Category: LEA Billing

In recent years, California has undergone significant changes in school-based medical billing, opening up new pathways for schools to secure funding for health services delivered in educational settings. The state is at the forefront of implementing diverse billing programs, including the Medi-Cal LEA Billing Option Program (LEA BOP), the Children and Youth Behavioral Health Fee Schedule Program, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, and specialty mental health billing. These developments are revolutionizing how schools access and leverage medical reimbursements to enhance student health services.

The Evolution of School-Based Medical Billing in California

California’s school-based medical billing journey began with limited programs that often struggled to connect medical services with the educational framework. School leaders faced challenges in navigating the regulatory and administrative complexities associated with billing for medical services provided in schools. This disconnect meant that many opportunities for reimbursement went unclaimed, and schools had to bear the financial burden of providing critical health services without adequate support.

Over the years, state policy changes and federal initiatives paved the way for a more inclusive approach to school-based health services. The approval of State Plan Amendment (SPA) 15-021 marked a pivotal moment in this evolution, transforming the LEA BOP into a cost-based billing program. Under this structure, schools can claim reimbursement for the actual cost of providing medical services to Medi-Cal eligible students, making the program more financially sustainable and encouraging districts to expand their services.

The Children & Youth Behavioral Health Fee Schedule Program: A New Era Begins

The recent launch of the Children & Youth Behavioral Health Fee Schedule Program in 2024 signifies a bold step forward. The program’s early-adopter cohorts are set to usher in a new era of reimbursement for mental and behavioral health services provided in schools. For the first time, schools in California are inching closer to real reimbursement for such services paid by Managed Care organizations and commercial health plans.

This program is unique, as California is the first state to develop and implement a school-based billing framework that includes behavioral health services in this manner. This ground-breaking model opens the potential for expansion into other practice types, and could provide even broader access to care for students while alleviating financial pressures on school districts.

Addressing Longstanding Challenges

Despite the progress, integrating medical services and billing within the educational setting has been an ongoing struggle for school administrators. Historically, school leaders have faced hurdles in aligning health services with educational priorities, often due to limited resources, lack of specialized staff, and the intricacies of navigating both healthcare and educational regulations. These challenges have made it difficult for schools to fully capitalize on available funding opportunities.

However, with the new programs and policy shifts in place, there is a growing recognition that health services are essential to student well-being and academic success. This alignment has led to increased collaboration between health and education agencies, streamlining the processes required for billing and reimbursement. Last year CMS released new comprehensive guidance geared to improve access to federal funding for school-based medical services. Schools are now better positioned, with clear knowledge and guidance, to track and report the services they provide, which, in turn, maximizes their potential for reimbursement.

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program

The EPSDT program has also become a key component of the school-based billing landscape. Designed to ensure that children and adolescents receive the necessary medical, dental, vision, and mental health services, the program allows schools to bill for a wide range of health services provided on campus. By broadening the scope of reimbursable services, EPSDT enables schools to proactively address the health needs of students, leading to earlier detection and treatment of conditions that could impact academic performance.

Riverside University Health and Behavioral Health Program

In addition to state-level initiatives, regional programs like the Riverside University Health and Behavioral Health Program offer promising models for expanding access to care. These programs work in tandem with school districts to integrate health services into students’ daily lives, making it easier for students to receive care without leaving the school environment. The inclusion of behavioral health services, in particular, highlights the evolving understanding that mental health is a crucial part of overall well-being, especially in the context of a student’s ability to learn and thrive.

A Path Forward: The Future of School-Based Medical Billing

The transformative changes underway in California’s school-based medical billing system hold the promise of a more equitable future for students across the state. As programs like the Children & Youth Behavioral Health Fee Schedule Program gain traction and demonstrate their value, other states may look to California as a model for integrating health and education systems.

To continue this momentum, ongoing advocacy is necessary to ensure that school-based health services are recognized as integral to public health and education policy. California’s pioneering efforts could serve as a blueprint for future legislation and funding opportunities at both the state and federal levels.

The success of these initiatives will depend on the ability of schools to adapt to the evolving landscape, build partnerships with health providers, and effectively manage the administrative aspects of billing. With the dust settling around recent policy changes, school districts now have a clearer understanding of how to navigate the complexities of cost-based reimbursement, making the path forward more accessible.

Conclusion

California is in the midst of a transformative period in school-based medical services and billing, with new programs and policies reshaping the landscape. The shift toward more inclusive, cost-based billing models like the LEA BOP, coupled with the groundbreaking Children & Youth Behavioral Health Fee Schedule Program, represents a significant opportunity to enhance the quality and accessibility of health services for students.

By overcoming historical challenges and leveraging new billing opportunities, California is setting the stage for a future where health and education work hand in hand to support the well-being and academic success of every student. As these changes continue to unfold, they will not only benefit California’s schools but could also influence national trends in school-based healthcare services.

Practi-Cal: Supporting Schools with EHR and Billing Solutions

In the evolving landscape of school-based medical billing, having the right tools to navigate billing complexities and ensure compliance is essential for success. Practi-Cal, a leading provider of Electronic Health Records (EHR) and documentation systems, offers a specialized solution designed to meet the unique needs of schools in California. With almost 30 years of experience, Practi-Cal has developed a robust platform that helps schools streamline their billing processes, manage health services, and maintain compliance with Medicaid, IDEA, and state-specific regulations.

Prepared by: Chuck Muirhead, Partner
Practi-Cal
cmuirhead@practi-cal.com

Seven-year-old Winnie Hoyt sits nestled in her mother’s lap in a therapy room at Oregon Health and Science University in Portland. She’s dressed in a lavender romper that sets off her soft brown eyes, and smacks her lips occasionally while her mom and her speech-language pathologist fiddle with settings on an iPad-like device hovering in her line of sight. Read more

Office of Special Education and Rehabilitative Services, Department of Education. Secretary proposes to remove the requirement for public agencies to obtain parental consent prior to accessing for the first time a child’s public benefits or insurance ( e.g., Medicaid, Children’s Health Insurance Program (CHIP)) to provide or pay for required IDEA Part B services.

We encourage your LEA to submit a comment in support of this proposed rule to remove parent consent requirements.

https://www.federalregister.gov/documents/2023/05/18/2023-10542/assistance-to-states-for-the-education-of-children-with-disabilities

The Center for Medicaid/Medicare Services has released an updated Comprehensive Guide for School-based billing programs. It has been over 20 years since the last update and there is new flexibility for states in improving school-based services and reimbursement.

https://www.cms.gov/newsroom/fact-sheets/delivering-service-school-based-settings-comprehensive-guide-medicaid-services-and-administrative

https://www.cms.gov/newsroom/press-releases/cms-approves-illinois-proposal-expand-access-care-kids-schools

Apr 18, 2023

• Medicaid & CHIP

Today, the Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), approved a state plan amendment (SPA) that will provide Illinois more Medicaid funding for eligible children receiving Medicaid-covered health care services in schools. This approval advances the expansion of school-based health services, a key priority for the Biden-Harris Administration to improve health care access, especially for youth mental health services. Today’s action is also part of ongoing efforts by HHS in support of President Biden’s call to address the nation’s mental health crisis, including its impact on children.

“Today we celebrate the historic action taken by Illinois to expand access to critical health care services in schools for eligible children,” said HHS Secretary Xavier Becerra. “The Biden-Harris Administration is committed to meeting children where they are to provide care that addresses the challenges our nation’s youth are facing, including mental health challenges. I am hopeful additional states will follow Illinois’ lead.”

“We’re thrilled to partner with states like Illinois to seize opportunities in Medicaid to expand access to health care in schools,” said CMS Administrator Chiquita Brooks-LaSure. “CMS encourages all states to consider adopting this flexibility. It just makes sense to deliver health care services and supports to children where they spend the majority of their time: in school.”

Illinois’ newly approved SPA allows schools to receive more Medicaid funding for covered services for all children with Medicaid, rather than only those children with an Individualized Education Program (IEP), which is a plan or program tailored for children with disabilities.

This SPA approval represents one of several steps CMS and HHS are taking to promote access to school-based health services and the availability of Medicaid-covered services, including mental health treatment in schools. Last year, Secretary Becerra and U.S. Department of Education Secretary Miguel Cardona issued two letters (available here and here) to states, encouraging them to leverage federal resources, especially Medicaid, to expand school-based health services for children. In August, the Centers for Medicaid and the Children’s Health Insurance Program (CHIP) Services released additional guidance outlining best practices for the delivery of health services to kids in schools.

Additionally, as part of its implementation of the Bipartisan Safer Communities Act, CMS expects to release a Comprehensive Guide to Medicaid Services and Administrative Claiming, launch a new school-based services Technical Assistance Center in partnership with the Department of Education, and release a notice of funding opportunity for $50 million in grants to states to strengthen school-based health services. 

The school setting provides a unique opportunity to deliver health care services to children and adolescents, especially those enrolled in Medicaid. Together, Medicaid and the Children’s Health Insurance Program (CHIP) cover over 41 million children, or more than 50% of all children in the country. School-based health services — which can include preventive care, behavioral health services, physical and occupational therapy, and disease management, among other Medicaid-covered services — are important resources for Medicaid-enrolled children and their families and have been shown to improve health and academic outcomes.

Illinois joins 11 other states that have already expanded Medicaid payment for school-based health care services under their state plans. These include: Arizona, California, Colorado, Connecticut, Georgia, Kentucky, Louisiana, Massachusetts, Michigan, Nevada, and North Carolina. CMS celebrates and supports all states in expanding school-based health care services to more children with Medicaid.

For more information on Illinois’ SPA, please visit Medicaid.gov. For more information on state opportunities to expand access to school-based services in Medicaid, see CMS’ August 2022 informational bulletin.

Beginning January 1st, 2023, LEA’s are able to bill for individual and group counseling provided by Credentialed School Counselors. California Education Code 49600 has been updated to include provisions for direct services, allowing the role of school counselors in mental and behavioral health. Specifically, it clarifies that school counselors are mental health professionals,

A recent California Association of School Counselors article by Loretta Whitson, Ed.D. discusses the changes and potential billing opportunities for LEA’s. Practi-Cal has also informed our clients of this new policy change and are working with our clients to identify potential service and billing opportunities. You can read the article here.