Provider Quality

Effective May 1, 2025, the provision of School-Based Health Center (SBHC) and SBHC-Dental (SBHC-D) services will be incorporated into the Mainstream Medicaid Managed Care (MMC) and HIV Special Needs Plan (HIV SNP) benefit package. Therefore, Fidelis Care will be responsible for reimbursing SBHC operators for SBHC services provided to Fidelis Care members. The goal of the transition is to maintain access to these critical SBHC and SBHC-D services while integrating the services into the larger health care delivery system.

It is anticipated that the integration of SBHC and SBHC-D services within the existing managed care framework, and coordination of services with the child's Primary Care Provider (PCP), will improve quality and promote an efficient, effective delivery system. Maintaining the continuity of care, as well as the wellness of the child, to facilitate learning and improve school attendance is of utmost importance in this transition.

Scope of the School Based Health Center Benefit:

• Effective May 1, Fidelis Care will cover services provided by SBHCs and SBHC-Ds.
• Students enrolled will have direct access to all services provided by SBHCs and SBHC-Ds, without the need for referral or prior authorization, with the following exceptions:
  • Dental Health: Routine preventive services, such as, sealants, fillings, fluoride treatments, simple extractions (which includes the elevation and/or forceps removal of an erupted tooth or an exposed root) and cleanings provided in SBHC-D sites do not require prior authorization.
• SBHCs and Fidelis Care will work collaboratively on quality improvement initiatives, including information sharing to improve outcomes for an individual child.
• Fidelis Care will work with the SBHC, and the child's PCP (if not a provider located in the SBHC), to assist in promoting wellness and ensuring that all children receive recommended well child visits and other needed services.

Resources for Providers:

• School-Based Health Center (SBHC) Transition to Medicaid Managed Care FAQs
• NYS Department of Health Transition Overview

For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.