3.__Reimbursement for self-referred services.__With respect to individual contracts that require the selection of a primary care provider, an insurer shall provide coverage and payment under those contracts for covered services provided in a school-based health center without requiring prior approval from a primary care provider as a condition of reimbursement.__Within 3 business days after an enrollee's visit to a school-based health center in accordance with this subsection, the school-based health center must notify the primary care provider of the enrollee's complaint, related history, examination, initial diagnosis and course of treatment. If the school-based health center fails to provide the notice required by this subsection, the insurer is not obligated to provide payment for services and the enrollee is not liable to the school-based health center for any unpaid fees.

4.__Reimbursement amount.__An insurer that provides coverage required under this section shall reimburse a school-based health center at the usual, customary and reasonable fee for a covered service.

5.__Limits; coinsurance; deductibles.__Any contract that provides coverage for the services required under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.

Sec. 4. 24-A MRSA §2847-J is enacted to read:

§2847-J.__Coverage for services provided in school-based

health centers

1. Definitions. As used in this section, unless the context indicates otherwise, the following terms have the following meanings.

A.__"Enrollee" means a student in an elementary, middle or secondary school who is enrolled in a group health plan provided by an insurer.

B.__"School-based health center" is a facility located in a school building or on school grounds in this State that provides comprehensive primary health care services, including, but not limited to, health screening, referral,

health education and counseling, medical diagnosis and treatment and mental health services.

2.__Coverage for school-based health centers.__An insurer that issues group health insurance policies and contracts shall provide coverage under those contracts for services performed in a school-based health center when those services are covered services and within the lawful scope of practice of a health care professional who is employed by or contracted to a school-based health center.

3.__Reimbursement for self-referred services.__With respect to group health insurance policies and contracts that require the selection of a primary care provider, an insurer shall provide coverage and payment under those contracts for covered services provided in a school-based health center without requiring prior approval from a primary care provider as a condition of reimbursement.__Within 3 business days after an enrollee's visit to a school-based health center in accordance with this subsection, the school-based health center must notify the primary care provider of the enrollee's complaint, related history, examination, initial diagnosis and course of treatment.__ If the school-based health center fails to provide the notice required by this subsection, the insurer is not obligated to provide payment for services and the enrollee is not liable to the school-based health center for any unpaid fees.

4.__Reimbursement amount.__An insurer that provides coverage required under this section shall reimburse a school-based health center at the usual, customary and reasonable fee for a covered service.

5.__Limits; coinsurance; deductibles.__Any contract that provides coverage for the services required under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.

Sec. 5. 24-A MRSA §4249 is enacted to read:

§4249.__Coverage for services provided in school-based

health centers

1.__Definitions. As used in this section, unless the context indicates otherwise, the following terms have the following meanings.

A.__"Enrollee" means a student in an elementary, middle or secondary school who is enrolled in an individual or group health plan provided by a health maintenance organization.

B.__"School-based health center" is a facility located in a school building or on school grounds in this State that provides comprehensive primary health care services, including, but not limited to, health screening, referral, health education and counseling, medical diagnosis and treatment and mental health services.

2.__Coverage for school-based health centers.__A health maintenance organization that issues individual and group health care contracts shall provide coverage under those contracts for services performed in a school-based health center when those services are covered services and within the lawful scope of practice of a health care professional who is employed by or contracted to a school-based health center.

3.__Reimbursement for self-referred services.__With respect to individual and group health care contracts that require the selection of a primary care provider, a health maintenance organization shall provide coverage and payment under those contracts for covered services provided in a school-based health center without requiring prior approval from a primary care provider as a condition of reimbursement.__Within 3 business days after an enrollee's visit to a school-based health center in accordance with this subsection, the school-based health center must notify the primary care provider of the enrollee's complaint, related history, examination, initial diagnosis and course of treatment.__If the school-based health center fails to provide the notice required by this subsection, the health maintenance organization is not obligated to provide payment for services and the enrollee is not liable to the school-based health center for any unpaid fees.

4.__Reimbursement amount.__A health maintenance organization that provides coverage required under this section shall reimburse a school-based health center at the usual, customary and reasonable fee for a covered service.

5.__Limits; coinsurance; deductibles.__Any contract that provides coverage for the services required under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.

Sec. 6. Development of standards and guidelines for school-based health centers. The Department of Human Services, Bureau of Health, Division of Community and Family Health shall convene an advisory group with members representing school-based health centers, the Department

of Education, school personnel, the Medicaid program and health insurers. The advisory group shall develop standards and guidelines for school-based health centers operating in the State and a certification process for school-based health centers based on those standards and guidelines. No later than December 31, 2001, the advisory group shall submit a report, along with its recommendations and any necessary implementing legislation, to the Joint Standing Committee on Health and Human Services. The advisory group shall consult with Office of Policy and Legal Analysis staff when drafting legislation to implement the advisory group's recommendations. The Joint Standing Committee on Health and Human Services may introduce a bill to implement the advisory group's recommendations in the Second Regular Session of the 120th Legislature.

Sec. 7. Application. Sections 2, 3, 4 and 5 of this Act apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed on or after January 1, 2002. All policies, contracts and certificates are deemed to be renewed no later than the next yearly anniversary of the contract date.

SUMMARY

This bill implements the recommendations of the Joint Select Committee on School-based Health Care Services. The bill does the following.

1. It requires the Department of Human Services to provide the state match for federal revenues under the Medicaid program for services provided in school-based health centers.

2. It requires the Department of Human Services to adopt rules allowing school-based health centers to become eligible for reimbursement for case management services to Medicaid-eligible children.

3. It requires health carriers to provide coverage for services provided in school-based health centers if the services would be covered under the policy in another setting. The bill also requires coverage for services under managed care plans without requiring prior approval from a primary care provider but requires school-based health centers to notify the primary care provider within 3 business days after the services are provided.

4. It requires the Department of Human Services, Bureau of Health, Division of Community and Family Health to convene an advisory group to develop standards and guidelines for school- based health centers and a certification process for

school-based health centers. The advisory group shall submit its report and any necessary implementing legislation to the Joint Standing Committee on Health and Human Services. The Joint Standing Committee on Health and Human Services has authority to introduce a bill to the Second Regular Session of the 120th Legislature.