Medicaid is Growing Up. It’s Time to Go to School.
Thanks to a clarification by CMS regarding the “free care” rule a little over a year ago, schools can be reimbursed for services provided to Medicaid-eligible students. This was a subject of a conference call and toolkit released earlier this month from HHS and Department of Education regarding how to support deeper coordination between health and education entities. Prior to the clarification issued by CMS in late 2014, schools were barred from receiving Medicaid reimbursement for health services. For example, if your school supported Early Periodic Screening, Diagnosis, and Treatment (EPSDT) related services such as vision screening, or managed chronic care conditions such as asthma, they could not be reimbursed by Medicaid even if the child was a Medicaid enrollee. There were two exceptions to this rule:
1) The child was enrolled in an Individualized Education Plan (IEP) or
2) The child was receiving services under the maternal and child health services block grant.
However, with the “free care” restriction lifted, there is now an opportunity for Medicaid to more broadly support preventive health activities such as screening and chronic care management. Schools are now able to further advance their pivotal role in increasing access to needed care and improving long term child wellness. This latest change in policy prompts a broader conversation about how schools and health care entities work together to increase access to health services for vulnerable children, especially because schools are a vital partner in advancing health equity goals for children (learn more about policy change here). Children’s health advocates are always looking for ways to make Medicaid work more intelligently; partnering with education and public health advocates to provide health services to children in a school setting should, and now can, be a primary pathway to prevention and better health outcomes.
So how are states doing?
In order to implement the new policy, states need to review which Medicaid services and providers are currently allowable in a school setting; due to the past restrictions on billing, there may be a need to revise or alter existing policy at the state level. In many cases, states will need to submit a state plan amendment to CMS with the new policy approach.
Over the past year, a handful of states quickly moved on this change in policy. Two examples include Louisiana and California. In 2011, Louisiana transitioned to Medicaid managed care and, in the process, developed a state plan amendment to allow Medicaid to pay for school nurses for special education students (those on an IEP, one of the two previous exceptions). With the change in the free-care rule, Louisiana will reimburse Medicaid-eligible services for all children enrolled in Medicaid, not just those for children on an IEP. While it is too early to assess the impact of this change, it is worth noting that close to 60 percent of Louisiana children are Medicaid-eligible and nearly 7 percent more are eligible but unenrolled, so the impact of this free-care policy change is truly significant.
In California, the legislature passed a law in late 2015 instructing their Medicaid agency to reimburse Medicaid health care services in schools when a managed care company denies payment. The bill enables local education agencies (LEAs) to receive Medicaid dollars through a billing option program; in response to the free-care rule change, the state also submitted a state plan amendment to CMS requesting ability to reimburse Medicaid services when there is no response from the insurer. This change will enable LEAs to more comprehensively draw down Medicaid dollars and sustain health services provided in a school setting.
There is ongoing work to do in implementing these changes in billing at both the state and local level. However, the process in California also highlights unique opportunities for stakeholders to engage in work around the relationships and dynamics between systems, such as:
- Working with Medicaid agency and local education agencies to redesign billing relationships
- Helping to re-think how educators view health services
- Examining how health providers think about schools as levers of health system change
Is your state drawing down needed dollars for schools?
As advocates contemplate varying political landscapes and design their 2016 policy agendas, directing more Medicaid dollars to school settings is one way to expand access to health care services for Medicaid-eligible children. It provides an additional location and touch-point to meet children where they are, ensuring that they have complete access to necessary preventive and health care services. Finally, Medicaid dollars that are directed at supporting a school health provider workforce is meaningful for local budgets and long term Medicaid savings. Advocates are important and needed partners in implementing the “free care” change in policy. Our Substance Use Disorder team developed a tool for advocates working to expand access to SUD screening in school-based settings. Stay tuned for a forthcoming resource to help guide advocates partner with states to reimburse school health services through Medicaid.
As advocates reach out to Medicaid agencies and local school boards to assess where the state stands on this new opportunity, we look forward to working with you to send Medicaid to school!