Community Driven School Health Planning Challenges and Outcomes in Colorado’s School-Based Medicaid Claiming Program

MESH Program Creation 1997 – Colorado Legislation CRS 26-4-531 Medicaid revenue would be used to expand preventive and primary health care services for public school children.

MESH Program Structure Claiming (HCPF) Bill Medicaid for medical services that are delivered to Medicaid clients in school setting Local Services Plans (CDE) Community-driven plan for delivery of health services to general student population Generalized health services are funded by Medicaid reimbursement dollars Second part is unique to Colorado HCPF = Health Care Policy and Finance CDE = Colorado Department of Education

Challenges Compliance with regulations Revenue Generation vs. Revenue Spending Lack of understanding Lack of direction from CDE

MESH Funding Flow Regulating Authority CMS (Federal $) State (HCPF) Federal Grant Contract Federal Law Medicaid Rules Federal Medicaid Law State Purchasing Contract State Purchasing Law Regulating Authority Program is administered through HCPF, not through CDE – it is not an education program CMS is billed for services delivered to the client. This is subject to Medicaid rules and regulations. CMS returns the Federal share of that service cost to the State in accordance with the State’s Medicaid Plan Service to Medicaid Client (District $) LSP Services to all students (District $)

Layers of Regulation Federal Medicaid Law CMS Guidelines State Plan (CMS Contract) State Purchasing Law State Statute Authorizing Program Department Rules Program Guidelines These all create challenges to the implementation of the program. Conflicting intent of Federal and State statutes.

Conflicting Intents Federal Law State Law To allow districts to recover some costs associated with unfunded IDEA mandates State Law No supplanting clause precludes districts from spending reimbursement funds on mandated services

Revenue Stream Revenue generation – Federal level requirements (State Plan) Revenue Spending – State level requirements

Spending Requirements No supplanting - No spending on mandated services Local Services Plans - Community driven health planning

Navigating the Complexities Contradictory Requirements Conflicting Systems Coordination Between Departments Lack of Definition Delay of CMS Guidelines - audit exceptions interpreted as policy change Medical vs. Health Service Lack of Definition = district administration not understanding - job duties not adequately identified (contract, fiduciary, legal, medical knowledge) - responsibility level not understood

MESH Planning Steps (LSP) Health Needs Assessment/Targeted Assessment Gather Community Input Organize Data Make Decisions (prioritize needs) Develop Program Plan Gather information to assess the health needs of your community – notebook has some material to get you started From community members with expertise or special information (health related) From statistics, available health and demographic data – certain health problems associated with different cultural groups and settings From other community members you feel would add to information Uninsured/underinsured as special target population Community Input is mandatory in decision-making process – Informed Participation Present participants with results of Needs Assessment Inform them of amount of reimbursement Inform them of their role in the process – what you want their input for Offer to send them the results of the process – final priorities Organize the information from different sources – categorize, generate statistics – Ranking methodology Prioritize health needs – determine process beforehand WHO? WHEN? HOW? Write your goals based on the list of priorities you identified, write objectives based on these goals

Community Involvement Community Based Organization Community Center Board Community Members Group Home and Foster Care Health Care Providers Homeless Liaisons Law Enforcement Local Government Mental Health Providers Migrant Programs Parents Probation and Parole Officers Public Health Public Housing Programs Refugee Programs Religious Organizations School Based Clinics School Board School District Staff School-to Work Programs Social Services, Students Special Education Staff/ Providers Teachers Teen Parenting Programs Transition Programs Treatment Programs

Competing Priorities

MESH 2000-2001 Health Service Expenditures Health Service Category # of Districts Total Expenditure % 0f Total Expenditure Assistance/Emergency Funds 6 $ 30,954.60 0.84% Assistive Technology 10 $ 86,496.58 2.34% Audiology 4 $ 34,527.84 0.93% Case Management $ 166,563.56 4.51% Dental Services 1 $ 198.00 0.01% Health Assistant/Clinic Aide $ 288,207.89 7.80% Health Education 3 $ 24,843.51 0.67% Health Tech 17 $ 450,618.00 12.19% Insurance Outreach - CHP+ & Medicaid 5 $ 178,783.15 4.84% Materials/Equipment/Supplies 32 $ 301,682.00 8.16% Mental Health 26 $ 568,321.30 15.38% Motor Therapy 2 $ 42,040.41 1.14% Nursing Services 40 $ 884,673.16 23.94% Nutrition $ 5,045.36 0.14% Occupational Therapy 8 $ 143,652.58 3.89% Occupational/Physical Therapy[1] $ 12,030.00 0.33% Orientation & Mobility $ 6,056.25 0.16% Parent/Family Services $ 7,685.00 0.21% Physical Therapy $ 58,584.30 1.59% Professional Development 11 $ 79,622.72 2.15% Speech Language 15 $ 252,996.30 6.85% Transportation $ 42,123.00 Vision $ 29,606.40 0.80% Nursing services is [1] Some districts did not report Occupational and Physical Therapy as separate categories.

MESH 2000-2001 Expenditures by Service Type Types of Service MESH 2000-2001 Expenditures by Service Type Service Type Expenditure Direct Services $2,938,076 Audiology, Case Management, Dental Services, Health Assistant/Clinic Aide, Health Tech, Mental Health, Motor Therapy, Nursing Services, Occupational Therapy, Orientation & Mobility, Physical Therapy, Speech Language, Vision Other Services $677,614 Assistance/Emergency Funds, Assistive Technology, Health Education, Insurance Outreach, Materials/Equipment/Supplies, Nutrition, Parent/Family Services Indirect Services $79,623 Professional Development

Contact Information Barbara Ramsey Colorado Department of Health Care Policy and Finance 1570 Grant St Denver, Co 80203 303-866-2430 barbara.ramsey@state.co.us Michelle Farrell Colorado Department of Education 201 E Colfax Ave Denver, CO 80203 303-866-6978 farrell_m@cde.state.co.us