April 3, 2000 
Timothy M. Westmoreland
Director
Center for Medicaid and State Operations
Health Care Financing Administration
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Mr. Westmoreland:

The undersigned associations are pleased to have had the opportunity to collect and summarizing the views of the nation’s school boards and school districts as they relate to HCFA’s draft Medicaid-Based Administrative Claiming Guide.

Although our associations welcomed the opportunity to participate in the formulation of the Guide, the process used by HCFA in circulating the Guide for school district comments created an impression among most of our constituents that HCFA was going to implement the draft regardless of their comments. We do not believe that the nation’s schools will have confidence in the program or the process unless HCFA withdraws the current draft Guide and institutes a new process which is truly inclusive of all stakeholders in this program.

The concerns we have heard about the process of developing the guidelines include:

• comments were to be directed to us, Washington based professional groups, and not to the cognizant agency, HCFA. We really appreciate the opportunity to participate, but it is very likely that some schools did not participate because the process seemed unusual. The process of our consolidating comment also likely resulted in some important nuggets being lost.
  
• the initial three week comment period proposed by HCFA created the perception that HCFA was "rushing to judgement" on the Guide. Although a 30 day extension to the comment period was ultimately allowed, the perception again was that the extension was only granted by HCFA because numerous members of Congress insisted upon it. 
  
• the disallowance by HCFA of the Alabama Administrative Claim Program citing variances in Alabama’s program methodology, and the Guide. Use by HCFA of the Guide several days before it was issued in draft form and long before HCFA had considered any public comments, convinced most of our constituents that HCFA had already "made up its mind about the Guide" before any input from schools had as yet been received.
   
• the tone, relying on prohibitions, exclusions and seemingly contradictory messages rather than positive enabling examples, is very negative. The negative tone will cut health care to needy children, or eliminate growth of such services because it will school districts from participating in this important program. No dispassionate reader of the Guide could conclude that its intention was to be helpful or supportive in assisting schools and/or State Medicaid agencies implement this important program. Rather, the tone repeatedly warns schools of the potential financial hazards associated with attempting to participate in this program.
   
• the failure of HCFA to select any of the existing programs as positive models gives the impression that HCFA has concluded that none of the 47 states and none 10,000 participating school districts have good programs to claim reimbursements. The failure to see anything good in providing health care services to millions of needy children caused many of our constituents to conclude that HCFA was not attempting to provide better services to children through improved programs. Designating selected existing states and school districts as models would have facilitated and expedited the rapid and systematic transfer of this program between states. 

This may well be the worst case example we have ever seen of professionals from different disciplines talking past each other. The words chosen to describe educational programs in the draft guide are understood by educators as hostile or exhibiting a profound misunderstanding of the culture of public schools. We know we share the same goals because the Administration has pushed so hard to improve health care services to needy children in the school setting, but we certainly could not tell after reading the draft Guide.

In addition to these very significant concerns about the process HCFA followed in developing the draft Guide, we also have very fundamental differences in terms of our view of the appropriate objectives of the Administrative Out reach Program and our interpretation of the statutory authority for the program.

Attachment B to this letter presents numerous comments which we have received which question the statutory and/or legal basis for many of the HCFA’s interpretations as set forth in the Guide.

In addition, our associations commissioned an independent review of the draft Guide by one of the nation’s leading authorities on Medicaid. We believe the programmatic and technical views expressed in the next section of this letter and in Attachments A and B also dictate the withdrawal of the existing draft Guide and the reinstitution of a far more inclusive process for formulation of the Guide.

Under the Individuals with Disabilities Education Act (IDEA), school districts have a legal obligation to furnish services to children and adolescents who qualify under the Act. Several Supreme Court decisions have affirmed that this obligation includes related services that include health care. The children who qualify for Medicaid are usually at disproportionate risk of developing physical and mental disabilities that must be effectively treated in order to make education in the most appropriate setting feasible. Many of these treatments have to occur in or through the school setting.

Congress requires that states perform outreach to identify and refer children who are Medicaid eligible for appropriate services and Medicaid allows that this outreach responsibility can be delegated to the states. As the President and the Administration has constantly emphasized, schools are one of the best locations for identifying Medicaid-eligible children.

However, the Draft Guide, would dramatically undermine schools’ responsibility and ability to identify children with health risks and other special needs. As published these guidelines will dramatically reduce such services and children receiving less health care services. . This is the judgment of Sara Rosenbaum, one of the nations’ leading authorities on Medicaid, and Professor of Health Law and Policy at The George Washington University School of Public Health and Health Service. In her analysis of the guidelines she states: "…the guide as drafted can only be characterized as having as its principal goal the ending of Medicaid payment for the cost of health services furnished in schools." She further states that "Any person reading this guide would immediately pull the plug on efforts to bring Medicaid revenues to bear on school services." (Attachment A)

Our Associations, representing school boards and administrators support the development of a well reasoned set of guidelines that reflects congressional intent, administration policy and the underlying Medicaid law. Such a guide could provide useful information for state Medicaid and education agencies regarding the circumstances under which Federal Medicaid funds are available to assist in the administrative and medical costs with providing services to Medicaid enrolled children.

To develop a meaningful and useful set of guidelines we recommend that a Blue Ribbon Commission be appointed consisting of all stakeholders to determine the policies that will result in the highest possible number of needy children receiving health care services in the most effective and efficient manner possible. The schools and their representative associations stand ready and willing to work with HCFA in such a Blue Ribbon Commission. The goal for all should be to develop guidelines that allow this program to meet its full potential in helping children access necessary medical services, and in carrying out the President’s directive to use the schools a critical means of identifying and enrolling eligible children.

We believe that a good starting point for the Blue Ribbon Commission’s deliberations would be to identifying existing programs in the states to ensure that the final guidelines reflect the challenges and opportunities and are workable and implementable in school environments.

Sincerely,

American Association of School Administrators
National School Boards Association