Medicaid Contract Purchasing Specifications
User Guide for Service Coordination with School Health1
IEPs and IFSPs
Coordination of Benefits:
§105A(a)(2) of Part
1A sets forth obligations of Contractor relating to enrolled children
with IEPs and IFSPs.
Coverage Determinations:
§101A(b)(7) relates
to provisions of an IEP or an IFSP as evidence to be considered in
making coverage determinations.
§101A(c)(5) specifies
prohibited grounds for denial or exclusion of services with respect
to an enrolled child in an IEP or an IFSP.
§102A(f)(3) specifies
personnel qualified to make coverage determinations for an enrolled
child with an IEP or an IFSP.
Covered Services:
§202(b) relates to the
Contractor's duties to furnish covered services (that are also in
the IEP or IFSP) to children under an IEP or IFSP at the time of enrollment.
Definitions:
§1401(o) defines an individual
educational program (IEP) as a plan of services developed by an educational
agency which sets forth the special education, health, medical, and
other related services required by a child.
§1401(p) defines an individualized
family services plan (IFSP) as a plan of services developed by an
early intervention agency which sets forth the early intervention
services required by a child and the child's family or caregiver.
MOU:
§706(b) of Part 7 relates
to the financial and administrative responsibilities enumerated in
a memorandum of understanding regarding the implementation of IEPs
and IFSPs for enrolled children.
Prior Authorization:
§103A(d)(8) of Part
1A relates to the exclusion of services provided under an IEP or an
IFSP from Contractor's prior authorization restrictions.
School-based Health Services: §005(g)
of the Overview relates to an enrolled child's right to receive covered
services from any school-based health center and Contractor's duty with
respect to payment for school-based services received by enrolled children
from out-of-network providers.
Coverage Determinations:
§101A(c)(7) specifies
prohibited grounds for denial or exclusion of services with respect
to services provided in a school setting.
School-based Providers
Network Participation:
§507 of Part 5 relates to
the participation of school-based health and related service providers
in Contractor's provider network and referral arrangements to school-based
health centers.
Endnotes
- See also HCFAÚs Letter to State
Medicaid Directors on reimbursement for school-based health services
under Medicaid, www.hcfa.gov/medicaid/smd52199
and the August 1997 Technical Assistance Guide on Medicaid and School
Health, www.hcfa.gov/medicaid/scbintro.htm.
- For additional provisions, see Optional
Specifications: Medicaid Managed Care for Children with Special Health
Care Needs (forthcoming, CHSRP).
The sample purchasing specifications include numerous provisions addressing a wide range of issues for Medicaid-eligible children and adolescents. The review process focused on specific policies for school health issues, including how IEPs and IFSPs can be coordinated with a child's traditional medical services.2 The following provisions may be of particular interest to purchasers interested in issues around school health issues. The provisions are listed in alphabetical order.