that students have access to the health services they need to succeed in school, while also helping to reduce healthcare costs and improve health outcomes for Medicaid-eligible children and their families.
What is the connection between Special Education and Medicaid Reimbursement?
There is a fundamental connection between special education provided in schools and Medicaid reimbursement. Medicaid can help fund certain health-related services that are provided to students with disabilities in the context of special education. When a student has an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) that includes health-related services, such as speech therapy or occupational therapy, Medicaid may reimburse the school district for the cost of providing those services. In some states, Non-IEP students are also eligible for Medicaid reimbursement, if the state has expanded their SPA under the Free Care Rule.
In general, Medicaid reimbursement for special education services is available for services that are both medically necessary and related to a student’s special education needs. For example, if a student with a disability needs speech therapy to improve their communication skills and to participate more fully in the educational program, Medicaid may reimburse the school district for the cost of providing that service.
Medicaid reimbursement can be an important source of sustainable funding for special education services, particularly for schools that serve a high proportion of underserved students. However, schools must meet certain requirements to receive Medicaid reimbursement, such as ensuring that services are provided by qualified professionals, maintaining accurate records of the services provided, and following specific billing and documentation requirements at the state and federal level.
What is the difference between Medicaid and IDEA?
Medicaid is a joint federal-state program that provides healthcare coverage to eligible individuals, including children and families with low income. Medicaid also covers school-based services for children with disabilities, which can help improve their academic performance and quality of life.
School-based services under Medicaid can include various therapies, such as speech, physical, and occupational therapy, as well as counseling, nursing services, and assistive technology. These services can be provided in the school setting, which can be more convenient and less disruptive to the child’s educational experience.
The Individuals with Disabilities Education Act (IDEA) requires public schools to provide a free and appropriate education to children with disabilities, and Medicaid school-based services can help support this obligation. These services can supplement the services provided by the school and can be tailored to meet the individual needs of each child.
To be eligible for Medicaid school-based services, a child must be enrolled in a public school, be eligible for Medicaid, and have an Individualized Education Plan (IEP) or a Section 504 Plan. In some states, Non-IEP students are also eligible for Medicaid reimbursement, if the state has expanded their SPA under the Free Care Rule. The IEP or Section 504 Plan should outline the specific services and support needed by the child and how they will be provided in the school setting.
It’s important to note that Medicaid school-based services are not limited to special education services. They can also include related services, such as transportation and nursing services, that are necessary for the child to benefit from their education.
In addition, if your state participates in Free Care expansion, schools can provide a range of services, including physical exams, dental care, vision care, and mental health services, to eligible students at no cost to the families. The goal of this policy is to improve access to healthcare services for children and adolescents who may not have access to regular medical care, due to economic barriers, geographic barriers, or other factors. These services don’t always require an IEP.
If you have a child with disabilities and think they may be eligible for Medicaid school-based services, speak with your school or healthcare provider for more information.
How can schools bill for Medicaid?
Schools can bill for Medicaid by following a specific process that includes the following steps:
- Identify eligible students: Schools must first identify which students are eligible for Medicaid reimbursement for special education services. This includes students who are enrolled in Medicaid and who have an Individualized Education Program (IEP) that includes health-related services. If your state participates in Free Care expansion, schools can provide a range of services, including physical exams, dental care, vision care, and mental health services, to eligible students at no cost to the families. The goal of this policy is to improve access to health care services for children and adolescents who may not have access to regular medical care, due to economic barriers, geographic barriers, or other factors. These services don’t always require an IEP. In some states, Non-IEP students are also eligible for Medicaid reimbursement, if the state has expanded their SPA under the Free Care Rule.
- Provide services: Schools must provide the health-related services that are included in a student’s IEP. These services must be provided by qualified professionals and must meet certain requirements, such as being medically necessary and related to the student’s special education needs.
- Document services: Schools must maintain accurate and detailed records of the health-related services provided to eligible students. This includes documenting the type and frequency of services, the dates on which services were provided, and the identity of the provider who delivered the services.
- Obtain parental consent: Schools must obtain written consent from parents or guardians before billing Medicaid for services provided to eligible students.
- Submit claims: Schools must submit claims for Medicaid reimbursement for the services provided to eligible students. This typically involves using a specific billing code for each type of service provided and submitting a claim to the state Medicaid agency or a contracted Medicaid provider.
It is important for schools to follow these steps carefully to ensure they are eligible for Medicaid reimbursement and to avoid any potential billing errors or other issues. Schools may also wish to consult with a Medicaid billing expert or legal counsel to ensure that they are following all applicable rules and regulations related to billing for Medicaid.
Refer to your specific state page to find more details about your individual state.
How do states determine Medicaid programs and eligibility?
States determine school Medicaid programs and eligibility through a process that typically involves the following steps:
- Establish eligibility criteria: States establish eligibility criteria for school-based Medicaid programs, such as income and disability requirements. These criteria may vary depending on the state and the specific program.
- Identify eligible services: States identify which health-related services are eligible for Medicaid reimbursement in the school setting, such as speech therapy or nursing services. These services must be medically necessary and related to a student’s special education needs.
- Determine provider qualifications: States determine which types of providers are qualified to deliver school-based Medicaid services. This may include licensed healthcare professionals or educators who meet specific training and certification requirements.
- Develop reimbursement rates: States develop reimbursement rates for school-based Medicaid services, which may be based on a fee-for-service or capitation model. These rates are typically lower than the rates paid to providers in other healthcare settings.
- Establish billing and documentation requirements: States establish specific requirements for billing and documenting school-based Medicaid services, such as the use of specific billing codes and documentation of the services provided.
- Monitor compliance: States monitor compliance with Medicaid regulations and requirements through a variety of methods, such as audits and reviews of documentation.
- Provide technical assistance: States may provide technical assistance to schools and other providers to help them understand and comply with Medicaid regulations and requirements.
It is important for states to carefully follow all applicable rules and regulations related to school-based Medicaid programs to ensure that they are in compliance with federal laws and regulations. States may also wish to consult with legal counsel and Medicaid experts to ensure that they are following all applicable rules and regulations related to school-based Medicaid programs.
Refer to your specific state Medicaid page to find more details about your individual state.