Tag: school health services

School Services That Can Be Billed to Medicaid

Posted on by Nicol Walsh

Brief Overview:

  • This information is good to know for families of students with Individualized Education Programs (IEPs) and Individualized Family Service Plans (IFSP) when those students have Apple Health (Medicaid/CHIP) for their health insurance.
  • Schools can bill Medicaid for many common IEP and IFSP services. When schools do this, they don’t have to spend special education funds on these services and can use that money to pay for other special education needs.
  • Medicaid billing can be complicated and difficult, and not all schools in WA State do it.
  • Parents can advocate for their student’s school to join the WA State Health Care Authority School-Based Services Program to bill Medicaid and free up money in the special education budget. Parents and caregivers can learn to advocate and resources for that are listed in the article.

Full Article

Individualized services that children receive through their IEP or IFSP may be covered by Medicaid. Medicaid will pay for health-related services in an Individual Education Program (IEP) or Individual Family Service Plan (IFSP) if they are already Medicaid-covered services, if the student qualifies for Medicaid for health insurance.

The Individuals with Disabilities Education Act (IDEA) requires that Medicaid be the primary payer to schools and providers of services included in an IEP or IFSP. (This means that if a school doesn’t use special education funds to pay for these services, Medicaid should be billed before any other insurance or individual.)

Which individualized services will Medicaid pay for?

  • An evaluation to see if a student is eligible for special education (if the student is found eligible)
  • Re-evaluations for special education
  • Nursing/health services
  • Physical Therapy
  • Occupational Therapy
  • Speech Pathology/Audiology
  • Mental Health Care
  • Other health services that schools provide, and Medicaid covers, as long as it’s included in an IEP or IFSP

Will Medicaid pay for services in a 504 plan?

If a student with a 504 plan needs medical services as part of their plan to receive a Free Appropriate Public Education (FAPE), Medicaid will not be the primary payer—but after a school bills any other potential payers (such as private health insurance), a school can bill Medicaid for any remaining costs.

If your student has Medicaid (Apple Health) or CHIP for health insurance, school health services like mental health care, substance use disorder services and monitoring medication can be covered by Medicaid, even if they are not included in a student’s IEP, IFSP, or 504 plan.

If a Local Education Agency (LEA, or school district) runs early childhood programs like Early Head Start, Head Start, or school-based preschool, schools can bill Medicaid for Medicaid-eligible Early and Periodic Screening, Diagnostic and Treatment benefits (EPSDT), even if they are not in a child’s IFSP. This ensures that children in these programs get these essential screening and well-child services.

Why is billing Medicaid important?

When Medicaid pays for services, schools do not have to use special education dollars for those services. Instead, special education dollars can be used for expenses like hiring adequate support staff, adaptive or communication technology, durable mobility supports, and enhanced accessibility supports for inclusive student activities.

How do schools get Medicaid to pay for these services?

Washington State public school districts, educational service districts (ESDs), public charter schools, and tribal schools are all eligible to participate in the School Based Health Services program at Washington State’s Health Care Authority (HCA).

Each school district that wants to bill Medicaid signs a contract with the state Medicaid agency and the Health Care Authority. School districts submit their costs for Medicaid-covered services to the state’s Health Care Authority (HCA), which reimburses their costs while billing Medicaid for those services. School or district staff are responsible to fill out the Medicaid claim forms with the proper billing codes. Staff need to take specific training to do this.

Some schools decide not to bill Medicaid and use special education funds for these services. Why?

Unlike healthcare providers, schools are not set up to bill programs like Medicaid. The billing process can be complicated and time-consuming (for example, the billing guide that HCA provides to schools who want to bill Medicaid is 57 pages long).

In 2023, a new federal law (the Bipartisan Safer Communities Act) required Medicaidto make the billing process easier for schools; in May 2023, the Centers for Medicare and Medicaid Services (CMS) announced new guidance on this topic, which was sent to all states.

The Network for Public Health Law says the law made “important and substantial changes to reimbursement for school-based Medicaid services”. The law requires updates to outdated Medicaid billing guides and gives more help to states and local education agencies (LEAs, or school districts) who want Medicaid to reimburse them for school-based healthcare services. The law also made grants available to states to “implement, enhance or expand school-based programs” for healthcare (HHS) and for programs run by the Department of Education.

One purpose of the new law was to make billing Medicaid simpler and less expensive for schools. A second purpose was to encourage states to allow schools to use Medicaid for more types of healthcare services. The law also provides grants and other funding for mental health services for students.

As of July 2024, the Health Care Authority is still examining the new guidance to see if they want to make changes to the School-Based Health Care Services program.

Parents may think it makes sense to use Medicaid funds rather than special education funds for IEP/IFSP services. This chart from the Health Care Authority lists the schools and districts who have contracted with HCA and get Medicaid reimbursement for school-based health services. (current as of June 2024).

If a school or district is not listed, what are some ways parents can advocate for a school to start billing Medicaid?

  • Ask the school principal or superintendent about the reasons for not billing Medicaid. Ask what would need to change for the district to start Medicaid billing. This information is useful for gathering support from other parents and school personnel, and for getting policymakers to make the change.
  • There are national and statewide organizations that want to expand the use of Medicaid to pay for school-based services for all Medicaid-eligible students, not only students with IFSPs/IEPs. Parents may wish to visit their websites, learn about what they want to change, and contact these organizations for information about advocacy and organizing other parents around this topic.
  • District-wide decisions and policies are often made locally by a district’s administration team, the School Board, or both together. Contact information for district administration will be on the district’s website (and possibly on the school’s website). Contact information for school boards is usually available on a town or city government’s website, and sometimes on the district’s website.
  • Does the school or district have a Special Education PTA? If so, this group of parents and educators may be a good way to find other people interested in this topic. If not, a school’s Parent Teacher Organization (PTO) is also a useful resource. List of WA State Special Education PTAs.
  • When parent advocate groups ask for change, it can be very helpful to offer assistance to help make their request a reality. Can parent volunteers be used in any way to make the change easier? What other creative assistance might be helpful? Discussions with district administration and school boards about “why this won’t work” will let you know where and what type of help is needed.
  • Many organizations which support families, including families whose child or children have disabilities can offer advice or training for parents who want to advocate about the need for services in schools. This list is a starting point—you may find other groups or organizations which are not on the list.