School-Based Medicaid

Topics:

Specialized Student Support Services

Medicaid is a federal/state cost sharing benefit program for health and medically necessary services for low-income individuals that was established as Title XIX of the Social Security Act in 1965. Originally, Medicaid benefits could not be used for services provided under the Individuals with Disabilities Education Act (IDEA). In 1988, the Medicare Catastrophic Coverage Act allowed Medicaid to pay for covered medical services provided to Medicaid-enrolled children with special health care needs on their individualized education program (IEP) or individual family service plan (IFSP).

Within the Iowa Department of Education, there are three aspects to reimbursement from the Iowa Medical Assistance Program (Medicaid). A Local Education Agency (LEA) is a community school district that is able to seek reimbursement for services provided to children requiring special education with services identified on an IEP. An Area Education Agency (AEA) is a regional service center able to seek reimbursement for services provided to children requiring special education. The Early ACCESS Program also allows reimbursement for services to children from birth to age three with at least a 25% developmental delay and services identified on an IFSP.

Medicaid Steps: From Identifying Students To Bill On to Paying Back State Share

Accounting for School-Based Medicaid

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Funding Sources

Medicaid services are funded by a mix of state and federal funds. Each state is able to define what services are covered in their program, with federal approval. In Iowa, all three of the education-related provider types return at least the state portion of the Medicaid reimbursement to the Department of Human Services (Iowa’s Medicaid agency). In fiscal year 2022-23 AEAs and LEAs were able to receive $75.5 million in federal Medicaid funds for special education services. Medicaid will only reimburse a provider for their ‘cost’ of the service and education regulations prohibit an AEA or LEA from charging more than their ‘cost’ for the service. The Department of Human Services, using cost data provided by the Iowa Department of Education, calculates the reimbursement rates for each AEA and LEA on an annual basis.

The Medicaid reimbursement rates for local districts and AEAs are cost based with rates set annually. The files below include the new rates.

Archived Medicaid Rates (dates of service from July 1, 2023, to June 30, 2024)

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State Share Invoices to be Paid

Any month in which an LEA has claims processed results in a Medicaid Billing Remittance posted to the Iowa Medicaid Portal. Below is a document walking the user through the registration process to access the system.

How to Get Your Medicaid Billing Remittance for the State Share

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Guiding Practices

Medicaid requires all providers to have appropriate documentation of the services reimbursed. The documentation must be kept for 5 years from the date of the claim submission (or last re-submission). As the documentation is sent to Medicaid for payment, FERPA privacy requires a parental consent to release the information to a third party (Medicaid).

Many districts are utilizing the free software from Iowa Medicaid (PC-ACE Pro 32). Learn more at EDI Support Services.

Compliance: Requirement to Report Any Data Breach

Medicaid providers are expected to report any breach of data as soon as possible to the Iowa Department of Health and Human Services (IDHHS) using this form. Complete the form with as much information as you know and submit it to the address on the form.

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Documents

The Iowa Department of Education has designed example documentation forms for the various covered services as follows:

LEA Service Forms

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Accounting

Accounting entries for Medicaid can be found on the document, UFA Journal Entries, located on the Uniform Financial Accounting webpage. Medicaid entries are on the last tab of the worksheet.

The National Alliance for Medicaid in Education, Inc. (NAME) represents the nation's Medicaid and Education agency staff, along with local education agency administrators, with programmatic responsibility for administering Medicaid's health related service programs in schools. The primary purposes of NAME are to provide an information network among the states on issues pertinent to the Medicaid programs in schools and to act as a focal point of communication between the states. Iowa is well represented in the NAME organization.

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Eligibility List

Each LEA has a Medicaid Eligibility Report that is updated each month.

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Checking Eligibility Through the Eligibility Verification and Information System (ELVS) Portal

Until Eligibility Information is available for the district or AEA, there are 2 options through the Eligibility and Verification Information System (ELVS) system and you can learn more about the ELVS system on the Iowa HHS website Medicaid Provider services section.

1. The ELVS web portal allows a provider to check multiple names, one at a time, with date of birth and gender. In this situation you do not need the Medicaid ID or the SSN. Your inquiry will generate an immediate response as to whether there is a match with the eligibility data and the Medicaid ID number will display. 

Eligibility Verification and Information System 2024 Update

2. The ELVS phone system is an automated 24/7 line in which the caller is asked a series of questions about a Medicaid member (student) and is expected to enter the school district/ AEA National Provider Identifier, then enter the Medicaid ID of the student you are checking on, and then enter a date for which you are checking eligibility. The caller can check eligibility for other dates for the same student, and on more than one student in the same call. If you do not have the Medicaid ID the Phone system allows a check using the student's Social Security Number but education agencies do not get or maintain the SSN. If the LEA/AEA billed on the student in the past, the Medicaid ID number should be in LEA/AEA Medicaid records

The SBA will announce when new Eligibility Reports are available.   

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FAQs and Training

Medicaid Exclusions and Suspensions Checks for School-Based Service Providers - Recorded 4-6-22. Explains the required monthly checks of two databases for all staff who provide Medicaid services. Presentation demonstrates how to perform and document checks and how to submit documentation.

Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification: Privacy, Security, Transactions - Recorded 3-6-20. A  1 hour, 3 minute video prepared by Iowa Department of Human Services for staff members who see Medicaid eligibility data including Medicaid ID numbers.

School-Based Medicaid Overview – Recorded 4-16-2020. A one-hour video reviewing: (a) the general history of school-based Medicaid; (b) responsibilities and requirements to be a participating school provider; (c) what health services are covered benefits in the school-based program; (d) how to identify students that qualify for billing; (e) resource materials for the school-based program; and (f) account coding.

2021 Medicaid Reference Guide

Co-Development Supports for LEA Medicaid

Medicaid FAQs (2013-07-29)

Medicaid Webinar Fall 2017 - Recorded 8-31-2017. Iowa Medicaid Services by LEA, AEA and Infant Toddler Providers: Changes & Review Fall 2017 – This session reviews Iowa’s school-based Medicaid programs: 2017–2018 news and changes, program history, provider responsibilities, resources and documentation reviews.

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Private Duty Health Care Agency Nurse Guidance

If your district has a student who receives services at school from a home health private health care agency nurse, as an extension of the services provided in the home, it is recommended that the student’s Individualized Education Program (IEP) team: (1) review the necessity of nurse level services; (2) if nurse level services are found necessary, review the necessity of using a private health care agency nurse instead of an employee nurse; and (3) review Iowa Department of Human Services Informational Letter 1935-MC-FFS. The letter states that “Schools may choose to contract with health care agencies to provide the needed services. Contracted services are the responsibility of the school and the contracted providers should bill the school and not Medicaid for services written in the student’s IEP. While the IEP might order nursing services, the school is not obligated to use the private duty nursing agency that provides services in the student’s home before and/or after school. In addition, an IEP might require health paraprofessional services supervised by the school nurse if private duty nursing services are not medically necessary. If rejected by the IEP team, the private duty nursing agency cannot fail to provide services at the other authorized times of day. The titles below are tools your district might use to determine the necessity of nurse level services and to provide guidelines for private agency nurses.”

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The following reference links may also provide valuable information or perspectives related to the Iowa Medicaid within the education environment:

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