Provider Notice issued 05/03/2023

This notice informs providers of approved changes to the School-Based Health Services (SBHS) program. The Illinois Department of Healthcare and Family Services (HFS) submitted a Medicaid State Plan Amendment (SPA) to the federal Centers for Medicare & Medicaid Services (CMS) to update and expand the Illinois SBHS program. The SPA includes two changes:

A.    Expand claiming outside of IEP/IFSP services to any Medicaid-enrolled student in the general education population

B.    Move to a cost settlement reimbursement methodology

Expansion

CMS policy provided an opportunity to expand reimbursement for school-based health services for Medicaid-enrolled students beyond those with an Individual Education Program/Individual Family Service Plan (IEP/IFSP). Medicaid services can now be furnished to Medicaid eligible student beneficiaries that require medical or mental/behavioral health services identified as medically necessary in an IEP, IFSP, 504 Plan, other individualized health or behavioral health plan, or where medical necessity has been otherwise established.

Cost Settlement

Cost settlement is a cost-based reimbursement methodology used to determine the actual cost of delivering school-based health services. The cost settlement methodology calculates the “true” cost of providing a service by determining the percent of actual costs that are attributable to Medicaid services. At the end of the fiscal year, it compares the actual total cost of providing services incurred by Local Education Agencies (LEA) to the interim reimbursement payments received throughout the year. If an LEA’s allowable costs exceed the interim payments received, the LEA will receive a payment for the difference. If an LEA’s allowable costs are less than the interim payments received, the state will then recoup any overpayments directly from the districts by withholding future interim payments until the overpayment has been fully recovered. Adjustments are calculated at the end of the fiscal year upon LEA submission of the Annual Medicaid Cost Report.

The Department has received approval from CMS on the SPA expanding the SBHS program. Medicaid services provided to all Medicaid-enrolled students in the school setting are now eligible to receive reimbursement of federal matching funds. All changes are retroactive to July 1, 2021. Services that have passed the window for timely filing will be reimbursed through the cost settlement.

Billing

At this time, school-based practitioners who have been submitting claims for services for special education students through an IEP/IFSP can now submit claims for those services for students in the general population without an IEP/IFSP. The following are the requirements for this expanded Medicaid claiming:

·         All current school-based licensed and qualified practitioners already involved in Medicaid claiming can now submit claims for the expanded population. Specialized transportation is the only service that continues to be allowable only for special education students.

·         The need for services must be documented as “medically necessary” in an individual health plan, which may be an IEP/IFSP, a doctor’s order, a 504 Plan, or any other plan that includes:

•       Scope, frequency, and duration of the service, including unit of frequency (such as 2x30 minutes/week or 3x45 minutes/month) and start and end dates for the service to be provided; and

•       Clinical rationale/justification for the service(s), following standards of clinical practice for each clinical discipline. At a minimum, this should be 1-2 sentences that describe why the service is medically necessary to treat the medical (physical or behavioral health) issue(s).

·         Services must be documented in accordance with Chapter U-200 Local Education Agency Handbook requirements.

Additional information regarding the new services allowed under the expansion will be provided in a later notice.

Public Consulting Group Training

As HFS’s School-Based Health Services administrative vendor, Public Consulting Group (PCG) is responsible for disseminating information and training related to the program. Any guidance they provide should be followed. PCG emailed information to program participants in their system about training sessions they are hosting to familiarize Illinois coordinators with the new program changes. We strongly recommend that at least one person from your LEA who manages the time study/SBHS program attend one of the sessions to learn more about program changes and requirements.

The training will address the following topics:

·         Random Moment Time Study (RMTS) in 2023-2024

·         Time study periods

·         Survey for first regular day for staff in the 2023-2024 school year

·         RMTS Lifecycle

·         RMTS reminders for Coordinators

·         Changes in Specialized Transportation Billing

·         Overview of new students/services which can be reimbursed

If you have not already attended a training, there is one remaining session. You can register through the link below.  

·         May 4, 2023 1:30pm CST

Required School Calendar Survey

Also included in communications from PCG was a required survey for the first calendar day of the 2023-2024 school year. Since the new time study will start with the earliest first regular day for staff for the 2023-2024 school year for any participating district in Illinois, school districts are required to provide the date for the first day of school in which staff will be required to return to work for 2023-2024 school year.  

Every LEA must provide a response by completing the First Day of School Survey by noon on May 12, 2023. Since the earliest date for any LEA must be the official start of the time study, failure to complete the First Day of School Survey may result in program suspension for your LEA for the remainder of this calendar year. This means your LEA would not be eligible to receive Medicaid Administrative Claim payments and you would not be eligible to bill for School-Based Medicaid Direct Services (Fee-for-Service). For this reason, we strongly encourage your LEA to submit the required data as soon as possible.  

To complete the survey, please select the appropriate link below that pertains to your school district. If you have already completed the survey from the PCG email, then you do not need to complete again.

·         LEAs / JAs names with letters beginning with A-L, please select the link below:

·         School districts A-L

·         LEAs / JAs names with letters beginning with M-Z, please select the link below: 

·         School districts M-Z

Intergovernmental Agreements

As a result of the program changes, all participating local education agencies will be required to sign a new Intergovernmental Agreement with HFS. PCG will be circulating the agreement in the coming weeks.

Questions regarding this notice may be directed to HFS.SBHS@illinois.gov.

Kelly Cunningham, Administrator

Division of Medical Programs