2011 OSEP Leadership Mega Conference Collaboration to Achieve Success from Cradle to Career 2.0 Children with Special Healthcare Needs & Special Education: The Intersection of Health and Education From Individualized Health Plans…to Medicaid…to Health Care Reform! Presented by Diana Autin, R1 SPAN Carol Tobias, The Catalyst Center Brooke Lehmann, National Family Voices Parent Center “Job-Alike” Session Presentation #110-G

Our Hypothesis If a child with special healthcare needs (CSHCN) doesn’t have access to health care and needed health services at home and at school, then it doesn’t matter what academic strategies are being used to help them achieve. 2

Our Purpose Provide an overview of the intersection of health and education for CSHCN: Individualized Healthcare Plans Implications of potential Medicaid changes for related services Impact of federal healthcare reform on special education and CSHCN, including immigrant children Resources for parent centers 3

Who are CSHCN? CSHCN have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and also require health and related services of a type or amount far greater than required by children generally 10.2 million children 1 in 7 children (13.8%) 4

Individualized Health Plan (IHP) A formal written agreement developed with the interdisciplinary collaboration of the school staff in partnership with the student’s family, the student, and the student’s health care provider(s) 5

Why an IHP? Ensures that the school has needed information and authorization Addresses family, school, & health provider concerns Clarifies roles & responsibilities Establishes a basis for ongoing teamwork, communication, & evaluation 6

7 Basis for an IHP IDEA Sec. 504 ADA 14 th Amend. State nursing Practice acts Safety Inclusion Public health Common sense Equity State laws c. Walt Kelly

8 Benefits of IHP to Schools Protect individual and district liability of school boards & administrators Documents compliance with federal and state laws and regulations Data from IHPs about individual and aggregate needs facilitates planning for staffing, budgeting, professional development, policies, & cost-effective use of school and community resources

9 IHP needs to address: Collaboration!! Access to medication Staff & peers Environment Crisis & Emergency Medical Equipment Personal fitness goals Therapy

10 IHP needs to provide for: Opportunities for collaborative planning & problem- solving among staff & parents Coordination of physical, social, emotional, academic & physical fitness goals Academic & social continuity Safe participation in physical education, sports, field trips and other special events Staff training & peer sensitization Environmental controls (maintaining air quality, elimination of irritants, allergens, & toxic hazards) Timely & convenient access to medication at all times Individualized crisis & emergency management

11 Process for IHP Parent speaks with child’s health care provider(s) about school experiences and the potential threats to their health in the school environment Parent seeks information from child’s health care provider(s) about child’s specialized needs in the school environment Parent requests that child’s health care provider documents child’s needs and necessary supports in writing to share with school Parent requests meeting with school

12 IHP & IDEA If child is receiving special ed services: – Incorporate the information relating to the IHP into the IEP meeting – Request that the IHP services be included as part of the IEP – Ensure that the IHP section is shared with relevant staff & administrators – If child is not receiving special ed services: – Consider request for evaluation – Ensure health issues are included

13 Section 504 & IHP Section 504: – If child’s special health care needs significantly impact daily activities (learning, breathing, seeing, walking, etc.) in the school environment, request a Section 504 evaluation – Meet with the 504 team to share information on child’s special health care needs & develop a Section 504 plan that incorporates an IHP

14 IHP & Other Other: – If the child’s special health care needs do not require special education or a Section 504 plan, ask to meet with the appropriate school or district staff to discuss an IHP – Share the information from the child’s health care provider(s) – Identify key times of day, activities, places, etc. that require special attention

15 Contents of the IHP – Description of child’s special health care needs & how they are impacted by the school environment – Description of the specific services, supports, etc. that will be provided to child to address their special health care needs & responsible parties –Ongoing services as well as protocols for emergency situations or back-up plans for absences of responsible parties –Description of training/professional development needed and how and when it will be provided

16 Developing & Implementing the IHP – How and how often will the family be informed of status of implementation? – Starting date for implementation – Dates for periodic review of the IHP to ensure that it is being implemented and is effective – Sign, date, copy, disseminate to all parties – Meet with staff who have responsibilities to explain their roles & set up needed trainin

17 Provide follow-up Ensure that training is provided Ensure the IHP is being implemented Contact appropriate staff periodically to ensure plan is working Check with the child frequently Keep the child’s health care provider(s) informed Inform the school of any changes Update the IHP at least annually

18 Medicaid Reimbursement Federal/state cost-sharing benefit program for low- income individuals & people with disabilities (Title XIX of the Social Security Act) Each state submits a plan to CMS of US DHHS defining the services it will provide The state must provide at least ten core medical services including EPSDT Each state is assigned a reimbursement % ranging from 50% to 80% based on state’s poverty level In 1997, the Children’s Health Insurance Program, a reduced-cost health insurance program, was added to Medicaid

19 Medicaid Reimbursement Medicare Catastrophic Coverage Act of 1988 (PL ) allows school districts to receive Medicaid payment for health services delivered to Medicaid- eligible children with disabilities who need: Diagnostic, preventive, & rehabilitative services Speech, physical and occupational therapies; and Transportation for such services. School districts may also claim reimbursement for administrative costs of providing school-based Medicaid services (outreach for enrollment; coordination and/or monitoring of medical care.)

20 Medicaid Reimbursement 1997 Amendments to IDEA [612(a)(12)(A)(i)] & Regulations [CFR (a)(1)] provide that the financial responsibility of each non-educational public agency, "including the State Medicaid agency and other public insurers of children with disabilities, must precede the financial responsibility of the LEA (or the state agency responsible for developing the child's IEP)" Parents may not be required to "sign up for or enroll in public insurance programs in order for their child to receive FAPE (free appropriate public education)" [CFR § (e)(2)(i)].

21 Medicaid Reimbursement In certain circumstances, schools may request reimbursement from Medicaid for IHP services provided in school under 1903© of the Social Security Act if Medicaid rules are followed To meet the requirements for Medicaid funds, a child must have an Individualized Education Program (IEP) under Special Education law and also must be enrolled in the Medicaid Program. Coverage is based on medically necessary services already being provided in the school setting and the state you live in

22 Medicaid Reimbursement Evaluations and tests performed for assessments Occupational and Physical Therapy services Orientation and Mobility services Assistive technology Device services Speech, Language and hearing Therapy services Psychological, Counseling and Social work services Developmental testing services Nursing services Physician and Psychiatrist services Personal Care services Targeted Case Management services Specialized Transportation services.

23 Medicaid Reimbursement States vary in: What they allow to be reimbursed How reimbursement requests are made (who makes the reimbursement requests/bills Medicaid) How much of the funds received from Medicaid go to local districts (from 15%-100%)

24 Possible changes Congressional discussions are underway to: Significantly reduce funding for Medicaid Eliminate the requirement for Medicaid to cover all “medically necessary services” Eliminate the requirement for every state’s Medicaid program to cover the ten core services including “EPSDT” (Early Periodic Screening, Diagnosis & Treatment) for all eligible children Eliminate the “maintenance of effort” provision in ACA

Insurance Coverage of CSHCN 9% of CSHCN were uninsured at some point during the survey year, 3.6% were uninsured when the survey was conducted. 25

Adequacy of Coverage Co-payments Deductibles Benefit limits – Therapies – Medical equipment – Supplies – Mental health Annual or Lifetime benefit caps 26

What do CYSHCN need from health reform? Coverage that is: Universal and continuous Adequate Affordable The Patient Protection and Affordable Care Act of 2010 (ACA) 27

Ban on coverage denial for pre-existing conditions Effective 9/23/2010, Applies to most children under age 19 with certain restrictions 20,000 applications for children’s coverage were denied for pre- existing conditions in 2008 Most of the ifs, ands or buts about this provision will be eliminated by

Other provisions Dependent coverage for youth up to 26 No rescission of coverage regardless of the cost or amount of services used, as of 9/10 Guaranteed issue, effective 2014 Exchanges for small employers, families and individuals will offer insurance with the provisions above in 2014 “Maintenance of effort” for Medicaid and CHIP 29

Grandparents But….. Many privately insured individuals will be in grandfathered plans Grandfathered plans only lose this status if there is a substantial: – Increase in premiums or – Reduction in coverage “Substantial” – to be defined 30

Essential Benefits Effective Jan, 2014 plans offered through the Exchanges (and some outside plans) must provide Grandfathered and self-insured plans are exempt* * Approximately 80% of privately insured individuals receive coverage in plans that would be considered grandfathered or self-insured today. 31

Typical coverage gaps for CSHCN Habilitative therapies: physical, occupational, speech/language**** Prescription medications**** Durable medical equipment*?*? (devices) Consumable supplies: diapers, wipes, hearing aid batteries, disposable dressings Eye glasses, hearing aids**** Mental health services**** Dental care**** 32

Eliminating benefit caps Effective Now – no more lifetime benefit caps for existing or new plans – no annual benefit cap of less than $750,000 Effective Jan – no annual benefit cap at all BENEFITS can still be capped, e.g. 20 physical therapy visits, 15 mental health sessions. 33

Other improvements to adequacy Medicaid benefits, including EPSDT, will be available to children < 133% of FPL Health homes for specific chronic conditions Increase in Medicaid rates for primary care services to match the Medicare rate. 34

Components of affordability Scope of covered services Cost of insurance premiums Cost and number of co-payments Cost of coinsurance Amount of the deductible 35

Subsidies and Tax Credits Premium tax credits, on a sliding scale, for families with incomes up to 400% of the FPL. Cost-sharing subsidies for families up to 250% of the FPL Available when purchasing silver category of coverage in Exchanges 36

Figuring it Out Exchanges will provide calculators to help families figure out the cost of coverage. Will help to compare both the benefits and cost of coverage Exchanges also provide a website for comparing plan benefits and costs 37

Affordable or not? Most CSHCN receive coverage in grandfathered or self-insured plans Cost-sharing limits not applicable Lower income families still face high expenses unless really low income In spite of all the changes, the more you use services, the more you’ll pay 38

Summary: Pluses & Minuses There are several major improvements in universal and continuous coverage through ACA. Major gaps in coverage adequacy Affordability? Exclusions from coverage for undocumented immigrant children Undocumented immigrants will not be able to purchase insurance on the exchanges 39

Resources for Parent Centers Every state has a Family to Family Health Information Center that focuses on helping families of children with special needs access health care & health coverage National Family Voices The Catalyst Center 40

Resources for Parent Centers Health, Mental Health & Safety Guidelines for Schools m?guideNum= m?guideNum=4-20 Centers for Disease Control School Health Services Resources National Association of School Nurses 41

Questions? 42