School Based Medicaid Services

School-based Medicaid is a specific aspect of the Medicaid program that focuses on providing healthcare services to students in schools.

The program allows schools to receive reimbursement for certain health services provided to Medicaid-eligible students, such as screenings, assessments, treatments, and therapies. These services are typically delivered by qualified healthcare professionals, including nurses, therapists, and psychologists.

School-based Medicaid in Idaho helps ensure that students have access to essential healthcare services, which can contribute to their overall well-being, academic success, and attendance. The program covers a wide range of health services, including preventive care, mental health services, speech therapy, occupational therapy, and physical therapy. School-based Medicaid services do not count againsta child’s budget or their other community services.

If you require more detailed information about school-based Medicaid in Idaho, Click here: https://idahotc.com/Topics/SBM

Idaho Medicaid Guidance Handbook for Educators – External PDF Link

School Districts have an obligation to determine if a student is eligible for Special Education, then develop an Individual Education Plan (IEP) whether the student is Medicaid eligible or not. IEP teams should not be developing IEP’s based on Medicaid Eligibility. IDEA requires that services identified on the Individual Education Plan be delivered based on need not funding source.

History of IDEA and Medicaid 

In 1988 with the passage of the Medicare Catastrophic Coverage Act and the Omnibus Budget Reconciliation Act of 1989, Medicaid was made accessible to student’s who met eligibility for Medicaid and had an Individual Education Plan in an educational or school setting. 

The Role of Health and Welfare

The Role of the Department of Health and Welfare is to provide oversight of all Medicaid programs in and out of schools. The Division of Medicaid has different units that help administer School Based Medicaid services. The two primary units are:

The Policy Unit whose function is to write state rules and interpretation of those rules.

And the Integrity Unit which monitors compliance with IDAPA rule and can perform audits of all Medicaid billings.

The Role of Local Education Agencies (School Districts)

If a school district desires to bill Medicaid for health related services, the district must apply to become a Medicaid provider. School district are under no obligation to come a Medicaid provider. Services that are identified on the student’s IEP must be delivered, per IDEA, regardless of the funding source.

Each school district is responsible for ensuring that all individuals who will be administering Medicaid billable services follow all applicable rules of the School-based Medicaid program.

Education and Medicaid

The Medicaid program provides support for children who are eligible for special education services and have specific healthcare needs that affect their educational performance and identified in their Individual Education Plan.

Medicaid benefits are allowed in the schools, but can’t be used to provide education. Educational activities are to be delivered using educational dollars. Medicaid dollars are used to assist the student in accessing their educational environment or educational curriculum.

Must be Medically Necessary 

In addition to being Medicaid eligible and having an IEP the student’s needs must also be considered Medically necessary.

What is Medically Necessary? To summarize – A service is medically necessary when it is needed to prevent, diagnose, or treat the student’s condition, there is no other equally effective treatment that is less costly, and the service meets professional standards of healthcare.

Remember that prior to identifying a Medicaid Reimbursable service the IEP team needs to be sure that the service is medically necessary to assist the student in accessing the educational environment or educational curriculum. Since Medicaid is a medical model of service delivery, Idaho has determined that a physician or practitioner of the healing arts is responsible to determine medical necessity in order for the services provided by a Medicaid provider to be reimbursed by Idaho Medicaid. 

A school district or charter school may not seek reimbursement for services provided prior to receiving a signed and dated recommendation or referral for those services.

Created in Partnership with the Idaho State Department of Education