School-Based Medicaid Claiming

/School-Based Medicaid Claiming

Which School Health Services are Covered by State Medicaid?

Children who are covered by Medicaid receive affordable and comprehensive health care coverage, to allow them to continue academic pursuits and become successful as adults. More than 30 million young people are currently receiving benefits under this program, and research has demonstrated clearly that this assistance makes a big impact on their future, as well as helping them deal with current medical conditions.

Services covered by state Medicaid

Probably the single most important area of coverage for eligible children is providing the medical services needed by children with disabilities, so they can receive a good education. The goal of these services is to allow disabled children to be educated in the least restrictive environment possible, given their specific disabilities. However, this is far from the only area of coverage supported by Medicaid. All children who are eligible can receive such health services as dental and vision screenings, to ensure that basic health needs are being attended to.

Some of the other specific services which participating schools can be reimbursed for under state plans for Medicaid are the following:

  • Nursing services
  • Mental health services
  • Audiology services
  • Physical therapy
  • Speech therapy
  • Nutritional assessments and counseling
  • Transportation
  • Facilitating of determination for Medicaid eligibility
  • Coordinating and monitoring Medicaid services
  • Providing transportation to Medicaid-covered activities
  • Making referrals
  • Medical service program planning
  • Positive effects of Medicaid coverage

    A significant amount of study and research have gone into determining the impact of Medicaid on students who receive coverage while in school. Quite naturally, the government agencies who contribute the funding for state Medicaid are anxious to know that the funding is having a positive impact, and is accomplishing what the program is intended to do. Statistics compiled on this subject are uniformly positive about the huge impact Medicaid coverage has on students in school and long afterward, when they reach adulthood.

    Research has shown that children covered by Medicaid in school retain better health as adults, with fewer trips to the hospital and fewer visits to the emergency room. Medicaid-eligible children have also shown that they are more likely to graduate from high school or college, earn bigger salaries, and pay more taxes than students who receive no Medicaid coverage due to ineligibility.

    It is also reported that virtually all school districts benefit from the funding they receive for Medicaid-covered services because those funds can be applied to health services administered to all students enrolled, not just those receiving Medicaid services. In a survey recently conducted, almost half of all school superintendents indicated that they used Medicaid reimbursement funds to pay for general school supplies and health services, which all students benefit from. These general health care services include such critical areas as monitoring and caring for children with asthma or diabetes, as well as providing limited dental care.

    One last service provided by many schools in this country is to serve as a kind of gateway for children in low-income families, by helping to get them enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The importance of Medicaid funding for schools would be hard to overestimate, given the fact that even for services which are not covered under Medicaid, the funding allows schools to reach out and connect children with services needed outside of school, and outside the Medicaid program itself.
Which School Health Services are Covered by State Medicaid?2018-12-20T15:43:44+00:00

CMS rule reversal for Medicaid free care: Will additional reimbursement be on the way for Massachusetts public schools?

Massachusetts public schools participating in school-based Medicaid claiming may soon see a revenue boost thanks to a CMS reversal of its long-standing Medicaid free care rule. This surprising reversal essentially allows schools to bill Medicaid-covered services for all students—even when those students don’t have a documented Individualized Education Plan (IEP).

In a letter to state Medicaid directors dated December 15, 2014, CMS formally withdrew its prior guidance on the free care policy with the goal of being able “to facilitate and improve access to quality healthcare services and improve the health of communities.”

These developments come in the wake of two other states—California and Oklahoma—successfully challenging the free care rule that had, for years, stated that schools may not use Medicaid funds to pay for covered services that are provided for free to the entire student population.

Both states successfully argued that this rule was not based on federal statute. However, many states—including Massachusetts—have continued to apply the rule due to a lack of technical guidance as well as confusion over whether schools nationwide—or only those in California and Oklahoma—could qualify for federal reimbursement.

In its 2014 letter, the agency goes on to state the following:

Under this guidance, Medicaid reimbursement is available for covered services under the approved state plan that are provided to Medicaid beneficiaries, regardless of whether there is any charge for the service to the beneficiary or the community at large. As a result, Federal Financial Participation (FFP) is available for Medicaid payments for care provided through providers that do not charge individuals for the service, as long as all other Medicaid requirements are met.

States nationwide are slowly coming on board to follow in the footsteps of California and Oklahoma. Massachusetts, for example, may announce statewide changes as soon as October. Once schools are able to expand Medicaid billing for all students, they could see a significant increase in reimbursement—particularly related to nursing services. According to, health advocates see this policy change as an opportunity to develop programs in public schools to help students understand and manage chronic conditions such as asthma, diabetes, and mental illness. In some cases, the additional reimbursement may also be able to help schools hire more nurses. According to the National Association of School Nurses, more than 30% of schools only have a part-time nurse, continuing to drive a school nursing shortage nationwide.

Medicaid-covered services include speech therapy, occupational therapy, physical therapy, audiology services, counseling, nursing services, personal care, behavioral health, and applied behavior analysis.

What can your school do now to prepare for potential changes? Consider these tips:

  1. Review all of your vendor’s services. Does your vendor have experience in school-based Medicaid claiming along with compliance for HIPAA and the Family Educational Rights and Privacy Act (FERPA)? If you haven’t done so already, you’ll need to find a vendor that understands the Medicaid program and all of its requirements. 
  1. Think ‘data integration.’ To bill for a potentially increased volume of Medicaid-covered services, schools must ensure that their billing vendor can streamline the process as much as possible. Has your vendor initiated meetings with various stakeholders to streamline data flow within the school nursing office along with other school departments? Or must the school absorb additional costs to enable that interoperability?
  1. Ensure that documentation is meeting standards. Schools will only receive additional reimbursement when all documentation and billing requirements are met. Specifically, documentation must include the following elements: School district name/provider number, provider credentials, student name, student date of birth, student Medicaid number, date of service, activity/procedure note (including whether the activity/procedure was performed individually or as part of a group), service time, and signatures. Note that thorough and complete documentation also mitigates the risk of a third-party audit.
  1. Seek out resources. For up-to-date information about school-based Medicaid billing, refer to the National Alliance for Medicaid in Education, Inc. (NAME). To learn more about compliant Public School-Based Medicaid Claiming, call Jennifer White at NEMB at 508-297-2068 x233.


About NEMB

New England Medical Billing is a leader in School-based Medicaid claiming and administration. We are a fully HIPAA-compliant Medical Billing Management and Administrative Service Firm. Our expertise is in program and system design as well as effective implementation and administration. Our multi-disciplinary approach and attention to detail consistently yields the maximum allowable returns on every client project.

Since 1993 NEMB has been built carefully, approaching each new engagement using proven management methods. Our superior, time-tested approach is applied to each and every engagement. We “zero-base” every new proposal to build a process that fulfills the unique requirements and goals of each project.

Our billing administration experience in ambulance & EMS services, emergency departments, school-based Medicaid claiming and private physician practices has honed and streamlined our clients’ operations in capturing and maximizing revenue opportunities on a large scale.

CMS rule reversal for Medicaid free care: Will additional reimbursement be on the way for Massachusetts public schools?2019-01-02T17:52:50+00:00