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.


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