School Health Services (SHS) Program
SHS Program Process
First, the school district or Board of Cooperative Educational Services (BOCES) must conduct a health needs assessment.
Many children in Colorado do not have health insurance or do not have enough health insurance to meet their needs. The district or BOCES must find out what health care services those children need.
Second, the district or BOCES must seek community input.
The district or BOCES must let the people in their community know that it plans to have a School Health Services Program. People from the local community are invited to help decide which health services will be delivered for the public school children.
Third, the district or BOCES writes a plan.
Using the information from the health assessment and from the local community, the district or BOCES writes a plan that describes the health services that the district wants to provide for its students. This document is called the Local Services Plan (LSP).
Fourth, the district or BOCES submits the LSP to the state for approval.
The LSP is sent to the Colorado Department of Education (CDE) and the Department of Health Care Policy & Financing (HCPF) (the Department). Both of these state departments are responsible for operating the School Health Services Program.
The LSP is reviewed to see that the plan follows the law that says all of the money that the district or BOCES receives must be spent for children's health care services. The review also looks to see how the community decisions were used to create the plan and to be sure that only new or expanded services are being provided with the School Health Services funds.
Fifth, the district or BOCES receives a contract to obtain the funds.
Some health services are already being delivered for children in public schools. And some of these services are for children on the Medicaid program. The Department of Health Care Policy & Financing (HCPF) is the agency in the state that operates the Medicaid program. When a district or BOCES has an approved Local Services Plan, the Department makes a contract to fund the LSP with dollars that are reimbursed to districts for the health services that they provide for Medicaid children.
Participating districts are reimbursed interim payments based on a monthly rate. The monthly rate shall be based on the districts actual, certified costs identified in their most recent filed annual cost report. For a new participating district, the monthly rate shall be calculated based on historical data. School Districts may use the interim reimbursement money to buy new or expanded health services identified in their Local Service Plan.
Interim payments shall be tied to claims submissions by the district. In order to obtain the reimbursed dollars for each service, the district submits a Medicaid insurance claim to the Department. The district must first obtain permission from the parent or guardian of the Medicaid child to bill Medicaid on behalf of the child. Then the claim can be submitted. The insurance claim shows that a service was delivered, who received the service, what the service was and how much it cost the district or BOCES to provide the service. The district or BOCES certifies that they paid for the service.
Claims shall be monitored by the Department and if claim volume decreases significantly or drops to zero in any two consecutive months while school is in session, interim payments shall be withheld until the issue has been resolved. The interim payment rate will be given to participating districts each year no later than 30 days prior to July 1 of that state fiscal year. The interim payment amount a district receives is equal to the federal share, not to exceed 100% of federal match rate. Interim payments are reconciled during the cost reporting process against each district's Medicaid allowable cost identified in the district's annual cost report.
Additionally, the district must participate in a random moment time study and cost reporting process. District staff that are Medicaid qualified to provide direct health services, targeted case management or Medicaid administrative activities may participate in the time study and those staff costs can be identified in the cost report. The cost report will determine the Medicaid allowable total costs a district should be reimbursed.
The total cost identified in the annual cost report for direct health services and target case management is reconciled against the interim reimbursement total the district or BOCES received from the claims they submitted. If the district or BOCES interim reimbursement total was less that the total cost identified on the cost report the district or BOCES will receive a payment for the difference. If the district or BOCES interim reimbursement total was more than the total cost identified on the cost report the district will be required to pay back the difference.
Sixth, reimbursed Medicaid dollars fund the health services identified in the LSP.
The reimbursed money is used to pay for the health services that the district or BOCES identified in their LSP. The health services provided through the LSP are the new or expanded services and cannot be claimed as a Medicaid service. The Medicaid service is only the service already being provided by the district or BOCES by a Medicaid qualified provider for a Medicaid enrolled child. Reimbursable services for the Medicaid enrolled child must also be prescribed in the child's Individualized Education Program (IEP) document. All of the reimbursed dollars that are received during the contract period are spent on services for children according to the LSP written with community input.