RE: SBHC COVERED SERVICES
TO: MEDICAID MANAGED CARE SCHOOL BASED HEALTH CENTER (SBHC) PROVIDERS
RE: SBHC COVERED SERVICES
IMPACTED PLANS: MEDICAID & HIV SNP (also known as Partnership in Care)
Dear MetroPlusHealth Provider,
Effective April 1, 2025, onwards, per New York State (NYS) Medicaid guidance, MetroPlusHealth will cover services provided by School-Based Health Center (SBHC) limited to Medicaid and HIV Special Needs Plan (HIV SNP) students under the age of 21 years.
- Child Health Plus (CHP) is not a NYS Medicaid program therefore excluded from the benefit carve-in.
Scope of SBHC Benefit and Authorization Criteria
MetroPlusHealth will reimburse SBHCs for covered services that are provided under the SBHC’s certification and Article 28 license and in the Medicaid benefit package such as:
- Health check-ups and well-child visits
- Diagnosis and treatment of injuries and sickness
- Diagnosis and ongoing care of chronic health problems
- Family planning and reproductive health services
- Behavioral/Mental Health services
- Dental services such as oral exams, and fluoride treatments
During the two-year transition period, MetroPlusHealth may not require concurrent review authorization, or conduct retrospective utilization review, for SBHC services. Students will have direct access to a variety of primary medical, social, mental health, dental, and health education services without a PCP referral or prior authorization for In-Network providers, *except for certain SBHC-Dental services.
A child/adolescent member can be enrolled in an SBHC if he/she lives in the school district.
For example, a child/adolescent who is home schooled or who attends another school in the same district could use the SBHC if the SBHC has the capacity to serve them, and the principal/school administration have made arrangements for building access.
*MetroPlusHealth may choose to request prior authorization for dental services that require more extensive care including root canals, crowns, dentures, fixed partial dentures, impactions, surgical extractions, and orthodontic treatment. Please contact our dental vendor, Dentaquest at 888.308.2508 for information on what requires prior authorization and for instructions on how to obtain if needed.
SBHCs that do not offer behavioral health or family planning and reproductive health services on-site in the SBHC are required to provide referrals for those services to a provider who is in the MetroPlusHealth network. Prior authorization is not required for behavioral health or family planning and reproductive health services.
SBHC Responsibilities
- SBHC will share a roster of enrolled students with MetroPlus Health to identify members in need of a comprehensive physical exam or other services.
- SBHC will be required to provide member health record information to MetroPlusHealth, specifically for reports required by the Department of Health or for any Quality Assurance Reporting Requirements.
Confidentiality
- SBHCs must obtain all consents prior to provision of services.
- Providers must comply with the policy of Protection of Confidential Health Information for Minors in Medicaid.
- SBHC Providers must prevent unauthorized disclosure of the child’s Protected Health Information (PHI).
- SBHC providers must honor a member’s request to receive communications through different methods or at a different location if the member states that sharing their information could put them at risk. Example: a member might ask for phone communication instead of mail communication.
DOH Billing Criteria & Guidelines
Duplicative Claims: If the SBHC provider is billing twice for the same member on the same day, the claim would be considered duplicative and will be denied.
• All SBHC claims must have a valid primary diagnosis noted on the claim.
• For additional guidance and information, please visit NYS Mainstream Medicaid Managed Care and School Based Health Center Billing Guidance.
If you have any questions regarding this memo, please contact MetroPlusHealth at: ProviderRelationsOps@metroplus.org.
Thank you.
MetroPlusHealth