Additional Considerations


Many lessons learned to date can inform the work of states ready to explore what it will take to expand their school-based Medicaid program. Here are some recommendations.

Collaborate Across Sectors

A number of states leveraged existing or new teams to bring together key people in state education and Medicaid agencies and school districts. Identifying and convening these players is critical both to changing policies and ensuring their effective implementation.

Collect Data

Data can be used to make the case for expansion and to inform recommendations around additional services and providers that the state might consider adding.

Both Illinois, which received CMS approval for its state plan amendment in 2023, and Minnesota, which can align its state policy with CMS without an amendment, conducted needs assessments to better understand the delivery of school health services and student health needs.

In addition, Colorado conducted a six-week expansion study in eight districts to better understand the financial impact of expanding its school Medicaid program. The results were favorable, and Colorado moved forward with a state plan amendment.

Align Efforts With Healthcare Transformation

The move to Medicaid managed care presents new challenges and opportunities for school health services, especially around billing and care coordination. The healthcare sector and public health systems are expanding their understanding of the social determinants of health and are placing more value on care coordination and chronic disease management.

States are bringing managed care organizations to the table to discuss the ways in which delivery of school health services can help them engage with otherwise hard-to-reach populations and meet accountability metrics. Tennessee developed a manual
to support these partnerships.

Create a Positive Policy Environment

A positive policy environment includes policies that 1) facilitate enrollment of eligible children in Medicaid and the Children’s Health Insurance Program (CHIP); 2) allow school health providers, particularly mental health providers, to bill Medicaid for eligible services; 3) ensure revenue generated from school-based Medicaid programs is reinvested in school health and wellness programs at the local level; and 4) address school climate, staff wellness and other components of a safe and supportive school environment.

Leverage Existing Assets

States can leverage their existing infrastructure and capacity. Some states might even have unique structures that make them especially well-suited to expand their school Medicaid program. In Michigan, for example, all of the 587 school districts belong to one of 57 Intermediate School Districts, and these districts function as the Medicaid provider under which all claims are made. Given this infrastructure, Michigan was well-positioned to move forward with expanding its school Medicaid program.

Engage Advocates

State policymakers, school district leaders, public health advocates and advocacy organizations have all contributed to the success and momentum around school-based health services. There is now greater awareness of the opportunity presented by CMS as well as increased support from both the health and education sectors.

Advocacy groups are often the drivers behind legislation urging state agencies to move forward with expanding school Medicaid programs. For example, due to groups such as Voices for Utah Children raising issue awareness and setting the groundwork, Utah passed legislation that directed the state Department of Health and Board of Education to develop a plan to expand Medicaid reimbursement to include services delivered to all Medicaid-enrolled students. As a result, Utah issued a legislative report that will serve as the foundation for this work moving forward.