Save School-Based Health: Stop 4/1/25 Managed Care Carve In

Kids Don’t Win with SBHC Medicaid Managed Care Carve In

January 7, 2025

The Honorable Kathy Hochul
Governor of New York State
Executive Chamber, State Capitol Building
Albany, NY 12224

Dear Governor Hochul,

State legislators, hospitals, clinics, unions, health and education providers, schools and others supporting the critical network of school-based health centers (SBHCs) are united in their strong opposition to the State’s proposed shift of SBHCs from Medicaid fee-for-service (FFS) to Medicaid managed care (MMC) on April 1, 2025. Please see attached list of organizations opposed to the carve in. Additionally, the state’s health plan association and its members, who would be charged with administering this benefit, have weighed in with opposition to a MMC carve in for SBHCs stating that their care coordination services do not fit the unique SBHC model. Instead, the health plans have urged that the program remain permanently in FFS.

We are now just over 80 days away from this major system transition and there has been no engagement with the SBHC community beyond one webinar held in October. Given the complexity, challenges and unaddressed questions, there is no way that this essential safety net for New York’s most vulnerable youth will be ready for such a reform which threatens to dismantle this highly unique, child- centered provider. We urge you to pause this transition and instead ask the Department of Health (DOH) to put a plan in place for regular meetings and a meaningful dialogue with the SBHC field at large to discuss the feasibility of a MMC carve in and needed elements and timeline for such a shift.

Unanswered Questions

During the October 2024 DOH webinar held with clinic staff only, dozens of questions and concerns were raised. Two months later they remain unanswered, and no further discussions have been had. Questions by the field are wide-ranging and include:

How will NYS help SBHCs sponsors absorb this increased burden of uncompensated care created by MMC integration? According to New York State regulation, SBHCs must provide care for all students regardless of their insurance type and without out-of-pocket cost to the student or family. This provision does not affect almost every other health care or MMC provider who will only provide services to patients within their contracted network. The regulation that SBHCs must provide care to all students under all insurance circumstances already results in an enormous burden of uncompensated care to out of network patients and patients. The cost of these uncompensated visits are currently absorbed by the SBHC sponsors. Medicaid Fee for Service has been the only source of reliable reimbursement for SBHC patient visits.
We are not aware of any communication, outreach or technical assistance provided to plans to date that supports the MMC go live. One sponsoring organization proactively reached out to plans in their area to discuss the carve in, contracting and confirming APG payments for two years. The plan responded that it was not aware of the change and does not need to pay APGs. When DOH was consulted for support, a technical chart was provided to the SBHC sponsor and they were instructed to give it to the plan directly, notwithstanding that the SBHC sponsor does not have oversight of the MMC.
DOH has stated that plans will be required to pay at the Medicaid APG rates for two years following the transition. What happens after two years? Based on the real experience of NY providers, when forced to negotiate directly with plans for rates, they lack the leverage to maintain or achieve an increase and the resulting rates are unsustainable.
There is lack of clarity around SBHC Dental services carved into MCC. Concerns with how a carve-in would affect a major SBHC dental provider which is not in plan networks and is a mobile provider. Would they be designated as a child’s primary dental provider? If they can no longer serve these children in the MMC model, who will care for these patients with the significant shortage of pediatric dentists in our state and few take Medicaid.
How would the state assure that plans make the necessary systems changes to protect adolescent confidentiality for those receiving reproductive health care and other confidential services to prevent EOBs from being sent home to members?
The transition will require significant administrative and technology changes by providers and plans. A new bureaucracy will be put in place for SBHCs to be part of all MMC plan networks in their areas, have all of their providers credentialed, expand their billing staff and other work to accommodate a managed care model. This is a significant infrastructure enhancement required of both MCC plans and SBHC sponsoring institutions and there is insufficient time or SBHC funding to allocate new resources to support this work.
There are approximately 250 SBHCs across the State with 50 unique sponsoring organizations which range in size, staffing and capacity from hospitals and healthcare networks to small, rural clinics and other providers who sponsor SBHCs. There are over a dozen MMC plans in some areas and subcontracts with other plans for certain services provided by SBHCs like mental health and dental care.
At this point in just over 80 days, contracts need to be negotiated between all of these plans, their subcontractors and SBHCs in each region, networks need to be formed and validated by the state, the thousands of individuals who work at SBHCs caring for children need to be credentialed with each plan by 4/1/25 for billing and countless other tasks, in addition to the beta testing the State would need to do prior to going live. This is impossible to accomplish in 80 days, and we do not understand why the State is trying to rush this massive transition through.
April 1, 2025 is in the middle of an academic school year where vulnerable children need to be able to continue to receive vital physical health, mental health, reproductive health, dental and other services uninterrupted. There is no way that this transition can happen in just over 80 days without interrupting services for children served by SBHCs, children who have no other access to care.

SBHCs are more critical than ever due to the state’s escalating mental health crisis, shortage of pediatric dental care, and to serve as a safety net for migrant families. SBHCs have been proven to reduce ethnic and racial disparities in the communities they serve and improve school attendance and performance. Further, the state’s own studies have demonstrated the marked reduction in hospitalizations and emergency department visits among children who receive care at SBHCs. The State has set SBHCs on a clear path to failure. We have already had two sponsoring organizations close their SBHCs upon hearing the MMC carve-in announcement.

Moving SBHCs to managed care does not have any savings attached to it. In fact, this shift will increase costs to the State. DOH will have to pay managed care plans to administer the coverage while also paying for many protections to try to compensate for this unworkable model for SBHCs. These funds should be going directly to services, not to health plans.

Children who are already facing many other challenges deserve to know their SBHC will always be there for their health, dental, reproductive, and mental health needs. Please hear our earnest appeal. Pause the 4/1/25 MMC transition and allow for the establishment of a meaningful engagement between the State and all stakeholders to ensure stability for SBHCs and all the children who depend on their essential services.

Sincerely,

Sarah Murphy
Executive Director
New York School-Based Health Alliance
518.694.3423, [email protected]

Cc:

Stacy Lynch, Chief of Staff to the Governor
Karen Persichilli Keogh, Secretary to the Governor
Edgar Santana, Executive Deputy Secretary to the Governor
Brian Mahanna, Counsel to the Governor
Angela Profeta, Deputy Secretary to the Governor for Health
Jack Marzulli, Assistant Secretary to the Governor for Health
Erin Kate Callichia, Senior Counsel to the Governor for Health
Dr. James McDonald, Commissioner of Health
Amir Bassiri, Medicaid Director
Andrea Stewart-Cousins, Senate Majority Leader
Carl Heastie, Assembly Speaker
Gustavo Rivera, Senate Health Committee Chair
Amy Paulin, Assembly Health Committee Chair

Organizations Opposed to NYS Medicaid Managed Care Carve-In of School Based Health Centers

New York School-Based Health Alliance
1199SEIU
Greater New York Hospital Association
Healthcare Association of New York State
Community Health Care Association of New York State
NY Society of Adolescent Health & Medicine
The Foundling
New York State Academy of Family Physicians
New York City Department of Health and Mental Hygiene
Kaleida Health
Northwell Health
Montefiore Health
Community Health Network
New York School-Based Health Foundation
Long Island Jewish Medical Center/CMCC
Children’s Aid NYC
NYU Langone Health
Morris Heights Health Center
Family Health Centers at NYU Langone
New York-Presbyterian Hospital
Harmony Healthcare Long Island
States Island University Hospital
Healthy Capital District
Open Door Family Medical Center
Community Health Academy of the Heights Essex Street Academy
Lower Manhattan Academy Arts Academy
Urban Assembly Academy of Government and Law
New Design High School for Dual Language and Asian Studies
Rochester Regional Health
Bassett Healthcare Network
Sun River Health
Community League of the Heights
Academy of Innovative Technology
Far Rockaway Educational Campus, Pathways to Graduation
New York State Community Schools Network
Network for Youth Success
Village Academy, Brian Piccolo MS53 Campus
North Country Family Health Center
Brooklyn Plaza Medical Center, Inc.
Urban Health Plan
University of Rochester
Institute for Family Health
Syracuse Community Health
East Harlem Council for Human Services Inc./ Boriken Neighborhood Health Center
NYU Langone Hospital – Long Island
Family Health Network of CNY, Inc.
NY Society of Adolescent Health & Medicine
Ariel Tassy Nunez, MD, Deborah Saunders, MD, Eric Weiselberg, MD, Rachel Bergeson, MD, Khalida Itriyeva, MD, members, AAP Chapter 2 Committee on Youth and Adolescents
Finger Lakes Community Health
Smile New York Outreach
FHC at NYU Langone School Based Dental Program
BMS Family Health and Wellness Centers
Connext Care
Mount Sinai Hospital
Mount Vernon Neighborhood Health Center Network
Ryan Health