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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.

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(The file is in zipped format, (scbguide.zip - 77,705 bytes). The unzipped file, (scbguide.rtf), is in rich text format which can be read by most current word processing software.)

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.

Contact:

Linda Tavener, (410) 786-3838 or E-mail, ltavener@cms.hhs.gov.

Suzan Stecklein, (410) 786-3288 or E-mail, sstecklein@cms.hhs.gov