Life’s Silver Linings, Inc.

he machineÂ? which would eventually restructure schools to reach students for contraceptionÂ? and population controlÂ? has been in the making for decades.Â? A 1976 news release from the Family Planning Council, Inc. of St. Louis states:

“A call for the schools to join with health agencies in providing teenagers with birth control� services was made today by (N,) Deputy Assistant Health Commissioner, and Project Director of the City’s Family Planning Project.

“(N) was one of three noted panelists presenting their prescriptions for the problem of teenage pregnancy, to the National Alliance Concerned With School Age Parents–which convened in Dallas, Texas,Â? today.

“The concept of dispensing contraceptives� through the schools makes a lot of sense,’ (N) said.� ‘We at health agencies have contraceptive supplies and expertise, but we don’t have direct access to the teens who need them.� Public schools have access to the teens but not to the supplies and medical services.

It is difficult to obtain consistent responses from government officials on the issue of family planningÂ? services and referralsÂ? relative to schools who provide Medicaid Administrative Case Management.Â? It seems they say one thing and then say the opposite in the next breath.

Questions were asked of state and federal officials on this topic.

The following correspondence was with the U.S. Department of Health & Human Services’ Region VII� office in Kansas� City, Missouri:

Question asked on July 19, 1995:

“–I received a chart from the U.S. Department of Health & Human ServicesÂ? titled Medicaid Services State by State.Â? It listed ten basic required Medicaid Services and states ‘Medicaid recipients receiving federally-supported financial assistance must receive at least these services.’

“It is my understanding that:

1. The state must financially cover these ten services
provided to those who are Medicaid eligible.

2. Medicaid providers may provide only those services
they choose to provide.

3. Medicaid providers must provide referralsÂ? for those
services they choose not to provide.

“If a school district chooses to become a Medicaid� provider, is it obligated to refer for those services it chooses not to provide?”

Answer dated July 25, 1995:

“You are essentially correct in your understanding of the services and providers.� Individual state programs may impact on the providers and referrals� for services not provided.� A school district provides services as outlined between the school district and the state agency through contractual agreements.� Further information regarding school-based services provided under the Medicaid program can be obtained from the Missouri State Medicaid Agency at:

Division of Medical Services

Department of Social Services

615 Howerton Court (65109)

P.O. Box 6500

Jefferson City, Missouri 65102”

Question asked on August 24, 1995:� “Among the ten basic required Medicaid services to be provided is family planning� services and supplies.

“Is it necessary for a school district which enters into a Medicaid Interagency Agreement� with the Missouri Department of Social Services� to provide required Medicaid services (or referrals� for Medicaid services they choose not to provide), in order that the State Plan be properly and efficiently administered?”

Answer dated September 1, 1995:� “The answer to your question concerning school district agreements with the Missouri Department of Social Services� is yes.

“Enclosed are copies of that portion of Missouri’s State Medicaid Plan� which describes services available to children under the category of Early and Periodic Screening, Diagnosis, and Treatment.”� (The document that was enclosed listed “case management” as a service available under the category of Early and Periodic Screening, Diagnosis, and Treatment Services).

Questions asked on September 20, 1995 were responded to in comment form on October 12, 1995:

“–Regarding school districts which enter into a Medicaid Interagency AgreementÂ? with the Missouri Division of Social ServicesÂ? to provide case managementÂ? services:

“1. Is Case Management considered a Medicaid� service?”

COMMENT: Under the agreements, case managementÂ? is an administrative service, not a medical service such as physician, hospital, or radiology.Â? This can be confusing because case management can be provided either as a medical service or an administrative service.Â? States usually treat case management as an administrative service because it is easier to keep records and does not require individual billing that a medical service does.Â? Individual billing requires a separate bill for each service identifying the recipient by name and number, date of service, unit of service, and type of service.Â? Under administrative services, only the overall costs are documented.

“2. Is a school district which receives Medicaid reimbursement for providing case management services through the Medicaid Interagency Agreement� with the Missouri Division of Social Services� considered a Medicaid provider?

COMMENT: Generally speaking, the school district is another government unit providing administrative services under the agreement.Â? They are not a Medicaid provider, like a hospital, physician, laboratory, or home health agency.

“In some instances where the school district employs physical therapists, speech therapists, or other medical professionals, they may serve as a Medicaid provider that provides individual professional services and bills the program for specific services provided to specific individuals.

“3. It is my understanding that Medicaid providers are to provide, at least, the ten basic required Medicaid services one of which is ‘family planning� services and supplies’ or referrals� for those services they choose not to provide.� Does this also apply to schools/districts who have entered into a Medicaid Interagency Agreement� to provide Case Management?”

COMMENT:� The statement regarding individual providers being required to provide ten basic services is incorrect.� It is the state that is required to provide certain basic ‘mandatory’ services if the State chooses to join the Medicaid program.� As indicated above, most schools provide administrative services and some may bill for individual professional services provided to individual recipients.

“As you may know, in the St. Louis metropolitan area, Missouri is initiating the Medicaid managed care� program, called MC+.� � Each of the seven managed care providers have agreed to provide most of the services covered under the Missouri Medicaid� program.� This list of required services applies only to the managed care� providers.� It does not apply to schools.”

The following questions were asked of the Missouri Department of Social Services, Division of Medical ServicesÂ? in a letter dated July 14, 1995.Â? The response was dated August 17, 1995:

Q #1:Â? “Page 4 of the Medicaid Interagency AgreementÂ? lists ‘comprehensive health’ as a service for which schools will be ‘making referrals.’Â? Adolescent Health Vol. I Summary and Policy Options by the Congress of the United States Office of Technology AssessmentÂ? defines comprehensive healthÂ? services to include ‘care for acute physical illnesses, general medical examinations in preparation for involvement in athletics, mental healthÂ? counseling, laboratory tests, reproductive healthÂ? care, family counseling, prescriptions, advocacy, and coordination of care …’ Is this definition accurate?Â? If not, what is included in comprehensive health as used in the Medicaid Interagency Agreement?”

A:� “For information about what the Missouri Medicaid program considers comprehensive health, see Section 9 of the Medicaid provider manual, about Healthy Children and Youth.”

Q #2:� “Does ‘refer’ mean to refer orally, in writing, or either/or?”

A:� “Refer can mean orally or in writing.”

Q #3:� “Who decides to whom referrals are made?”

A: “Referrals are made by involving the parent or guardian of the child.� In some instances a parent may already be linked to appropriate healthcare providers, and may need little or no assistance in choosing a provider and scheduling appointments to obtain medical care.� In other instances, the parent may request assistance in locating a health care provider and accessing treatment.� When the child is Medicaid eligible, families may require assistance in locating providers who accept Medicaid.”

Q #4:� “Page 3 of the Medicaid Interagency Agreement� states the school district will ‘develop and submit within 90 days of the signing of this agreement, for approval by DMS, an internal process for measuring the progress of the district toward attainment of the ACM Program goals.’ What are the ACM Program goals?� What is the recommended internal process for measuring progress?”

A:Â? “The ACM program goals are listed on page two of the interagency agreement between DSS and a school district under ‘Mutual Objectives.’Â? A copy of this agreement–is contained in the administrative case managementÂ? manual for schools.Â? Enclosed is a copy of guidelines districts may use to measure progress toward goals.Â? Schools have some flexibility in establishing an internal process for measuring progress.”

Q #5:� “Page 7 of the Medicaid Interagency Agreement� states that the agreement shall be from October 1, 1994.� Why is the agreement predated by 9 months?”

A:� “When schools do not sign and return interagency agreements within several months, we recommend they request another when they are ready to sign, so that a more recently dated agreement may be signed.� When a school district does sign the agreement and it is approved by HCFA [HHS’s Health Care Finance Administration Region VII� headquarters in Kansas� City, MO),] Medicaid� reimbursement for administrative activities is not available for any time period prior to the time the written methodology� is approved.”

Q #6:� “Family Planning Services 14,553 of the Medicare and Medicaid Guide� says, ‘State Medicaid programs must offer family planning� services and supplies directly or under arrangements with others to categorically needy individuals� of childbearing age (including minors� who can be considered to be sexually active) who desire such services and supplies and may offer them to comparable medically needy individuals� (see ‘Mandatory and Optional Services’: at 14,511.) [Soc. Sec. Act 1905(a)(4)(C); Reg. 440.40(c) and 440.250(c).]

- “Does this Medicaid law and regulation compel schools which sign the Medicaid Interagency Agreement� to refer Medicaid eligible children and their families for family planning, even though the school/district may wish NOT to provide such referrals?� If not, Why?

- How is ‘categorically needy’ defined?

- How is the determination for ‘considered to be sexually active’ made?”

A:� “While Medicaid� agencies (the Department of Social Services� in Missouri) are required to provide those services described in the documents you cite, school districts are not required to make referrals for such services.� [Editor’s note: the ten basic required Medicaid services include family planning� services and supplies.]� School personnel must follow their own district’s procedures for such referrals, which are established locally by the governing body of the district.

“ ‘Categorically needy’ refers to the manner in which the Division of Family Services determines eligibility� for Medicaid.

“Determination of who is considered to be sexually active� takes place when an individual voluntarily seeks clinic services.� As part of the evaluation of the individual’s needs, the provider may assess the sexual activity of age appropriate individuals.� The findings of the exam may result in counseling� and/or treatment.” � [Emphasis added. Counseling and/or treatment may include contraception.]

Q #7:Â? “Family Planning Services 14,553; B. Scope of Services on page 6273 of the Medicare and Medicaid GuideÂ? says, ‘the state is free to determine the specific services and supplies which will be covered as MedicaidÂ? family planning–‘It must also establish procedures for identifying individuals who are sexually activeÂ? and eligible for family planning services.’

- “What family planning� services and supplies are included in Missouri’s Medicaid family planning?

- What are the procedures for identifying individuals who are sexually active?

- What are the procedures for identifying those eligible for family planning� services?”

A:� “Family planning is defined as any medically approved diagnosis, treatment, counseling, drugs, supplies, or devices which are prescribed or furnished by a provider to individuals of child-bearing age for purposes of enabling such individual to freely determine the number and spacing of their children.� Such services include:

“a) Physician office visits for family planning� services, which may include medical history, PAP, pelvic exam, breast exam, bacterial smear, etc.

“b) IUD, oral contraception, diaphragms.� PLEASE NOTE: spermicidal jellies, foams, condoms, and devices or supplies available as non-prescribed, over-the-counter products, are not covered by Medicaid.

“c) Elective sterilization.”

Q #8:� “Please send me a copy of Mandatory and Optional Services 14,511, EPSDT� 14,551; Other Diagnostic Screening, Preventive, and Rehabilitative Services 14,595; and Case-Management Services 14,604C as listed in the Medicare and Medicaid Guide� 699 6-92.

A:� “Enclosed are copies of Sections 14,511; 14,551; 14,595; and 14,604C from the 1994 Commerce Clearing House Medicare and Medicaid Guide.”

The following questions were asked of the Missouri Division of Medical Services in a series of letters dated August 8, 14, and 24, 1995.Â? Each was responded to in a letter dated September 29, 1995:

Questions dated August 8: � “Does a district which does not provide referrals, or has a policy stating it will not provide family planning� services and/or referrals violate the school Medicaid Interagency Agreement?”

A: � “Our opinion is that school districts are not required to provide family planning� services and/or referrals.� The purpose of the interagency agreement� is not to permit schools to become providers of services.� The purpose is to provide Medicaid administration and to reach the mutual goals identified in that agreement.� A school district bills according to the costs of staff performing administrative activities, and if a particular activity is not engaged in by anyone at the school, then the school does not bill for it.

“[W]e do feel that in order to completely meet the goals and objectives, the school district should be prepared to make referrals� and assist in coordination of any needed medical service. (See also response to questions of August 24 letter.”)

Q:� “Does a district policy stating that family planning� services and/or referrals� will not be provided violate federal Medicaid� confidentiality� mandates� and protections?”

A:� “We do not believe so.”

Q: � “Under the school Medicaid Interagency Agreement, is the school district obligated to provide referrals� for family planning� to the parents of students?”

A:Â? “–Each school district would establish its own procedures and protocols for making referrals.”

Q:� “Page 9-2 of Section 9 of the Medicaid Manual regarding a health care home, speaks of a health care home being a child’s primary care provider.� Is the intent here to identify the child’s doctor, or the child’s caretaker?”

A:� “The ‘health care home’ is the child’s primary medical care provider.”

Questions dated August 14:� “Please send me a copy of the State Plan which shows how Missouri will comply with federal Medicaid program mandates, including confidentiality.”

A:Â? “There is a 50-cent per page charge.Â? Two pages of material are enclosed.Â? Send payment to–.”

Q:� “Please send me a copy of the Nurses Procedures Manual referred to on page 2 of the methodology.”

A:� “This document is not known to us. Please clarify.”

Q:� “Please send a copy of Guidelines for Special Health Care Procedures in Missouri Schools referred to on page 2 of the methodology.”

A:� “Please clarify, the document you referenced is not known to us.”

Q:� “Please send me a copy of (N) school district’s Cost Allocation Plan referred to on page 7 of the methodology.”

A:� “This office does not have copies of school districts’ cost allocation plans.� This should be obtained directly from the district.� The following will briefly explain how reimbursement works for Medicaid administrative case management.� The formula is:

cost x percent of time x percent of MedicaidÂ? eligibles x FFP rate = reimbursement.

(Editor’s note:� See the chapter titled “Universal Health Care Reform’s ‘Creative Financing’” for an explanation of the equation).

Q:� “What ‘data’ is being referred to in this statement?”

A:� “The time study.”

Q:� “Since there is no school during the summer months, why is it necessary for the school/district to develop a billing for this period?”

A:� “Because the annual cost is divided by four (see explanation above) this spreads the reimbursement over four, roughly equal, quarters.”

Q.:� “Is Medicaid reimbursement for services provided in a nine-month school year reimbursed� to the school/district over a 12-month period?”

A:� “Only when costs are spread over a 12-month period.”

a) q:� “Does this mean that the school/district receives LESS than the amount actually due during each of the quarters that school is in session?

a:� “No.”

b) q:� “Wouldn’t it be necessary to wait at least two quarters before beginning reimbursement, so as to estimate what the average quarterly reimbursement would be?”

a:� “Yes, in fact, a district must bill three complete quarters before being allowed to bill a summer quarter.� A school district which begins with the January-March quarter or after is not entitled to bill for the summer quarter.”

c) q:� “If payment is averaged so as to be spread out over a 12-month period, what arrangement is made for adjustment of reimbursements that were over or under paid to the school/district?”

a:� “The program review, conducted by DSS staff, will later determine if funds� were over or under paid, and an appropriate adjustment made.”

Question dated August 24:Â? “What happens in school districts–whose board has not provided such procedures?”Â? (regarding whether or not to provide referralsÂ? for family planning.)

A:� “When a school district has not established procedures for referrals, then it must be difficult for staff to make referrals.� What does your district currently do when a child is in need of medical care?

“You ask again the question about whether or not districts are exempt from certain requirements.� We believe you are confusing services with administration.� Certainly, a provider of services, such as a doctor or clinic, is required to provide referrals for services they do not themselves provide.� When signing the interagency agreement, the school does not become a service provider, but rather enters into an agreement with [the] Department of Social Services� (DSS) to meet specified mutual goals.� The district then becomes eligible for reimbursement for time spent in administrative activity.� If certain activities are not engaged in, they are not billed.

“Before entering into such an agreement, the district must assess its own vision and agenda for the health status of its children.� If the district is not interested in comprehensively meeting the health needs of children, either by direct service provision or referral, then the district should not participate in Medicaid.� I don’t feel that a district who selectively engages in only parts of Medicaid administration, or makes referrals for some services and not others, can successfully meet program goals (emphasis added).

“We will contact our regional office and will request clarification of the differences between requirements of a service provider and those of an agency providing Medicaid administration, and will notify you of the response.”

To date a response has not been received.Â? Notice how the state went from saying, “We believe you are confusing MedicaidÂ? services with administration” (indicating that schools do not have to provide or refer for the ten basic required Medicaid services which includes family planningÂ? services and supplies) to stating, “We–will request clarification of the differences between requirements of a service provider and those of an agency providing Medicaid administration” (emphasis added).

Federal and state documents verify the family planning� component of Medicaid.� One version of the state’s Goals/Outcomes Program Evaluation Plan� contains a family planning component for schools.

There is concern that in order to entice districts to become Medicaid providers, the government will initially “look the other way” from schools which choose not to provide family planning� services and/or referrals, until they become dependent on the Medicaid dollars.� There is concern that at that point, the government may threaten to discontinue the Medicaid funding to those schools that do not provide family planning services and/or referrals. There is concern that school districts may be coercively� forced to sacrifice the fertility of their students to the “god” of Medicaid on the “altar” of accreditation, since the district will have become dependent on the Medicaid funds� to provide health “services” mandated� by school health and education reforms.

November, 1997

MC+ is the state’s Medicaid funded managed care program.� Family planning is one of the basic required Medicaid services. A Catholic health plan (Sisters of Mercy Health System) was among the health plans with whom the state Division of Medical Services had contracted to provide managed care services.� Does this mean the Catholic health system also includes family planning? Yes.

The afternoon of November 4, 1997 a gentleman from the state Department of Social Services directed me to dial 1-800-796-0056 to reach the state MC+ office. So when a lady answered “(N) with Mercy Health Plans,” I was surprised. She explained that Mercy Health Plan has two sides to their program: one is Medicaid and the second is commercial.� When I questioned whether they included family planning services she emphatically reiterated twice: “Mercy does provide family planning� services for the state.� It’s the law and family planning is a Medicaid allowable fee! Mercy contracts for family planning and provides tubal ligations.” She went on to explain that the bills were handled in another part of the state.

Interestingly enough, I recognized the lady’s name as being the same person whom our school district had invited to represent the Catholic Diocese on their Medicaid panel that successfully convinced the school board to vote in favor of being a Medicaid provider.� (See the true story in this book titled “Church Convinces Public School District to Become a Medicaid Provider.”)

What a scandal it is that the faith is being sacrificed to the god of Medicaid dollars, on the altar of universal health care!!