Background

In 1975 the federal government enacted the Individuals with Disabilities Education Act (IDEA). Among other things, IDEA mandates a free appropriate public education for all children with disabilities, which means that schools must provide special needs children with health-related services necessary for their participation in a standard educational setting free of charge.

Each state has subsequently developed its own program to ensure compliance with IDEA. Some funding for IDEA comes from the federal government, but the balance comes directly from state and local taxes. Since its inception IDEA-mandated special education programs have become increasingly expensive to run, and recent cuts to state budgets place considerable financial pressure on school districts.

In order to manage shrinking budgets while maintaining compliance with IDEA and other state and federal regulations, districts are forced to find additional revenue streams. One such avenue is through Medicaid reimbursements. In most states, schools are able to claim Medicaid reimbursements for health-related special education services and associated administrative costs.

There are three Medicaid claiming programs available to school districts:

• Fee-for-Service (FFS) - This program allows districts to bill Medicaid for many health-related services provided to Medicaid-eligible special education students. FFS is also commonly known as direct service billing.
• School District Administrative Claiming (SDAC) - This program allows districts to bill Medicaid for a percentage of the cost of administering the special education program. Administrative activities include, for example, program management, organization, and outreach activities. SDAC is also commonly known as Medicaid Administrative Claiming (MAC).
• Cost Reconciliation - This program reimburses districts for the difference between the actual Medicaid allowable costs for providing health-related services and the amounts received from Fee For Service Claiming.

Maximizing Reimbursements

Currently millions of students in the United States receive school-based healthcare services that are partially reimbursed by Medicaid, and every year school districts receive more than $2 billion in Medicaid reimbursements for their FFS and SDAC claims. Many school districts, however, do not take full advantage of these programs and are consequently leaving hundreds of millions of dollars on the table nationwide. Even districts that do participate in Medicaid claiming are often not receiving their full shares of reimbursements.

A school district’s ability to maximize its FFS reimbursements depends heavily on the following factors:

1. The types of services authorized by the state for Medicaid reimbursements
2. The district’s diligence in ensuring that all Medicaid-eligible services authorized in a child’s Individualized Education Plan (IEP) are delivered and claimed
3. The district’s effectiveness and thoroughness in documenting services for reimbursement

A district’s ability to maximize SDAC reimbursements depends heavily on the following factors:

1. The number of eligible staff members who opt to participate in the SDAC program
2. The accuracy with which staff members complete the time study forms
3. The accuracy with which the district calculates its administrative cost pools

Accelify specializes in managing both Medicaid claiming programs. We have developed cutting-edge technology solutions designed specifically to handle school-based Medicaid claiming, and our team has extensive experience maximizing Medicaid reimbursements for school districts.