Recommendations for Policy and Practice
Community Colleges
1. Create partnerships with state Medicaid agencies. Community colleges should actively reach out to and form a partnership with the appropriate liaison at their state Medicaid agency. As part of this partnership, the community college and the state Medicaid agency should do the following:
a. Review eligibility to participate. The community college and the state should conduct a review of the college’s health services program to determine the extent to which the community college meets the state’s criteria for participation in the Medicaid program. The community college should share with the state an overview of its health services program, including the services it provides, the qualifications and licenses of its providers, the types of facilities in which services are performed, the funding sources for the services offered, the breakdown of insured vs. uninsured students served (if known), the number of Medicaid-eligible students served (if known), and any other information pertinent to the eligibility review. The state should identify the services that are and are not eligible for reimbursement and offer advice on the steps the college can take to implement a Medicaid program and to optimize revenues from the program.
b. Analyze revenue potential. The community college should work with the state Medicaid agency to analyze the college’s services provided, cost of services, student Medicaid eligibility, and other pertinent data to conduct a preliminary analysis of the community college’s Medicaid reimbursement revenue potential.
c. Request technical support. The community college should request technical support from the state Medicaid agency and/or its affiliated technical assistance center for enrollment in, onboarding for, and ongoing administration of the community college’s Medicaid program. The request for technical support should include but not be limited to:
i. Assisting the college to develop and implement the systems necessary to actively and continuously identify Medicaid-eligible students.
ii. Assisting the college to develop and implement the systems and materials necessary to conduct outreach to Medicaid-eligible students to encourage and support them to enroll in Medicaid (and to re-enroll when required).
iii. Assisting the college to develop and implement a data system to track student Medicaid enrollment.
iv. Assisting the college to develop and implement the record-keeping, billing, and reporting systems required for the Medicaid program.
v. Providing training to college staff members on how to effectively and efficiently implement the Medicaid program.
2. Set targets and monitor program effectiveness. Following an analysis of Medicaid revenue potential and a review of student Medicaid eligibility, community colleges should set goals for the percentage of Medicaid-eligible students enrolled in the Medicaid program and for Medicaid reimbursement revenue generated (total Medicaid reimbursement revenue and/or Medicaid reimbursement revenue as a percentage of overall health services expenditures). College administrators should review Medicaid enrollment and reimbursement performance on a quarterly basis and make programmatic adjustments as necessary to meet the established targets.
State Medicaid Agencies
3) Explicit recognition of IHEs: State Medicaid agencies should explicitly recognize institutions of higher education (IHEs) in the regulatory frameworks and administrative procedures governing Medicaid in their states. Currently, most state Medicaid agencies explicitly recognize an array of organizational types in their frameworks and procedures, including K-12 schools, clinics, hospitals, free-standing birthing centers, laboratories, and nursing facilities. However, IHEs are not currently accounted for or considered in state or federal regulations when it comes to Medicaid participation. By producing and publicizing an efficient set of guidelines, requirements, and reimbursement rates explicitly designed for IHEs, states can significantly reduce the complexity for community colleges and other IHEs to navigate the Medicaid process, while simultaneously raising awareness of IHEs’ ability to engage with Medicaid.
4) Include IHEs as LEAs for administrative activities, but maintain distinctions for direct services: Following the lead of California, state Medicaid agencies in states that allow local education agencies to claim reimbursement for Medicaid administrative activities should also allow IHEs to claim reimbursement for Medicaid administrative activities. In California, the inclusion of IHEs in the school-based Medicaid administrative activities claiming program made it possible for 29 colleges to realize over $1 million in revenue to support the proper and efficient administration of health services to their Medicaid-eligible students.
However, state Medicaid agencies must be cognizant of the differences between the conditions through which K-12 schools and community colleges offer health services and the different kinds of services they offer when establishing guidelines for IHEs to claim reimbursement for direct services. While California’s inclusion of IHEs in the school-based administrative activities claiming program has made community colleges eligible for a significant source of funding, the state’s application to IHEs of restrictions on service reimbursement eligibility that are more appropriately reserved to the K-12 setting has effectively eliminated a separate source of funding for IHEs.
Because community colleges are more likely to offer one-off or time-limited services that are not part of pre-established plan of care, and because many community college students are over the age of 22, state Medicaid-agencies should take care not to apply restrictions on community college service reimbursement eligibility that are more appropriate or relevant to the K-12 environment. Instead, state guidelines for Medicaid participation for IHEs should allow community colleges to claim Medicaid reimbursement for direct services in a fee-for-service model similar to that of a community clinic.
5) Outreach to and partnership with community colleges: State Medicaid agencies should make proactive outreach to community colleges to encourage them to participate in the Medicaid program. Mirroring the activities proposed in recommendation one above, the state Medicaid agency should engage with the state’s community colleges to review each college’s eligibility to participate in the Medicaid program, to conduct an analysis of Medicaid reimbursement revenue potential, and to offer technical support to launch and maintain a Medicaid program.
6) Track and publish data: State Medicaid agencies should track and publish on Medicaid participation by the state’s community colleges. Important data elements that should be included are: the list of participating colleges, the number of Medicaid enrolled students at each participating college, the amount of direct services and administrative activities reimbursement received by each college, the types of services offered by each college, and the unique number of students receiving each of the types of services offered by each college.
7) Communities of practice: State Medicaid agencies – either directly or through their affiliated technical assistance center – should convene communities of practice of community colleges participating in Medicaid. These communities of practice should bring together administrators from the state’s participating community colleges for collective learning, problem solving, and networking regarding effective implementation of the Medicaid program at their respective colleges. They should also serve as a forum for state officials to receive feedback from practitioners about how to continuously improve and streamline program administration and implementation in the future.
8) Removal of batteries to enrollment: State Medicaid agencies should review their provider enrollment policies to ensure that the following do not present barriers to entry for community colleges interested in enrolling as Medicaid providers:
Staffing requirements – States with Medicaid provider enrollment policies that require providers to be affiliated with a doctor, to employ a minimum number of various types of health professionals, or to meet other minimum staffing requirements should carve out exemptions from this policy for IHEs. Doing so would put IHEs on similar footing with K-12 public schools which are eligible to enroll in Medicaid despite not meeting these types of staffing requirements.
Service requirements – States with Medicaid provider enrollment policies that require providers to provide a “comprehensive set of services” should carve out exemptions from this policy for IHEs. Allowing this exemption would enable those colleges who provide a targeted set of services, such as mental and behavioral health or nursing services, to be able to enroll in Medicaid.
Provider types – States should review their lists of Medicaid provider types and the requirements for each type of provider to make sure that there are options under which the state’s community colleges can enroll. Ideally, the state Medicaid agency would create a specific provider type for IHEs, with enrollment requirements specifically designed to enable participation for IHEs given the current set of services they provide.
Limitations on the Ability to Claim Direct Services – States should review any requirements that limit the ability of providers to claim reimbursement for eligible services provided on an acute or one-off basis. Whereas K-12 schools often provide services in accordance with an ongoing plan of care established through students’ individualized education programs (IEPs), community colleges are much more likely to provide as-needed care to their students. As such, states should carve out exemptions for IHEs for any such ongoing care plan requirements.
The level of difficulty to enact the changes listed here may vary by state. Depending on the state, changes may be needed to state law, changes may be needed to state rules and regulations, amendments may be needed to the state Medicaid plan, or changes may be needed to state Medicaid agency policies. Additionally, some changes may have a budgetary impact that the state should carefully examine and plan for as it enacts the recommendations.
CMS (Center for Medicare and Medicaid Services)
9) Convene state and college leaders: The Center for Medicare and Medicaid Services (CMS) should convene state Medicaid agency leads, state higher education executive officers, and higher education health officers to review Medicaid policies as they apply to community colleges and other IHEs. The National Association of Medicaid Directors (NAMD), the State Higher Education Executive Officers Association (SHEEO), and the American College Health Association (ACHA) are the professional organizations representing each of these groups, and they could each likely play a supporting role in recruiting the appropriate people to convene and in endorsing and amplifying the recommendations that emerge from the convening.
10) Raise awareness and promote participation: CMS recently issued a memo encouraging greater participation in Medicaid by K-12 schools and announcing new guidelines to streamline implementation of the school-based Medicaid program. CMS should issue a similar memo and set of guidelines that promotes participation in Medicaid by community colleges and other IHEs. The materials should also encourage state Medicaid agencies to promote IHE Medicaid participation within their state. Furthermore, the materials should inform states of how they can create effective and streamlined rules, regulations, processes, and support systems that encourage community colleges and other IHEs to participate in the Medicaid program.
11) Technical Assistance: CMS should offer technical assistance – either directly or through grants to Medicaid technical assistance centers across the country – to state Medicaid agencies seeking to establish regulations, systems, and processes to promote Medicaid participation by community colleges, and to community colleges seeking to launch Medicaid programs.
For the technical assistance to state Medicaid agencies, the topics should includes areas such as a review of federal laws and regulations governing Medicaid participation by IHEs; considerations and recommendations for establishing rules, regulations and processes for Medicaid administrative activities claiming by IHEs; considerations and recommendations for establishing rules, regulations and processes for Medicaid direct services claiming by IHES; implications for the Medicaid state plan; and, a checklist for launching an effective IHE Medicaid program.
For technical assistance to community colleges seeking to launch Medicaid programs, CMS should work with the state Medicaid agency and/or provide funding to the state Medicaid agency or the appropriate technical assistance center to implement the supports previously outlined in recommendation 1C.
Law and Policy Makers
12) Data requests and hearings: Federal congressional committees with oversight over Medicaid – notably the Senate Finance committee and its subcommittee on Health Care and the House Energy and Commerce Committee and its subcommittee on Health – should request data from the Center for Medicare and Medicaid services regarding the participation of community colleges in the Medicaid program. The committees and/or subcommittees should hold annual hearings on the extent to which community colleges offering health services are being reimbursed for eligible services, and should inquire with CMS regarding the steps the agency is taking to encourage and support increased Medicaid engagement by community colleges.
In a similar manner, state legislative committees should request data and hold hearings regarding the participation of their state’s community colleges in Medicaid, and actions taken by the state Medicaid agency to promote increased participation.
13) Review of legal and regulatory obstacles: Both federal and state legislative committees should request that their staffs and/or their official Medicaid agencies conduct a review of existing laws and regulations related to Medicaid that may interfere with community colleges’ ability to fully and optimally claim reimbursement for the eligible medical services that they offer. Based on the results of this review, lawmakers should introduce appropriate legislation to improve the ability of community colleges to fully and optimally claim reimbursements from Medicaid.
14) Executive branch advocacy: Lawmakers should engage in advocacy with the leadership at the Department of Health and Human Services and with CMS, with their state’s governor’s office, and with the leadership of their state’s Medicaid agency to promote participation of community colleges in Medicaid. This advocacy should include a request that Medicaid agency leadership review existing regulatory obstacles to the optimal participation of community colleges in the program and take steps to remove any identified barriers to participation.
15) Appropriations for implementation and technical assistance: State lawmakers should introduce appropriations into their state’s budget that provide funding for community colleges to hire or contract the staff necessary – and to procure the systems and materials necessary – for the colleges to develop and implement the systems and processes needed to bill Medicaid for eligible services.
Advocates
16) Elevate the importance of healthcare access: If they are not already doing so, advocates who are passionate about holistically addressing the challenges faced by community college students should include and elevate access to affordable healthcare as part of their advocacy platform.
17) Champion Medicaid participation with college administrators: Student success advocates who have the ability to gain an audience with college administrators – or the people who influence college administrators – should work with community college administrators to encourage colleges to begin engaging with Medicaid if they have not already done so.
18) Executive and legislative branch advocacy: Community college student success advocates should contact their elected representatives and appointed officials from the executive and legislative branches and encourage them to take the actions listed in the preceding section.