School-based health care services (SBHS)
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The SBHS program reimburses school districts for Medicaid covered health care related services provided to Medicaid eligible children requiring special education services consistent with section 1905(a) and section 1903(c) of the Social Security Act.
These services must be included in the student's current Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) and must be provided by a licensed health care provider.
Children with a disability (age 0 through age 20) who require special education services must be receiving Title XIX Medicaid under a categorically needy program (CNP) or medical needy program (MNP). Children enrolled in managed care receive SBHS on a fee-for-service basis.
Evaluations: When the child is determined to have a disability, and is in need of special education and health care related services that result in an IEP or IFSP.
Reevaluations: To determine whether a child continues to need special education and health care related services.
Direct health care related services which are included in a child’s IEP or IFSP, including:
- Audiology services
- Counseling services
- Nursing services
- Occupational therapy services
- Physical therapy services
- Psychological assessments
- Speech-language therapy services
School-based health care services must be delivered by health care providers who meet state licensure and certification requirements according to Washington State law (WAC 182-537-0350).
School districts can confirm provider qualifications on the Department of Health’s website. All providers must apply for a National Provider Identification (NPI) number through National Plan and Provider Enumeration System (NPPES). Providers must be enrolled as a servicing provider under the school district’s billing NPI number.
The SBHS program is an optional Medicaid match program with a 50/50 state/federal match funding structure. Reimbursements are based on fee-for-service established rates, and are facilitated via an Intergovernmental Transfer (IGT) process. School districts must sign an inter-agency agreement with HCA and a core provider agreement with the provider enrollment unit in order to participate. When a fully executed contract is in place, the district can begin submitting claims for Medicaid covered services.