The MassHealth School-Based Medicaid program (SBMP) affords an opportunity for local education agencies to be awarded with federal money that will help to offset the costs for schools which have to provide specific Medicaid-covered services to students. MassHealth is the governing body which oversees SBMP, and which ensures compliance with laws enacted by state and federal agencies. The entire program is administered by the University of Massachusetts Medical School (UMMS), on behalf of MassHealth, and this has been true since the program began in 1994. Here are some of the most important things to know about this School-Based Medicaid Program.

How local education agencies (LEA’s) are reimbursed

Reimbursement for local education agencies is based on actual cost, so that these LEA’s can seek reimbursement for direct health services through the process of Direct Service Claiming (DSC). Specific administrative expenses can also be claimed if they’re associated with providing medical services, or with assisting students in becoming enrolled in MassHealth, via the administrative activity function.

At the present time, the only health services which are covered are those which are pursuant to an IEP, although this will change as of July 1, 2019. At that time the requirement will be lifted, and other services as well as additional provider types will be included. In the world of SBMP, this July 1 amendment is referred to as Expansion.

Random moment time study (RMTS)

The random moment time study is a program which aids MassHealth in determining how educational staff members spend their time, and the results of this time study have a major impact on local education agency reimbursement. Any LEA seeking reimbursement through AAC or DSC must be included in an RMTS pool, so that MassHealth can gain an understanding of where time is being spent by staff members.

Throughout the school year, educators are queried about exactly what they were doing at a specific moment in time, and are given two school days to respond to that query. This methodology has proven to be statistically valid in estimating the amount of time that educators spend across the state, performing various types of work activities relevant to the pools that they’re in.

Pools for random moment time study

All educators associated with local education agencies seeking reimbursement through AAC or DSC must belong to one of the specified RMTS pools, since admin reimbursement must be claimed for all participants of the RMTS program. Staff members are allowed to change RMTS pools each quarter, unless you are a staff member who is federally funded, or who is part of the indirect cost rate program.

At present, there are three distinct RMTS pools, consisting of ABA Therapy, Administrative, and Direct Services. When Expansion comes into play on July 1, there will be four RMTS pools, and these will be comprised of Administrative, Medical Services, Therapy Services, and Mental/Behavioral Health. Staff members who are in the Direct Service pools can have their costs claimed by the appropriate LEA when those costs are associated with either Direct Service or Administrative Activities.

Staff members included in Direct Services

Each staff member involved with an LEA must be considered individually, rather than in any grouping which is based on job title or job description. That means LEA’s are allowed to include in their Direct Service Pool any staff members who are associated with the following services:

  • speech or language therapists
  • Medicaid billing personnel
  • social workers
  • psychologists
  • psychiatrists
  • applied behavior analysts
  • audiologists and audiology assistants
  • counselors
  • occupational therapists and assistant occupational therapists
  • physical therapists and assistant physical therapists
  • personal care service providers
  • nurses, either LPNs or RNs
  • autism specialists.

Reimbursable Administrative Activities

There are a number of reimbursable Administrative Activities, beginning with what’s considered to be an outreach function, involving the information of potentially eligible families about MassHealth and how it should be accessed. Assistance with the application for MassHealth is also a reimbursable administrative activity, as is any activity which helps to develop strategies that improve delivery of covered services. Such activities include collaborative efforts with other agencies relative to health services.

Another reimbursable activity is setting up referrals for health service, or coordinating and monitoring the delivery of Covered Services. Helping an individual to obtain transportation through MassHealth is reimbursable, as are translation services when they are needed in order to access health-related services. Finally, any activity which provides staff training at an LEA which is related to Medicaid topics is also a reimbursable activity.

For a free consultation or to talk to a MassHealth School-Based Medicaid expert please contact us.


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