Chapter 76. School-Based Health Centers (SBHC)

“Department” means the Maryland Department of Health, the State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

“Early and periodic screening, diagnosis and treatment (EPSDT)” means the provision of preventive health care, including medical and dental services under 42 CFR §441.50 et seq., in order to assess growth and development and to detect and treat health problems in Medical Assistance eligible individuals younger than 21 years old.

“Federally qualified health center (FQHC)” means an entity that has entered into an agreement with the Centers for Medicare and Medicaid Services (CMS) to meet Medicare requirements under 42 CFR §405.2464 and in accordance with 42 CFR §405.2401(b).

“Managed care organization (MCO)” has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland.

“Medically necessary” means that the service or benefit is:

“Medicare” means the insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.

“Participant” means an individual who is certified as eligible for, and who is receiving, Medical Assistance benefits.

“Primary care provider (PCP)” means a practitioner who is the primary coordinator of care for the participant, and whose responsibility it is to provide accessible, continuous, comprehensive, and coordinated health care services covering the full range of benefits required by the Maryland Medical Assistance Program.

“Primary health services” means a basic level of health care, including diagnostic, treatment, consultative, referral, and preventive health services, generally rendered by:

“Program” means the Maryland Medical Assistance Program.

“Provider” means a school-based health center which has been approved by the Department.

“School-based health center (SBHC)” means a health center that:

“Specialty behavioral health” means services specified in COMAR 10.09.59.06 and 10.09.80.05.

Meet the conditions for participation as set forth in COMAR 10.09.36; and

If delivering services via telehealth, comply with COMAR 10.09.49 and any subregulatory guidance issued by the Department.

Be approved by the Maryland Department of Health as an SBHC;

Meet conditions for participation as a:

Provide somatic health care services through health professionals who:

Ensure staff is assigned responsibilities consistent with the staff's education and experience and within the staff's scope of practice;

Designate an individual to be responsible for overall management of the SBHC;

Whenever comprehensive primary health services are being delivered, maintain a staffing pattern that includes at least one of the following on-site:

Maintain policies and procedures that ensure confidentiality of services and records which are practiced consistently, in accordance with Health-General Article, §4-301, Annotated Code of Maryland;

Maintain data collection and storage capabilities adequate to maintain medical records and standard demographic data;

Require any physician assistant employed by the provider to have a delegation agreement with the supervising physician in accordance with COMAR 10.09.55.02 and .03; and

Transmit a health visit report:

Performed by EPSDT certified providers; and

Rendered according to EPSDT standards set forth in COMAR 10.09.23.03;

Nasogastric tube feedings;

Catheterization;

Oral, nasotracheal, or tracheal suctioning; and

Nebulizer treatments;

Hearing and vision screening unless completed as part of an EPSDT well-child check-up;

Routine assessment of minor injuries;

First aid;

Administration of medications including supervision of self-administered medications;

General health promotion counseling; and

Review of health records;

Administering medication;

Checking blood pressure;

Measuring weight;

Interpreting lab results; or

Group or individual health education; and

The provider:

The provider’s reimbursement is not limited to the provider’s customary charge.

The provider’s customary charge to the general public unless the service is free to individuals not covered by Medicaid; or

The maximum rates according to COMAR 10.09.02.07.

The provider accepts Medicare assignments;

Medicare makes a direct payment to the provider;

Medicare determines the services are medically necessary;

The services are covered by the Program; and

Initial billing is made directly to Medicare according to Medicare guidelines.

A deductible shall be paid in full;

Coinsurance shall be paid at the lesser of:

Services not covered by Medicare, but considered medically necessary by the Program, shall be paid according to the limitations of this chapter; and

Coinsurance shall be paid in full to FQHC providers.

Verify eligibility and MCO assignment through EVS on the day of service;

Submit claims within 180 days of performing the service;

Submit claims using the CMS 1500 for paper processing and the HIPAA compliant 837P for electronic processing; and

Bill third party insurers before billing the MCO with the exception of well-child care and immunizations.

Completion of forms and reports;

Broken or missed appointments;

More than one visit to complete an EPSDT screen; and

Providing a copy of a participant’s medical record when requested by another licensed provider on behalf of the participant.