Third Party Reimbursement

SBHCs run by community clinics, hospitals, and other community health providers can bill public programs (e.g., Medi-Cal and Healthy Families) and private carriers for many of their services. In addition, California has several other programs that can reimburse SBHCs: Family PACT and Medi-Cal Minor Consent for reproductive health services; EPSDT for mental health services (see below); and the Child Health and Disability Prevention (CHDP) program for uninsured children and youth. School districts may currently only bill under the CHDP, LEA Medi-Cal, and LEA MAA programs. Read more below about these programs in our Third Party Billing Manual.

The billing process is complicated and time-intensive, but ultimately it can provide a sustainable funding source for SBHCs. For this reason, it is extremely important that SBHCs actively pursue reimbursement revenue, and that sponsoring organizations provide adequate staffing and expertise for their affiliate SBHCs to effectively bill.

Fortunately, most community health providers have billing systems in place and can use these systems to support their SBHCs in securing reimbursement. For SBHCs that are run by other organizations, including school districts, setting up billing systems may require an up-front investment, but will prove to be financially “worth it.” For more information on the programs that school districts can bill and how they can do it, see our Education Funding webpage.

CSHA Resources

Third Party Billing: A Manual for California’s School Health Centers

This manual is intended to help increase billing revenue and strengthen sustainability and to aid those starting a school health center in understanding potential sources of revenue. It provides tips on how to develop/improve billing practices and effectively submit billing claims. The manual covers billing for primary care services, reproductive health services, and services provided by school districts. Sample forms and effective practices for billing within the managed care system are also provided. The manual was developed jointly by CSHC and LA Care Health Plan.

This brief guide on maximizing third-party billing, covers best practices for the Child Health and Disability Prevention Program (CHDP), FamilyPACT Program, Medi-Cal Managed Care, and Minor Consent Medi-Cal.

Other Resources

Guide to Medi-Cal Programs

This easy-to-use Guide to Medi-Cal Programs from the California Health Care Foundation provides an orientation to Medi-Cal with information on immigration, disability, the application process, services covered – and includes an Aid Code Quick Reference Guide. The guide also provides a summary of each program; a description of who is eligible and how many recipients are covered; and a listing of the corresponding aid codes. Specific sections include information on the following Medi-Cal programs: Cash-related programs; 1931(b) Medi-Cal; Programs for children; Pregnancy-related programs; Programs for the medically needy and medically indigent; Transitional and continuing coverage; and Other Medi-Cal and non-Medi-Cal programs, such as Family PACT and Healthy Families.

Overviews of Medi-Cal and Healthy Families Presentations

The California Health Care Foundation has developed two easy-to-use presentations that provide detailed information about Medi-Cal and Healthy Families: Medi-Cal Facts and Figures: A Look at California’s Medicaid Program and The Healthy Families Program: An Overview. Both presentations cover the basics on eligibility, enrollment, benefits, service delivery and many other program details. The presentation formats can be used by policy leaders, health care administrators, or others to include localized information.

Mental Health Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The EPSDT program offers reimbursement for Therapeutic Behavioral Services provided to children who qualify for full-scope Medi-Cal. The  program is administered by local county departments of mental health or behavioral health care. To learn more or find an EPSDT provider, visit the California Department of Mental Health website. Also, read a case study on how Alameda County has leveraged funds to grow their EPSDT program in schools.

Developing a Business Plan for Sustaining School Mental Health Services

The Center for Health and Health Care in Schools has developed this resource for creating a financially sustainable school mental health program. It includes detailed case studies from across the country, as well as general advice and recommendations for maximizing revenue to pay for student mental health services.