Public schools may receive Medicaid funds for some health services provided to students at school. The services must be medically necessary and the student must be enrolled in N.C. Medicaid. In North Carolina, the following services may be reimbursed in schools:

Audiology
Nursing services
Occupational therapy
Physical therapy
Psychological/counseling services
Speech-language pathology services

UPDATES/INFORMATION FROM DHB/DPI:

Medicaid Expansion:

With Medicaid expanded enrollment beginning December 1, 2023, school personnel are in a critical position to identify and support parents and children who can benefit from Medicaid coverage. Healthy children need healthy parents in order to thrive and do well in school and beyond. Follow this link to the DHHS toolkit on Medicaid expansion and resources.

Medicaid Provider Re-certification Information:

PSUs are required to complete a recertification process for the Division of Health Benefits (DHS) this year. The application requires "documentation showing approval to enroll as a LEA from a local school administrative unit" which created most of the difficulty. While we have not been able to ascertain fro DHB what documentation meets this requirement, we have learned some combination of the following has been accepted for PSUs that have successfully recertified:

This screenshot of your PSUs instance of PowerSchool:
A screenshot of your PSUs profile in EDDIE.
This LEA list with your PSU highlighted.

UPDATES/INFORMATION FROM CMS:

Centers for Medicare and Medicaid Services (CMS) School-based Services Technical Assistance Center
2023 Delivering Services in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative Claiming from the Centers for Medicare and Medicaid Services (CMS)

IDEA Parental Consent Final Regulations (sample notice and consent form to follow)

Contact:

Lauren Holahan, Coordinator for Medicaid
Lauren.Holahan@dpi.nc.gov
984.236.2564

Laurie Ray, Medicaid Consultant
Laurie.Ray@dpi.nc.gov
919.636.1827

EPSDT Policy Instructions
On August 17, 2007, the Division posted the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Policy Instructions Update. These instructions became effective September 01, 2007, and clarify the Division’s initial EPSDT Policy Instructions issued January 28, 2005. Please review the instructions carefully. Providers and case managers should communicate the information contained in the instructions to recipients under 21 years of age and/or their representatives. Children who have previously been denied or terminated from services may be eligible for additional Medicaid services if the services are medically necessary and if a request for services is made in accordance with Medicaid’s policies and procedures. The EPSDT Policy Instructions Update is located on the following website: https://medicaid.ncdhhs.gov/providers/clinical-coverage-policies/epsdt-policy-description.

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Resources

Medicaid Policy and Resources

Medicaid Policy for LEA based services Scroll down to Specialized Therapies, then click 10C, Local Education Agencies (LEAs)
NC DHHS Division of Health Benefits [Medicaid] Bulletins
LEA Fee Schedule
Medicaid in Education On-Demand Course
- These on-demand modules provide background on why public schools recover costs for health services from Medicaid, the three programs available for Public School Unit (PSU) participation, how each program works, helpful practices and considerations for all who participate (and much more...). This course includes 4 modules; and will provide .3 CEUs (3 hours).
- Trouble accessing the on-demand course through NCEES? Please complete this request form for alternate access.
Sign up for the Medicaid List Serv
Medicaid Tools

Information for Parents and Families

Medicaid and Families: Get the Facts
Introduction to Medicaid in Schools (on-demand course)

Guidance Documents

FERPA

Annual Notice and One-time Consent for FERPA
Medicaid and Families: Get the Facts
2019 HIPAA FERPA Joint Guidance 508

Documentation

DHB Contacts

Roseann Sparano, LEA Policy 10-C
Jim Flowers, Annual Cost Report
John Mathewson, Random Moment Time Study

Cost Report

Medicaid Administrative Claiming (MAC) and Random Moment Time Study (RMTS)

Nursing

School Nursing Support: Medicaid Reimbursement for School Nursing Resource

Psychological and Counseling Services

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EPSDT Program

Medicaid covers a broad array of health and dental services for recipients under age 21. Early Periodic Screening, Diagnostic and Treatment (EPSDT) is known in North Carolina as Health Check and is defined by federal law. EPSDT/Health Check are important because it:

Provides early and regular medical and dental screenings for all Medicaid recipients under age 21.
Is a part of the federal Medicaid EPSDT requirement that provides recipients with medically necessary health care to correct or ameliorate a defect, physical or mental illness or a condition identified through a screening examination.

EPSDT/Health Check includes periodic screening, vision, dental and hearing services. In addition, section 1905(a) of the Social Security Act requires that any medically necessary health care service listed in section 1905(a) be provided to a Medicaid recipient under age 21 even if the service is not available under the State’s Medicaid plan. EPSDT may also cover some services that are not covered for recipients aged 21 and older. Health Check examinations and other Medicaid covered services are free of charge to the recipient.

All requests for services must be made in conjunction with the recipient’s physician or other licensed clinician and in accordance with the Division of Medical Assistance’s published procedures. If approval of a request is denied or services are reduced or terminated, the recipient or his/her representative will receive written notification. Additionally, the notice will contain information about how the decision may be appealed.

For additional information about Health Check and EPSDT, visit the address below:
https://medicaid.ncdhhs.gov/programs-and-services/medical/wellness-visits-and-diagnostic-and-treatment-services.