Medicaid Reimbursement

Medicaid is a jointly funded Federal and State health insurance program for persons with low income and/or disabilities. School Based Medicaid Services allows reimbursement under the Medicaid program for services administered to students under the age of 21 with special needs under the Individuals with Disabilities Education Act (IDEA) and is administered through Eaton RESA.  Although partial reimbursement is available for students who are Medicaid eligible, services are provided to ALL students with disabilities regardless of their Medicaid eligibility status. 
School Based Services DO NOT affect the family's Medicaid insurance benefits and are at NO COST to the family.  Districts are required to notify the family of children who qualify for special education services and obtain consent prior to requesting reimbursement from Medicaid. The School Based Medicaid Services Program is designed to ensure that eligible children who receive special education services have access to needed health care.


School Based Services consist of two programs:

The Administrative Outreach Program offers partial reimbursement for the cost of administrative activities that support efforts to identify and enroll potentially eligible persons into Medicaid and that are in support of the state Medicaid plan.

The Cost-Based Reimbursement (Fee-for-Service) Program which offers partial reimbursement for direct medical services provided to special education students through the age of 21. Services that are eligible include:

  •  Assistive Technology
  •  Audiology
  •  Case Management
  •  Evaluations
  •  Nursing
  •  Occupational Therapy
  •  Orientation & Mobility
  •  Personal Care
  •  Physical Therapy
  •  Psychology
  •  School Social Work
  •  Specialized Transportation
  •  Speech & Language Therapy

Requirements for Reimbursement

To be covered by Medicaid, services provided must address a beneficiary’s medical need that affects his/her ability to learn in the classroom environment. The District may claim reimbursement for special education and related services specified in the IEP/IFSP if all of the following are achieved:

  • The student is eligible for Medicaid
  • The student aged birth through five has an IFSP, or the recipient over five has an IEP
  • The student is under the age of 21
  • Parental Notification has been provided to the parent/guardian
  • The District has a signed parental consent form on file
  • The services are medically necessary and covered under an existing Medicaid category
  • The required physician’s referral/authorization is on file
  • The service is provided by a qualified health care professional and the District has their signature on file
  • The scope, frequency, and duration of the service is documented
  • A Monthly Progress Summary for therapy services has been completed
  • Documentation of services requiring supervision of another provider is on file

The IEP/IFSP treatment plan must include the appropriate annual goals and short-term objectives, criteria, evaluation procedures, and schedules for determining whether the objectives are being achieved within an appropriate period of time (at least annually).

Services Not Covered

  • Academic instructional services provided directly to the student
  • Group therapy involving more than 8 students
  • Consultation or consultative services are an integral part or an extension of a direct medical service and are not separately reimbursable
  • Attendance of the Designated Case Manager at the initial IEP Team meeting (once the DCM is identified in the IEP, any further meetings are covered)
  • Services not related to the IEP
  • Notes/meetings without any explanation of the purpose or its connection to the IEP
  • IDEA assessments that do not result in implementation of an IEP/IFSP within one year
  • Vocational or work skills services
  • Report writing is included as part of an evaluation and is not separately reimbursable
  • Services considered observational or stand-by in nature, including “supervision” of medication administration or other medical services
  • First Aid       
  • Manifestations Reviews