The New England region is home to some of the most highly respected medical institutions in the world. The excellent quality of care these facilities provide comes at a high cost, which is why Medicaid funding is so important in this part of the country. New England Medical Billing (NEMB) is dedicated to helping our clients secure the Medicaid reimbursement they deserve. We have a team of experienced professionals who understand the ins and outs of the Medicaid system, and we know how to get results. NEMB has a proven track record of success in getting Medicaid reimbursement for our clients.

Medicaid is a federal-state program that offers free or low-cost health care to millions of Americans, including certain low-income individuals, children and families, pregnant women, the aged, and those with disabilities. The federal government contributes a share of Medicaid’s funds and establishes the program’s criteria, and Medicaid programs in each state differ. 

States need to provide Timely, Periodic, Detection, Diagnosis, and Treatment services to children who qualify. States may also provide optional treatments, such as prescription medicines, dental services, hearing devices, and physical and other therapeutic services that are especially vital to those with disabilities who are qualified. 

What is the School-Based Medicaid?

School-Based Medicaid is a state Medicaid program that pays for health and related services for children enrolled in school. School-Based Medicaid is jointly funded by the federal and state governments, with the federal government paying between 50 percent and 83 percent of the costs, depending on the state’s per capita income. States have the flexibility to design their programs within federal guidelines.

What types of services does School-Based Medicaid cover?

Covered types of direct care services in the SBMP include: 

  • Applied Behavior Analysis for members with Autism Spectrum Disorder (ASD)
  • Audiology
  • dental assessments/screenings 
  • medical nutritional services
  • mental/behavioral health services
  • skilled nursing care
  • occupational therapy
  • physical therapy
  • physical and behavioral health screening
  • speech therapy

These are just a few examples of the many different types of medical services that Medicaid can help pay for. If you have any questions about whether or not a particular service is covered by your state’s Medicaid program, you should contact your state’s Medicaid office.

How do I know if my child is eligible for School-Based Medicaid?

To be eligible for School-Based Medicaid, a child must meet two criteria:

  • The child must be enrolled in school.
  • The child must be eligible for Medicaid under one of the following eligibility categories:
  •   Children under age 19 who are from families with incomes at or below 133 percent of the federal poverty level (FPL)
  •   Children ages 6 through 18 who are from families with incomes at or below 100 percent of the FPL and are also recipients

Financing Of Medicaid

Federal Medical Assistance Percentage (FMAP)

The federal government provides corresponding funds to states for Medicaid expenses that qualify; states are promised at least $1 in federal cash for each $1 in state Medicaid expenses. This structure permits federal funding to move to states depending on real costs and requirements as economic conditions change. 

State Financing of the Non-Federal Share

States have autonomy over the sources of financing for the non-federal portion of Medicaid expenditures. State general fund allocations provide the principal source of money for the non-federal portion. The utilization of alternative funding by governments has grown marginally but consistently over the last decade. This is certainly partially attributable to states’ increasing dependence on providers’ taxes and fees to fund their Medicaid contributions. 

Higher Match Rates

In some circumstances, Medicaid offers a greater matching rate for certain services or demographics, the most prominent of which being the increased matching rate for Medicaid expansion under the ACA. From 2014 to 2016, the federal government paid 100 percent of the Medicaid expenditures for freshly eligible individuals in states that expand coverage.

The government share eventually decreased to 90 percent in 2020, where it stays. There does not involve any deadline for adopting the expansion, but federal match rates have links to certain years. 

How is Medicaid part of the School-Based Claiming program?

The Medicaid program is a critical source of revenue for school districts across the country. In the 2016-2017 school year, Medicaid provided $4 billion to schools, representing about 3 percent of all public education funding.

School-based Medicaid programs are structured so that schools can be reimbursed for certain health- services that they provide to students. These services must be related to a student’s Individualized Education Program (IEP) or 504 plan and must be ones that the school would not otherwise be able to provide without Medicaid reimbursement. To receive reimbursement, schools must first enroll in their state’s Medicaid program and then submit claims for payment.

How New England Medical Billing Can Help

At both the state and federal levels, a large-scale program like Medicaid will always be the subject of budget crises. State governments, the federal government, and Medicaid recipients would all experience an impact of the changes to the program’s finance structure. Thus, these changes would need to be carefully considered.

When you partner with NEMB, you and your team will have access to all of our knowledge and resources. To save you from having to worry about the administrative procedure, we streamline the medical billing process for you. Additionally, you’ll experience higher revenues than you have in recent history! Anyone interested in claiming school-based claims should contact NEMB for a consultation.


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