Medicaid and Free Care Opportunities for Covering Services in Schools Healthy Homes, Schools, and Communities Health Determinants of Early School Success: Leveraging Medicaid for Impact Sarah Somers, Managing Attorney November 17, 2016
Overview of presentation Overview of Medicaid for children Health care services provided in schools Reversal of the free care policy State Medicaid Plans: Results of survey
National Health Law Program NHeLP protects and advances the health rights of low income and underserved individuals NHeLP advocates, educates and litigates at the federal and state level NHeLP s health equity work spans over 2 decades Offices in Washington, D.C.; Los Angeles, CA; Carrboro, NC 3
NHeLP s work on the free care policy Funded by Kellogg Foundation Partnering with Healthy Schools Campaign and Trust for America s Health 4
Adminstration: State Medicaid Plans Required for all states Comprehensive, written Describes administration, eligibility, services, coverage, beneficiary protections Submitted and approved by HHS Centers for Medicare & Medicaid Services (CMS) State Plan Amendments (SPAs) 5
Adminstration: Federal Reimbursement and Matching FFP: Federal Financial Participation FMAP: Federal Medical Assistance Percentage Services 50%-74.6% Administration 50% (mostly) Family planning 90% Expansion population 2017 95% 6
Medicaid Managed Care 74% of Medicaid population All states but AK, WY Dominant method of service delivery: Incl. CA, CO, MA, MS, NJ, NY, OH, SC, TN SOURCES: Kaiser Family Foundation (www.kff.org); CMS (www.cms.gov) 7
Medicaid for children Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) A benefit that provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services. 8
EPSDT Requirements - Mandatory medical, vision, hearing, and dental screening Medical Screens Additional Required Screens Vision, including eyeglasses Hearing, including hearing aids Dental, including relief of pain, restoration of teeth and maintenance of dental health
EPSDT Requirements Treatment All services that could be covered under state Medicaid plan (mandatory and optional) All Medicaid-covered services necessary to correct or ameliorate physical and mental illnesses and conditions, even if the service is not covered under the state plan.
EPSDT Services, e.g. Physician and nursing services Examinations Vaccinations Psychological and psychiatric services Rehabilitative services Physical, occupational, and speech language therapy Therapists Dental Dentists and hygienists Personal care Trained personnel Transportation Targeted case management 11
Available at: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/early-and-periodic-s creening-diagnostic-and-treatment.html (June 2014) 12
Special education services Individuals with Disabilities Education Act (IDEA) Requires provision of a free, appropriate, public education Can include related services Individual Education Program (IEP) Medicaid can cover IDEA services if they meet Medicaid requirements 13
Medicaid Administration Free Care Rule No FFP for services that are free to the community at large (and therefore free to Medicaid beneficiaries) Name of presentation goes in footer 14
CMS Free Care Guidance (12/15/14) GOAL: Increase access to quality care and improve community health RULE: Public agencies and programs carrying out general responsibilities to ensure access to health care are NOT legally liable third parties E.g. schools RESULT: FFP for Medicaid services available for otherwise free care https://www.medicaid.gov/federal-policy-guidance/downloads/smd-medicaid-paymen t-for-services-provided-without-charge-free-care.pdf Name of presentation goes in footer 15
Barriers to Medicaid Reimbursement for School Health Services: Review of State Plans Direct prohibition FL, GA, MD Indirect barrier IDEA-related policies e.g., CO, DC, NJ, NY No barrier discovered in state plan MS, SC, TN 16
Barriers to Medicaid Reimbursement for School Health Services: Other Managed care Finite school funding streams (non-entitlement) 17
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