Volume 9 Number 1

In final regulations published in the Federal Register December 28, the federal Centers for Medicare and Medicaid Services (CMS) made it official that schools may not bill Medicaid for certain school-based administrative and transportation activities, "because the Secretary [of Health and Human Services] has found that these activities are not necessary for the proper and efficient operation of the Medicaid state plan." The regulation, which goes into effect February 26, 2008, is identical to proposed regulations that were issued by CMS in September last year. The new 25-page Federal Register notice includes extensive comments CMS received after publication of the proposed rules, with the largest group of comments coming through a write-in campaign initiated by the Council for Exceptional Children and California the state generating the largest number of comments. Exact status of the new regulations is unclear, however, since the regs appeared just one day before President Bush signed into law a bill (S. 2499) that imposes a moratorium on any regulatory guidance concerning payment for school-based administration and school-based transportation, "if such restrictions are more restrictive in any aspect than those applied to such areas as of July 1, 2007." As background for its regulations, CMS noted that Title XIX of the Social Security Act authorizes federal grants to states for Medicaid programs, "operated by each state under an approved Medicaid State plan that provides medical assistance to needy individuals, including low-income families, the elderly, and persons with disabilities." With respect to schools, this means that some "medically necessary direct medical services" provided to children with disabilities, including services specified in their Individualized Education Plans (IEPs) or Individualized Family Services Plans (IFSPs), and also including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), may be covered by Medicaid, "if they meet all other Federal and State Medicaid regulations." What are not covered by Medicaid, the CMS points out, are services that states must provide as part of their educational mission, including administrative activities that are primarily associated with education program requirements. "Though these activities may include coordinating the delivery of Medicaid services with educational services, they are primarily associated with educational program requirements. Transportation to and from the school for most students is also part of the schools' educational responsibility." Funding Issues Many of the comments CMS received involved the financial effects schools anticipate when the new Medicaid regulations go into effect. Commenters argued that they will not be able to fund staff positions, equipment, or instructional materials, or that their states or districts will have to raise taxes to make up the shortfall. In response, CMS notes that "such comments appear to support our view and concern that Title XIX funds are being used as a funding source without specific benefit to the Medicaid program." Provision of Services CMS responded at length to charges that the new regulations will adversely impact the provision of needed services to school-age children. "The provision of, and reimbursement for, school-based medical services are not affected by the changes specified in the final rule," CMS said. "Medicaid reimbursement would remain available for covered services provided to children pursuant to an IEP or IFSP, whether they are provided in the school or the community … including transportation from school or home to a non-school-based direct service provider that bills under the Medicaid program." Support for School-Based Administration In response to comments that "Families are familiar and comfortable with the people and the school" making schools a logical place to provide opportunities to enroll children in health care, CMS noted that the regulations "in no way preclude state or local Medicaid agencies from engaging in such activities. Nor do we preclude school employees from conducting activities that inform individuals of the availability of Medicaid services. This rule simply sets forth a clear test for the administrative activities that are appropriately claimed as necessary for the proper and efficient administration of the state Medicaid plan, and distinguishes those activities from the administration of a school program." Transportation-Specific Issues In response to commenters concerned about the new regulations' effects on transportation of students, CMS pointed out that Medicaid will continue to pay for transportation of a student from home or school to a non-school-based medical provider, but transportation from home to school, even if the child is to receive some medical services at school, is a responsibility of the school system. "This final rule will not interfere in any way with the ability of states to determine school transportation policy, but simply recognizes that transportation from home to school and back and related administrative activities are not authorized under the Medicaid statute as necessary for the proper and efficient administration of the state Medicaid plan. Children are transported to school primarily to receive an education, not to receive medical services." The full text of the final rule, "Elimination of Reimbursement Under Medicaid for School Administrative Expenditures and Costs Related to Transportation of School-Age Children Between Home and School," the comments received by CMS, and the agency's replies are available online at http://www.federalregister.gov/articles/2007/09/07/07-4356/medicaid-program-elimination-of-reimbursement-under-medicaid-for-school-administration-expenditures

Recent U.S. Congress hearings into steroid use by professional athletes also focused attention on suspected widespread use of steroids by adolescent athletes, with concerns expressed about the long-term effects on young people's health of the use of steroids or other drugs. Concern about drug use by adolescents has prompted many schools to institute random testing of student athletes and in some cases of all students who participate in extra-curricular activities, and there have been challenges to such testing programs in state and federal courts. The United States Supreme Court ruled in June 2002, for example, that public schools have the authority to perform random drug tests on all middle and high school students who participate in extra-curricular activities. In December 2007, the Committee on Substance Abuse and the Council on School Health of the American Academy of Pediatrics (AAP) issued a policy statement on the role of schools in curbing illicit substance abuse. "As the physical, social, and psychological 'home away from home' for most youths, schools naturally assume a primary role in substance abuse education, prevention, and early identification," the statement notes. But the pediatric groups are cautious about the use of random drug testing as a component of drug prevention programs, calling for more rigorous scientific evaluation to determine if such testing is effective in curbing drug use and to evaluate possible harm. In any case, the statement stresses, if drug testing is conducted, it should never be in isolation—a comprehensive assessment and therapeutic management program should be in place for the student who tests positive, and students undergoing intervention should be given privacy, with information limited to the student's parents and physician, and only those school officials who "need to know." Here are excerpts from the December 2007 AAP policy statement: The benefits and risks of drug testing as a component of comprehensive programs to prevent or reduce substance abuse in such groups as nonusers, first-time and/or occasional users, and more frequent or addicted users must be determined by scientific studies. Implementation of random drug testing of students should await these results. Schools may adopt a variety of alternatives to drug testing, including offering after-school programs, incorporating life-skills training into drug education curricula, helping parents become better informed, providing counseling, identifying problem behaviors for early intervention, and promptly referring students to health care professionals for assessment and evaluation. Some societal leaders support broad drug testing as an aid in the prevention of drug use and possible early identification of youth who have used drugs, thereby facilitating appropriate assessment and therapeutic referral. Others, including most parents and physicians, are concerned that school-based drug testing could unnecessarily label or stigmatize a child and compromise personal and family privacy. The Health Insurance Portability and Accountability Act (HIPAA) applies to medical facilities, but children and adolescents do not have the same safeguards to privacy of medical information at school. Recording positive drug-test results on students' permanent educational records (under guidelines of the Family Educational Rights and Privacy Act (FERPA), which are accessible to many school personnel, could have negative and long-term consequences. Strict attention to issues of confidentiality must be ensured. In an earlier policy statement, issued in March 2007, the AAP noted that "A key issue at the heart of the drug-testing dilemma is the lack of developmentally appropriate adolescent substance abuse and mental health treatment. Adequate resources for assessment and treatment must be available for students who have positive test results. However, many communities lack substance abuse treatment services dedicated to adolescents, and adult substance abuse treatment programs may be inappropriate and ineffective for adolescents." The two AAP policy statements are available online at www.pediatrics.org

The annual recommended immunization schedules for children and adolescents in the United States for January-December 2008 were approved by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians. There are three schedules: one for children 0 to 6 years of age, one for those 7 to 18 years of age, and a catch-up immunization schedule for those who start late or fall behind. These schedules reflect current immunizations for use of vaccines licensed by the U.S. Food and Drug Administration. For the full text of the 2008 recommendations, see http://www.cispimmunize.org.