Medicaid School-Based Claiming (MSBC) is a joint federal and state program that offers reimbursement for both the provision of covered medically necessary school-based services and for the costs of administrative activities, such as outreach activities to identify eligible students and enroll them in the program, that support the Medicaid school-based program. Schools may provide a wide range of health care and related services to their students, which may or may not be reimbursable under the Medicaid program.
Many children receive covered Medicaid services through their schools. Medicaid will reimburse schools for documented medically necessary services that are provided to children who are both Medicaid eligible and who have been identified as eligible under the Individuals with Disabilities Education Act (IDEA), 34 CFR §300.306. Currently, schools can receive reimbursement for physical therapy, occupational therapy, speech therapy, nursing services, health aides, certain transportation, and behavioral health services. These activities are considered “direct medical services,” and reimbursements for these services are handled through the Direct Service Claiming (DSC) program.
Schools are often involved in informing families of their potential eligibility for Medicaid or in helping them arrange medical appointments for children. These activities are considered Medicaid outreach and are administrative costs; schools are able to receive reimbursement through the Medicaid Administrative Claiming (MAC) program for these activities.
Both types of claiming must comply with federal and state guidelines related to provider qualifications, covered services, claiming requirements, and documentation.
Public education agency (PEA) participation in the Medicaid School-Based Claiming program is voluntary. If school districts wish to participate in the MAC program, they are required to also participate in the DSC program. School districts cannot participate solely in MAC.
Arizona Health Care Cost Containment System (AHCCCS) is Arizona’s managed-care Medicaid program that was developed as a result of Title XIX of the Social Security Act. While AHCCCS also administers other state and federal health care programs, only Medicaid-eligible students may have costs reimbursed through the Direct Service Claiming (DSC) program.
The Direct Service Claiming and Medicaid Administrative Claiming programs are two of the federally funded programs endorsed by the Arizona Department of Education (ADE) and AHCCCS. AHCCCS is the agency that develops the policies and administers the Medicaid School-Based Claiming program through the Public Consulting Group (PCG) and in collaboration with the ADE.
In order to contract with PCG, a Public Education Agency (PEA) must:
Be an Arizona public school district or an Arizona public charter school
Have students eligible under the Individuals with Disability Education Act (IDEA)
Provide one or more of the Medicaid-covered services on site
Sign an agreement with PCG
The agreement details the responsibilities and rights of both PCG and the participating PEA and the services to be provided to the PEA. The completed contract allows the PEA to participate in the Medicaid School-Based Claiming program administered by PCG. On receipt of the signed contract, PCG will work with the PEA to implement the Medicaid-claiming processes.
For information about the Medicaid School-Based Claiming programs or to learn how to participate in these programs, please contact the Public Consulting Group.
Public Consulting Group, Inc. 101 North First Avenue, Suite 1800 Phoenix, Arizona 85003 Office Number: (602) 324-5090 Toll-Free Number: (877) 877-8011 Fax Number: (602) 324-5091
For information about communication disseminated by ADE/ESS, please contact: ESS Main Desk (602) 542-4013
An enhancement to Integrity Rule -40055 will be introduced into the integrity process on FY21 SPED data shortly. This update is a continuation of our effort to ensure clean data for the state. Updated one-sheet Integrity Tools are available on our AzEDS SPED Reporting webpage for troubleshooting tips.