1. Name of School District CT SBCH Medicaid Reimbursement Program If you have questions about the CT Medicaid School Based Child Health Program contact the district staff listed below. Who are some of the Connecticut school districts participating in the program? Currently are over 100 towns participating in SBCH program in CT Director of Pupil Personnel Services/ Medicaid Coordinator Contact Name Contact Email Contact phone Name of District SBCH CT Medicaid Program Department of Social Services (DSS) CT SBCH program Kathy Blackwood kathleen.blackwood@ct.gov Help Us Help Them CT School-Based Child Health Medicaid Program (SBCH) AnsoniaNorwich BerlinPlymouth BranfordPortland BridgeportPreston ColchesterRegional District No. 1 CromwellRegional District No. 6 DanburyRegional District No. 7 DerbyRocky Hill East HamptonShelton East HavenSomers East LymeSouth Windsor EnfieldSterling GranbyThomaston GriswoldTolland GrotonTrumbull KillinglyVernon MiddletownWallingford MilfordWest Haven NaugatuckWilton New BritainWinchester New HartfordWindsor New HavenWindsor Locks New LondonWolcott

2. What is the Medicaid reimbursement Program? Is there a cost to me? What types of services for children does the program cover? Will it impact my family’s Medicaid benefits? The Medicaid Reimbursement Program assists school districts by providing partial reimbursement for medically-related services that are listed on a student’s Individualized Educational Program (IEP.) Although this partial reimbursement is available only for students who are eligible for Medicaid, services are provided to ALL students with disabilities regardless of their Medicaid eligibility status. Name of District has been successfully billing Medicaid for related services for eligible special education students for many years. In these times of reduced state funding for schools, all reimbursements are extremely important. NO – IEP/IFSP services are provided to students while they are at school at NO cost to the parent/guardian. The Medicaid Reimbursement Program does NOT impact a family’s Medicaid services, funds, or limits, and does not affect your family’s Medicaid benefits in any way. There is no impact on your child’s Medicaid eligibility to obtain medical services under HUSKY when your school district bills Medicaid for School Based Child Health eligible services provided to your child by an IEP.  Audiology  Respiratory services  Physical Therapy  Speech & Language  Occupational Therapy  Counseling  Nursing  Evaluations  Transportation  Other medically necessary services What will Medicaid reimbursements be used for? Your participation in this program will help Name of district Special Education students receive the support services they need. Reimbursement funds contribute to the hiring of additional paraprofessionals, purchasing instructional materials and providing other necessary support services. How can I help assure my school district receives benefits from the Medicaid reimbursement program? Federal regulations give you the choice to permit your child’s school district that is participating in the Medicaid School Based Child Health Program to bill for Medicaid eligible services included in your child’s IEP/IFSP. The school district must obtain your permission to bill Medicaid (HUSKY) for the services provided to your child at district expense. You can help by giving written consent which will allow the Name of district Special Education department to receive partial reimbursements from Medicaid for the support services your child is currently receiving. Participation is easy. Simply sign the attached consent form and return it to the Special Education department in the enclosed envelope. It’s that easy. Your child will receive the services written in your child’s IEP/IFSP at Name of District Public Schools expense regardless of your consent to allow us to bill Medicaid. You may revoke consent at any time.