Medicaid and Schools

^Pr^ep^ar^{ed f}^o^r^M^e^m^b^ers^an^d^Com^mⁱ^t^t^ees^of^C^ong^r^e^ss

As a condition of accepting funds under the Individuals with Disabilities Education Act (IDEA),
public schools must provide special education and related services necessary for children with
disabilities to benefit from a public education. Generally, states can finance only a portion of
these costs with federal IDEA funds. Medicaid, the federal-state program that finances medical
and health services for the poor, can cover IDEA required health-related services for enrolled
children as well as related administrative activities (e.g., outreach for Medicaid enrollment
purposes, medical care coordination). Despite written federal guidance, schools have difficulty
meeting the complex reimbursement rules under Medicaid. According to federal investigations
and congressional hearings, Medicaid payments to schools have sometimes been improper. P.L.
110-173 included a moratorium on any administrative action restricting Medicaid coverage or
payments for school-based administration and transportation services until June 30, 2008. P.L.
110-252 extended this moratorium until April 1, 2009. This moratorium would be further
extended to July 1, 2009, via the American Recovery and Reinvestment Bill of 2009 that was
approved by the House Energy and Commerce Committee on January 22, 2009.

Recent History.................................................................................................................................1
Current Issues..................................................................................................................................2
Table 1. Medicaid School-Based Expenditures by States for FY2006............................................5
Author Contact Information............................................................................................................6

nder IDEA, public schools are required to provide children with disabilities with a free
appropriate public education (FAPE), including special education and related services
according to each child’s individualized education plan (IEP) or individualized family U

service plan (IFSP). States receive some federal aid under IDEA, but are otherwise responsible
for the expense of special education and related services. One approach Congress has taken to
ease the burden on states and school districts of fulfilling these IDEA requirements is to allow
Medicaid to finance covered health services (e.g., physical, occupational and speech therapy, and
diagnostic, preventive and rehabilitation services) delivered to low-income, Medicaid-eligible
special education students.

Prior to 1988, Medicaid did not pay for coverable services that were listed in a child’s IEP/IFSP
since special education funds were available to pay for these services, and because generally
(with a few explicit exceptions), Medicaid is always the payer of last resort. Congress changed
the financing relationship between IDEA and Medicaid in the Medicare Catastrophic Coverage
Act of 1988 (P.L. 100-360). However, there is some controversy about the exact nature of this
legislative change. IDEA requires states to establish interagency agreements to ensure that IDEA-
eligible students receive the services to which they are entitled. These agreements must include
an identification of the financial responsibility of all relevant agencies. IDEA regulations further
stipulate that the financial responsibility of Medicaid and other public insurers must precede the
financial responsibility of the local education agency (LEA) or the state agency responsible for
developing the child’s IEP. In other words, Medicaid is deemed to be the first payer. In contrast,
according to officials with the Centers for Medicare and Medicaid Services (CMS)—the federal
agency that administers the Medicaid program—the 1988 law allows, but does not require, state ¹
Medicaid agencies to pay for services included in an IEP/IFSP. Thus, given CMS’ interpretation
of this law, the IDEA requirement that Medicaid be the first payer applies only to those states that
have elected to pay for services listed in IEPs/IFSPs. According to CMS, most states do pay for
these services.
Since 1988, other complicated issues surrounding the relationship between IDEA, schools and
Medicaid have arisen. While Congress made it clear that Medicaid funds can be used to pay for
reimbursable school-based services rendered to IDEA children enrolled in Medicaid, at various
points in time some Members have expressed concern that some of these Medicaid payments may
be made improperly. In 1999 and 2000, the Senate Finance Committee asked the U.S. General
Accounting Office (GAO; later renamed the Government Accountability Office) to examine ²
Medicaid school-based services and held two hearings on this subject. Three main concerns were
identified by GAO:
• Billing practices for school-based administrative services, coupled with uneven
oversight of these practices by the Health Care Financing Administration (HCFA;
now CMS), resulted in at least 2 of 17 states receiving improper payments.

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• “Bundled” billing methods for school-based services used by seven states failed
to account for variations in service needs among children and often lacked
adequate documentation demonstrating that the benefits paid for were actually ³
delivered in every case. However, both GAO and HCFA believed that bundled
rates, if proper assurances can be built into the approach, are the preferred
method for LEAs to bill Medicaid.
• In some states, school districts received little of the reimbursements claimed for
school-based services because state agencies and private contractors, hired by
schools to assist in billing Medicaid, retained significant portions of federal
payments. For example, seven states retained from 50% to 85% of total federal
reimbursements for both health services and administrative activities. Some
school districts paid private contractors contingency fees as high as 25% of
federal payments for school-based administrative activities. In the worse case
reported, schools received as little as $7.50 for every $100 claimed for services
and activities performed in support of Medicaid-eligible children.
In order for LEAs providing IDEA-related services to qualify for reimbursement under Medicaid,
four conditions must be met: (1) the child receiving the service must be enrolled in Medicaid, (2)
the service must be covered in the state Medicaid plan or authorized in federal Medicaid statute,
(3) the service must be listed in the child’s IEP, and (4) the LEA (or school district) must be
authorized by the state as a qualified Medicaid provider. To help schools obtain Medicaid
reimbursement for health care services, and also related administrative activities, HCFA and later
CMS issued two manuals, Medicaid and School Health: A Technical Assistance Guide (August
1997) and Medicaid School-Based Administrative Claiming Guide (May 2003). Prior to the
release of the 2003 guide, on two occasions, Congress urged the Administration to revise early ⁴
drafts. The 2003 guide represents a consolidation of existing requirements for administrative
claiming, and drew on the input from education community on the two earlier draft versions
released in 2000 and 2002. Some in the education field have questioned the usefulness of these ⁵
guides.

Nationwide, estimated Medicaid expenditures for school-based services were $2.7 billion in
FY2006 (see Table 1). Roughly $1.9 billion or 69% of total expenditures was for Medicaid
benefits provided in schools and about $849 million or 31% was for school-based
administration/training activities. There was wide variation in spending patterns across states with
respect to the proportion of expenditures for benefits versus administration and training. Among
the 45 states reporting any school-based spending, 14 had expenditures for benefits only. At the
other extreme, six states reported school-based spending for administration and training only.

³^Bu^nd^l^e^d^p^a^ymen^t^s^t^y^pⁱ^cal^l^y^meaⁿ^{s a f}ⁱ^xed^rat^eⁱ^s^p^aⁱ^d^f^o^{r a p}^{ackage o}^f^sp^eci^fⁱ^{c ser}^vⁱ^ces^mad^e^avai^l^a^b^l^{e t}^o^chi^l^d^ren
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^he^a^{lth s}^e^r^v^ic^e^s^pr^of^e^s^sⁱ^ona^{l f}^o^r^s^p^e^cⁱ^a^l^e^duc^a^{tion s}^t^ude^nts⁾^.”^Ed^uc^a^tion^Daily^,^Fe^br^ua^r^y^{6, 2}⁰⁰³^.

In the President’s FY2008 budget proposal, the Bush Administration noted that Medicaid claims
for services provided in school settings have been prone to abuse and overpayments, especially
with respect to transportation and administrative activities. As of November 2007, the HHS
Office of Inspector General (OIG) has published reviews of school-based claims in 22 states. ⁶
Based on this and other research, both the HHS OIG and GAO have reached similar conclusions.
For transportation services, examples of inappropriate Medicaid billing include (1) no verification
that transportation was in fact provided, (2) a Medicaid-covered school health service other than
transportation was not provided on the day that transportation was billed, and (3) child/family
plans did not include a recommendation for transportation services, or there was no IEP or IFSP.
School districts may perform administrative functions for Medicaid purposes, such as outreach,
eligibility intake, information and referrals, health service monitoring, and interagency
coordination. Examples of inappropriate Medicaid billing include (1) payments based on
inaccurate time studies used to allocate the cost of these administrative activities across funding
sources including Medicaid; (2) expenditures for school employees who do not perform Medicaid
administrative activities; (3) expenditures for operating costs such as nursing supplies, non-
Medicaid outreach supplies, and education-related expenditures; (4) expenditures for personnel
funded by other federal programs; and (5) payments for personnel who render only direct medical
services.
On December 28, 2007, the Bush Administration published a final rule⁷ regarding Medicaid
payments for school-based administration and transportation. First, the rule would restrict federal
payments for school-based administrative activities (e.g., outreach, service coordination,
referrals) that may be conducted on behalf of children dually eligible for Medicaid and IDEA, as
well as those eligible for Medicaid only. Second, the rule would restrict federal payments for
certain transportation services provided to children dually eligible for Medicaid and IDEA. This
rule supercedes prior guidance from CMS on these issues, and is estimated to reduce federal
Medicaid outlays by $635 million in FY2009 and by $3.6 billion over the period FY2009-
FY2013. The Congressional Budget Office (CBO) estimates that this final rule will reduce federal ⁸
Medicaid outlays by $4.2 billion over 5 years and by $10.2 billion over 10 years. A recent
congressional report indicates that this rule would result in the loss of roughly $3.2 billion over ⁹
the next five years in 34 states affected by the rule that could provide such estimates. CMS
indicated that school budgets for the 2007-2008 school year would not be affected by the rule.
According to CMS, federal Medicaid reimbursement would no longer be available for (1)
administrative activities performed by school employees or contractors, or anyone under the

⁶^S^ee,^f^o^{r exa}^m^p^l^e,^HHS^OIG^,^Re^vie^w^{of M}^e^dic^aⁱ^d^Tr^ans^p^o^r^t^a^tioⁿ^C^l^aim^s^M^ade^by^the^N^e^w^Y^o^r^k^Cⁱ^ty^D^e^par^tm^eⁿ^t^of
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^D^e^m^{and I}^m^pr^ov^e^m^eⁿ^ts^{in H}^C^F^A^O^v^e^r^sⁱ^ght^,^GA^O/HES^/^OS^I-0⁰^-⁶⁹^,^A^p^{ril 2}⁰⁰⁰^,^an^d^M^e^dic^a^id:^St^ate^s^’^Effor^t^s^t^o
^M^a^xⁱ^mⁱ^z^e^Fe^de^r^a^{l Re}^im^bur^s^e^m^eⁿ^t^s^Hⁱ^ghl^ig^{ht N}^e^e^d^f^o^r^I^m^pr^ov^e^d^F^e^de^r^a^{l O}^v^e^r^sⁱ^ght^{. T}^e^stim^on^y^by^Ka^thryⁿ^A^lleⁿ
^be^f^o^r^e^the^Se^na^te^Fi^na^nc^e^C^o^m^mⁱ^tte^e^,^J^une²⁸^,²⁰⁰⁵⁽^G^A^O^-^05-⁸³⁶^T⁾^.
⁷^“^M^e^d^ic^aⁱ^d^P^r^og^r^a^m^;^Eli^m^ina^tion^of^R^e^im^bur^s^e^m^e^{nt un}^de^r^Me^dic^a^{id f}^o^r^Sc^h^ool^A^d^mⁱ^nis^t^r^a^{tion Ex}^p^e^ndit^u^r^e^s^a^nd
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^Base^line^{, Fe}^br^ua^r^y^{29, 20}^08.
⁹^S^ee^The^A^d^mⁱ^nis^t^r^a^tio^n’^s^M^e^dic^a^id^Re^gul^ati^ons^:^St^ate^-^by^-^S^t^a^te^I^m^pac^ts^,^p^r^ep^ared^f^o^{r Ch}^ai^rm^an^Hen^r^y^W^a^x^m^an^b^y
^the^Ma^jori^ty^Sta^f^f^,^{U.S. House}^of^Re^pre^s^eⁿ^ta^tiv^e^s^{, Com}^m^itte^e^{on O}^v^e^r^sig^h^{t a}^{nd G}^o^v^e^rn^m^e^{nt Re}^f^o^r^m^{, Ma}^rc^{h 2}⁰⁰⁸^.

control of a public or private educational institution, because of inconsistent application of
Medicaid requirements by schools, or (2) transportation from home to school and back for
school-aged children with an IEP or IFSP, because such transportation does not meet the
definition of an optional medical transportation service, nor is it necessary for the proper and
efficient administration of the Medicaid state plan.
Many in the education and state Medicaid communities are opposed to these cuts.¹⁰ Opponents
argue that the rule (1) will reduce the availability of, and access to, needed health care for
children; (2) is inconsistent with decades of approved state plan amendments allowing federal
funding of these administrative and transportation services; and (3) falsely assumes that health
care administrative activities performed by school personnel are inconsistent with the proper and
efficient administration of the state Medicaid plan because such activities improve children’s
health, reduce inappropriate medical care utilization, and thus ultimately save money. Moreover,
additional federal funding for existing programs like IDEA or other new appropriations to offset
these Medicaid cuts are unlikely to be on the horizon.
While the final rule eliminates federal matching funds for certain school-based spending under
Medicaid, other types of school-based expenditures remain reimbursable. States may still claim
federal matching dollars when school-based administrative activities are conducted by employees
of the state or local Medicaid agency for which proper oversight and allocation of costs to
Medicaid is more reliable according to CMS. In addition, federal funding would still be available
for administrative overhead costs (e.g., patient follow-up, assessment, counseling, education,
parent consultations, and billing activities) that are integral to, or an extension of, a specified
direct medical service to the extent that those costs are represented in the rate paid for such
services and reimbursed at the applicable federal matching rate. Medicaid outreach and eligibility
intake, conducted by local or state Medicaid employees, would also remain reimbursable. CMS
would continue to reimburse states for the costs of school-based direct medical services under
IDEA that are covered in approved state Medicaid plans, and for transportation of school-age
children from school or home to a non-school-based direct medical service provider that
participates in Medicaid, or from the non-school-based provider to school or home. CMS would
also continue to reimburse states for transportation of children who are not yet school age from
home to another setting (including school) and back to receive a direct medical service, as long as
the visit does not include an educational component or activity unrelated to the direct medical
service.
P.L. 110-173 prohibited the Secretary of HHS from restricting coverage or payments for school-
based administration and transportation under Medicaid, relative to policies in place on July 1,
2007. This moratorium was effective until June 30, 2008. On June 19, the House passed an
amendment to the Senate-passed version of H.R. 2642 that would extend this moratorium to April

1, 2009. On June 26, the Senate passed this same bill. On June 30, this bill became P.L. 110-252.

(See CRS Report RS22849, Medicaid Financing, by April Grady, by April Grady, for more
information on this legislation). This moratorium would be further extended to July 1, 2009, via
the American Recovery and Reinvestment Bill of 2009 that was approved by the House Energy
and Commerce Committee on January 22, 2009.

¹⁰^S^ee,^f^o^{r exa}^m^p^l^e,^Joⁱⁿ^t^A^sso^ci^a^tⁱ^oⁿ^L^e^t^t^e^{r t}^o^S^ecret^a^r^{y Mi}^ch^a^e^l^O.^L^evi^t^t^{, f}^r^om^a^c^ons^or^tia^of^s^c^hoo^l^or^g^a^niz^a^tions^,
^A^u^g^u^s^t^23,²⁰^{07; T}^e^s^tim^ony^b^y^D^a^vⁱ^{d P}^a^r^r^e^lla^{, D}ⁱ^r^e^c^t^or^of^Me^dic^a^{l C}^a^r^e^A^d^mⁱ^nis^t^r^a^{tion, C}^oⁿⁿ^e^c^tic^{ut D}^e^pa^r^t^m^e^{nt of}
^Socⁱ^a^l^Se^r^v^ic^e^s^{, a}^{nd D}^e^nis^e^H^e^r^r^m^a^{nn, N}^a^tio^na^{l A}^s^s^o^cⁱ^a^{tion of}^Sc^hoo^{l N}^u^r^s^e^s^a^t^a^he^a^rⁱⁿ^g^he^ld^by^the^H^ous^e
^Com^m^itte^e^{on Ov}^e^r^sig^h^{t a}^{nd G}^ove^rnm^e^{nt Re}^f^o^r^m^eⁿ^title^d^T^h^e^Ad^mⁱ^nis^t^r^a^ti^on’^s^Re^gul^at^or^y^Ac^tio^ns^{on M}^e^dic^a^id:^The
^Effe^c^t^s^on^Patie^nts^,^D^o^c^t^or^s^,^H^o^s^p^itals^a^nd^Sta^t^e^s^{, N}^o^v^e^m^b^e^r^{1, 20}^07.

Table 1. Medicaid School-Based Expenditures by States for FY2006
^{(in tho}^{usands of doll}^ars)
^{Benefits Admin/Trainin}^g
^{State Total}^Dollars^{% of T}^otal^Dollars^{% of T}^otal
^{Alabama 5,97}⁴⁰^0.0^5,97⁴^100.⁰
^{Alaska 15,2}³⁵³⁸^0.2^15,1⁹⁷^99.8
^Arizona^91,1^{26 75,5}^{50 82.9}^15,5⁷⁶^17.1
^Arkansas^4,08^{1 3,13}^{6 76.8}⁹⁴⁵^23.2
^California^309,⁹³^{2 130,}⁴⁰^{7 42.1}^179,⁵²⁵^57.9
^Colorad^o^27,8^{83 27,8}^{83 100.}⁰⁰^0.0
^Connecticut^44,1^{57 33,5}^{85 76.1}^10,5⁷²^23.9
^Delaware^24,9^{50 24,9}^{50 100.}⁰⁰^0.0
^{District of Columbia}^26,4¹⁴^26,4¹⁴^100.⁰⁰^0.0
^{Florida 110,}⁷⁹⁷^16,0⁹¹^14.5^94,7⁰⁶^85.5
^Georgia^41,7^{60 10,1}^{31 24.3}^31,6²⁹^75.7
^Hawaii^{0 0 —}⁰^—
^Idaho^15,4^{68 15,4}^{68 100.}⁰⁰^0.0
^{Illinois 245,}³⁴⁶^82,5⁷²^33.7^162,⁷⁷⁴^66.3
^Indiana^2,69^{5 2,69}^{5 100.}⁰⁰^0.0
^Iowa^25,1^{90 24,8}^{83 98.8}³⁰⁷^1.2
^Kansas^65,8^{55 61,4}^{02 93.2}^4,45³^6.8
^{Kentucky 7,51}⁴⁸⁵⁰^11.3^6,66⁴^88.7
^Louisiana^{0 0 —}⁰^—
^Maine^15,7^{94 15,7}^{94 100.}⁰⁰^0.0
^Maryland^180,³²^{8 180,}³²^{8 100.}⁰⁰^0.0
^Massach^usetts^117,⁰³^{4 113,}⁵³^{5 97.0}^3,49⁹^3.0
^Michigan^{0 0 —}⁰^—
^Minnesota^54,9^{06 42,7}^{02 77.8}^12,2⁰⁴^22.2
^{Mississippi 3,40}⁸⁰^0.0^3,40⁸^100.⁰
^{Missouri 76,9}³⁴⁶⁸^0.1^76,8⁶⁶^99.9
^Montana^17,0^{36 14,9}^{66 87.8}^2,07⁰^12.2
^Nebras^{ka 67,9}⁹⁵^6,62⁶^9.7^61,3⁶⁹^90.3
^Nevada^1,38^{7 1,38}^{7 100.}⁰⁰^0.0
^New^Ham^pshire^35,7^{59 35,7}^{59 100.}⁰⁰^0.0
^New^Jers^ey^{0 0 —}⁰^—
^New^Me^xico^16,9^{21 13,0}^{02 76.8}^3,91⁹^23.2
^New^York^469,⁶⁵^{3 469,}⁶⁵^{3 100.}⁰⁰^0.0
^North^Carolina^37,3^{13 15,4}^{03 41.3}^21,9¹⁰^58.7

^{Benefits Admin/Trainin}^g
^{State Total}^Dollars^{% of T}^otal^Dollars^{% of T}^otal
^North^Dakota^1,54^{7 1,54}^{7 100.}⁰⁰^0.0
^Ohio^11,5^{32 11,5}^{32 100.}⁰⁰^0.0
^Oklahoma^5,78^{0 5,78}^{0 100.}⁰⁰^0.0
^{Oregon 23,9}³⁸^6,19⁰^25.9^17,7⁴⁸^74.1
^Pennsylvania^240,³²^{8 193,}³⁷^{8 80.5}^46,9⁵⁰^19.5
^{Rhode Island}^5,52⁶⁰^0.0^5,52⁶^100.⁰
^South^Carolina^56,1^{93 45,2}^{58 80.5}^10,9³⁵^19.5
^{South Dakota}^5,54³⁰^0.0^5,54³^100.⁰
^{Tennessee (see}^note)⁵⁰⁴⁽²¹⁶⁾^-42.9⁷²⁰^142.⁹
^{Texas 301}⁰^0.0³⁰¹^100.⁰
^Utah^16,4^{29 15,0}^{60 91.7}^1,36⁹^8.3
^Vermont^{0 0 —}⁰^—
^{Virginia 36,1}⁷⁸^3,90⁰^10.8^32,2⁷⁸^89.2
^Washington^34,3^{64 23,6}^{32 68.8}^10,7³²^31.2
^West^Virginia^52,4^{00 52,4}^{00 100.}⁰⁰^0.0
^Wisconsin^72,6^{97 69,4}^{80 95.6}^3,21⁷^4.4
^Wyoming^{0 0 —}⁰^—
^National^2,72^2,10^{5 1,87}^3,21^{9 68.8}^848,⁸⁸⁶^31.2
^Source:^{CMS, Form-64 I}^nformat^{ion Forms. As submitted q}^uarterl^{y by state}^{s on a volunta}^ry^{basis. States may}
^{forego completing Information F}^{orms if it delays reporting of ove}^{rall Medicaid expenditures. Data}^{may be}
^{incomplete for some q}^uarte^{rs an}^{d may contain amou}^{nts for}^prior^{periods. Unadjusted by CMS or}^{CRS. S}^ome
^{services can}^{be claimed as either}^{administrative expe}^{nses or as a}^b^{enefit (e.g., case management, tra}^{nsportation).}
^Note:^{In FY200}^{6, Tennessee}^had^{a negative adjustme}^{nt made to its spe}^{nding on be}^{nefits, th}^{us, all net school-}
^{based spe}^{nding was for administr}^{ation and training.}
^{Elicia J}^.^Her^z
^Specialis^{t i}ⁿ^Healt^h^C^a^{re Fi}ⁿ^aⁿ^c^ing
^eh^erz@^crs^.^l^o^c.g^o^v^,^7-¹³⁷⁷