School-Based Medicaid Claiming

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Medicaid Billing For Schools in 2019

In the state of Massachusetts, the Medicaid program is administered by MassHealth, which works jointly with the School-Based Medicaid Program (SBMP), and is administered by the University of Massachusetts Medical School (UMMS).

Program Overview

In the state of Massachusetts, school children can be enrolled in the Medicaid program, so as to have access to benefits which are made available to them through state and federal funding. Matching funds from the Federal Financial Participation program are made available to participating LEA’s who are members of the school-based Medicaid program. Reimbursement for SBMP services and for the administration of activities is based on allowable costs which are incurred by the LEA’s.

When a claim is made through MassHealth, the state is authorized to pass along that claim so as to receive federal funding for administrative activities and direct services, which have previously been approved by the Centers for Medicare and Medicaid (CMS). There are three major components to the SBMP, which includes direct service claims submitted to MassHealth, administrative activities claims, and the Random Moment Time Study, each of which will be explained in detail below.

Direct Service Claiming

The program known as Direct Service Claiming (DSC) provides a channel through which LEA’s can seek federal reimbursement for Medicaid provided services delivered in their schools. These type of direct medical services include physical and occupational therapies, speech therapies, counseling of a psychological nature, audiology services, skilled nursing, personal care services, and therapy services considered to be in the arena of Applied Behavior Analysis (ABA).

Up until July 1, 2019 any of these services covered by Medicaid can only be reimbursed when they are provided in concordance with a student’s Individualized Education Plan (IEP). After July 1, the program will be expanded to include reimbursement for all services covered under Medicaid, even without the IEP accompaniment.

This will now include such additional services as behavioral health screenings, fluoride varnish treatments, and many other services which are ordered by a physician, a nurse practitioner, or a physician assistant, as deemed medically necessary. When the fiscal year concludes on June 30, all LEA’s are required to submit a Cost Report which details the total allowable costs incurred by the LEA during the previous fiscal year. This Gross Medicaid Reimbursable Amount report must necessarily be submitted with a certification which verifies the accuracy of all claims listed on the report.

Administrative Activities claims

The program identified as the Administrative Activities Claiming (AAC) program works to reimburse government agencies for allowable costs related to Medicaid administrative functions. Reimbursement for the AAC element of SBMP services centers around allowable incurred Medicaid costs which are related to the execution of Medicaid administration activities, as described by the Random Moment Time Study (RMTS).

All these expenditures are detailed quarterly, under the administrative claim made in the Massachusetts School Based Medicaid program. Examples of the allowable administrative expenditures which would be reimbursed under the program include all of the following:

  • transportation expenditures of a specialized nature
  • tuition expenditures which are out of district
  • supply and material costs which are supporting Medicaid administrative activities
  • employer paid benefits and staff salary expenditures
  • capital costs which are derived by applying a pre-set capital percentage allocation rate
  • indirect costs derived by applying a DESE indirect cost rate.

Random Moment Time Study

In order to quantify the actual portion of reimbursable staff time claimed through direct service claims and administrative activity claims, the method known as the Random Moment Time Study is imposed. At random moments through the entire school year, LEA staff time is sampled by having pool respondents provide answers to questions about what they were doing at a specific random moment in time. After compiling statewide results from these responses, the methodology then generates a statistically valid proportion of reimbursable time for each of the respondent pools participating in the survey.

This entire process is carried out online using the Massachusetts RMTS system, and is designed to be as quick and unobtrusive as possible. The results of the statewide RMTS survey are combined with costs relative to each provider, and are then submitted in an annual cost report, so as to determine the level of reimbursement appropriate for Direct Service Claiming, as well as for Administrative Activity Claims.

SBMP and MassHealth

MassHealth is the agency that oversees the School-Based Medicaid Program in Massachusetts. The organization develops policies as well as ensures that schools are in compliance with federal and state regulations for the Medicaid program. The University of Massachusetts Medical School works with MassHealth to administer SBMP. LEAs must seek reimbursement through MassHealth. The contracting process begins through the MassHealth Provider Enrollment Center.


While there is currently a requirement that direct services be through an IEP, this requirement will be lifted beginning July 1, 2019. In addition, additional provider types and services will be added through an effort called Expansion. The goal of the Expansion is to broaden the program and to provide services for students that may not be associated with an IEP. Specifically, services will be covered if they are part of a section 504 plan, an individual health care plan (IHCP), an individualized family service plan (IFSP), any state-mandated screenings, and some services deemed medically appropriate. This broadens access to reimbursement significantly to include nutritionists, school psychologists, respiratory therapists, dental hygienists, and other health care professionals working through educational institutions. The four pools of services acceptable under the Expansion are medical services, therapy services, behavioral/mental health services, and administrative services.

To help make this transition easier, the SBMP will offer trainings as well as updated website information and documents in the SBMP Resource Center.

Training programs include:

  • RMTS
  • Cost Report
  • Administrative Claiming
  • Interim Claiming

Training dates will be made available to LEAs.

Program guides will be made available for:

  • RMTS User Guide
  • SBMP Administrative Claims Instruction Guide
  • Massachusetts School-Based Cost Report Instruction Guide
  • SBMP User Guide
  • Procedure codes and interim rate bulletin for providers

Challenges to keep in mind

There is a difference between a covered service and a reimbursable service. Even though a service may be included in what is covered and reimbursed, there are requirements that must be met in order for reimbursement to take place. Along with factors like parental consent, a reimbursable service must be part of the direct service pool and documented correctly. If a service does not meet reimbursement requirements, even if it is covered under the program, it will not be reimbursed.

Parental consent is needed for the service in order for it to be reimbursable. In alignment with federal law as well as the Department of Elementary and Secondary Education’s (DESE’s) student records regulations, parental consent is required for reimbursement. LEAs should only submit claims for MassHealth-enrolled students after parental consent has been obtained. In addition, only students from whom parental consent has been obtained should be included in Medicaid eligibility statistics. A sample parental consent form can be found on DESE’s website. The link for the sample form can also be obtained from MassHealth.

LEAs are directly involved in the process. Updated contact requirements mean that LEAs are involved in most processes rather than relying on billing vendors. It is the LEAs who are the contracted provider. It’s important to remember that LEAs are the entities audited by agencies like MassHealth.

Medicaid Billing For Schools in 20192019-06-19T16:24:33+00:00

School-Based Medicaid Program Expansion in Massachusetts – What You Should Know

The School-Based Medicaid Program (SBMP) provides an opportunity for local education agencies (LEA’s) to be reimbursed by the federal government for the coverage of costs associated with providing specific services covered by Medicaid in a school environment. Local education agencies  can include public, vocational or technical schools, regional school districts, and charter schools.

The SBMP program is directly administered by MassHealth, which not only oversees the program, but also develops any new policies, and is responsible for ensuring compliance with all state and federal regulations and laws. In cooperation with MassHealth, the University of Massachusetts Medical School oversees the School-Based Medicaid Program, to ensure that program directives are carried out in all areas of the state.

Reimbursement under the School-Based Medicaid Program

Any LEA which is considering becoming involved or is already involved in the program would be well advised to review information available from the Resource Center, or contact School Based Claiming at 1-800-535-6741 option #0, so they can learn more about the program. The SBMP provides a contact information page on its website to facilitate all queries of this nature.

Up to and including the date of June 30, 2019, any claims made under SBMP must be identified as reimbursable, according to an individualized education plan (IEP) established with a specific learning institution. As of July 1, 2019, that IEP requirement will change, so that a number of additional services and provider types can then be considered valid as well. This changeover of IEP requirements has been termed Medicaid Expansion Program.

Impact of Expansion

The major thrust of Expansion by MassHealth is to broaden the School-Based Medicaid Program, so as to also include payment for medical services given to students under different plans besides the IEP. In addition to covering services pursuant to an IEP, the Expansion program will now also cover services pursuant to an individual health care plan (IHCP), a section 504 plan, and individualized family service plan (IFSP), state mandated screenings, and even some services which are simply deemed medically appropriate.  

The practical effect of Expansion means that it will now be possible to claim reimbursement for medical services offered by a dental hygienist, a nutritionist, a respiratory therapist, a school psychologist, and several other medical professionals in residence or contract at learning institutions. As of July 1, 2019, there will be four acceptable pools for services provided under the School-Based Medicaid Program. These four include medical services, therapy services mental or behavioral health services, and administrative services. LEA’s will be required to implement all amendments necessary to provider contracts with MassHealth, in order to continue their involvement with the School-Based Medicaid program, even if they only intend to make claims for IEP services. To prepare LEA’s for Expansion, a number of training and guidance tools have been made available by MassHealth, so as to ensure a smooth changeover.

School-Based Medicaid Program Expansion in Massachusetts – What You Should Know2019-03-14T14:45:13+00:00

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