Illinois School Medicaid Billing & Reimbursement Process

Healthy Schools Campaign created the Guide to Illinois School Medicaid Billing and Reimbursement to assist school districts in navigating the school Medicaid program and in developing streamlined processes and procedures to maximize reimbursement, ensure compliance, and ultimately increase the availability and quality of health services for students. For detailed guidance on implementing each step in the reimbursement process, click on the links in the flowchart or view the Reimbursement Process Guidance documents below.

More Information

• How to Use the Guide to Illinois School Medicaid Billing & Reimbursement
• Key Background Information: Illinois School-Based Health Services
• Getting Started With School Medicaid

Reimbursement Process Guidance

• Obtain Consent to Bill Medicaid
• Identify Medicaid-Enrolled Students
• Identify Eligible Providers and Services (Summary Chart)
• Conduct Ongoing Training for Providers
• Update Provider Information Required by PCG
• Document Medical Necessity
• Provide and Document Services
• Respond to Random Moment Time Study (RMTS)
• Submit Service Claims to HFS
• Monitor Completion of Random Moment Time Study (RMTS)
• Submit Required Financial Reporting
• Review Reimbursement From State and Record to Designated Budget Category
• Monitor Compliance and Maintain Documentation

Additional Resources

• District Needs Assessment Guide
• LEA Internal Program Review Checklist
• School Medicaid Calendar
• Commonly Used Acronyms

This guidance is intended to assist school districts with improving and expanding Medicaid reimbursement for school health services. It should not be construed as legal advice. The information is accurate to the best of our knowledge as of August 2023, based on a review of publicly available guidance from the Illinois Department of Healthcare and Family Services (HFS) and its partner Public Consulting Group (PCG), and discussions with subject matter experts. School Medicaid requirements are subject to change. Please refer to the most recent guidance from HFS and PCG.

School Medicaid Resources

This section features policy briefs, guidance and other school Medicaid resources developed by Healthy Schools Campaign, followed by Illinois state agency resources and websites.

HSC Publications

• Frequently Asked Questions About the Illinois State Plan Amendment
  FAQs explaining the benefits and changes in the Illinois state plan amendment.
• Medicaid 101 for School Superintendents
  This brief explores what Medicaid is, what it covers — in and out of school — and how school districts can leverage Medicaid to enhance school health services.
• MESH Guide to Illinois School Medicaid Billing & Reimbursement
  Guidance to assist school districts in navigating the school Medicaid program, developing streamlined processes and procedures, and maximizing reimbursement to support health services for students.
• Promoting All Kids Health Insurance: Outreach and Enrollment Tips for Schools
  Helpful strategies to assist school districts with Medicaid outreach and enrollment.
• Documenting Medical Necessity Through Plans of Care
  Policy brief explaining the importance of using a plan of care to document medical necessity and offering guidance on implementing plans of care for students without an IEP or 504 plan.
• How Illinois Can Leverage Medicaid Funds to Expand School Health Services
  Building off HSC’s national brief Schools Are Key to Improving Children’s Health, this 2020 policy brief on the state of children’s health and school staffing in Illinois played a role in urging the state to move forward in expanding Medicaid-funded school health services.

Illinois State Agency Resources

• Sample Parental Notice for Consent to Allow the School District to Access Medicaid Benefits
  Sample parental consent form developed by the Illinois State Board of Education (ISBE).
• Illinois Medicaid School-Based Health Services (SBHS) Program Changes Frequently Asked Questions: School Health and Mental Health Service Providers
  FAQs on Illinois School-based Medicaid for school health service providers issued by the Illinois Department of Healthcare and Family Services (HFS) and ISBE.
• Illinois Medicaid School-Based Health Services (SBHS) Program Changes Frequently Asked Questions: Local Education Agency (LEA) Business Officials
  FAQs on Illinois School-based Medicaid for school business officials issued by HFS and ISBE.
• LEA Handbook on School Medicaid Claiming
  Official guidance on school Medicaid billing from HFS (as of August 2023, it does not yet reflect changes in the state plan amendment).
• PCG Claiming System
  Official portal for school Medicaid administrative claiming and cost settlement. Log in to access training webinars and additional resources on school Medicaid.
• Illinois Application for Benefits Eligibility (ABE)
  Interactive website designed to assist Illinois families with applying for Medicaid and other benefits.