District of Columbia School Medicaid Snapshot
Expansion of School Medicaid Program
Washington, D.C. has not expanded its school Medicaid program beyond school health services documented in a student’s IEP or IFSP.
Coverage & Billing
D.C. covers the following school-based health services:
- Audiology
- Behavioral Supports
- Nutrition Services
- Occupational Therapy
- Speech Therapy
- Physical Therapy
- Orientation and Mobility
- Personal Care Services
- Skilled Nursing
- Specialized Transportation
Eligibility: Medically necessary school-based health services provided to Medicaid-eligible children ages 3 to 21 as delineated in D.C.’s Medicaid State Plan Amendment (SPA) pursuant to an IEP under IDEA.
Billing: The billing providers for school-based services are local education agencies (LEAs) – schools and school districts. Individual rendering providers are not required to enroll separately in Medicaid for billing. The LEA is responsible for ensuring that rendering providers are qualified to provide services under federal and District law. School-based services are carved out of managed care.
Reference Document: D.C. Medicaid Reimbursement Guidelines for Participating Local Education Agencies
Nursing Services
Nursing services are covered as skilled nursing.
Provider types eligible for reimbursement:
- Skilled nursing:
- Licensed RN
- LPN
Must be recommended by a qualified health care professional who meets DOH licensure requirements (RN or LPN).
Reference Documents: D.C. Medicaid Reimbursement Guidelines for Participating Local Education Agencies; D.C. Medicaid State Plan, Attachment 3.1B: Supplement 1 (P.1-16)
Behavioral Health Services
Behavioral health care is covered in schools as: behavioral supports (counseling) and psychological evaluation.
Providers types eligible for reimbursement:
- Social Workers – DOH licensure requirements
- Clinical Psychologist – DOH licensure requirements
- School Psychologist – Board of Psychology License, or an OSSE Certification for LEA Employees only. Please note: the DOH licensure exemption for this provider type only applies if the provider is solely employed by an academic institution.
- Guidance Counselor – OSSE licensure requirements
Psychological evaluations must be recommended by a physician or clinical psychologist with DOH licensure
State Plan notes coverage of other professionals in regulation by DC as certified school counselors, school social work, and school psychologists defined under DC Municipal Reg, title 5 1663; it appears DOH administers.
*Note: contracted providers cannot qualify with only an OSSE Certification.
Reference Document: D.C. Medicaid Reimbursement Guidelines for Participating Local Education Agencies; D.C. Medicaid State Plan, Attachment 3.1B: Supplement 1
Bright Spot
The District of Columbia improved coordination and service delivery by implementing a data-sharing agreement among the D.C. State Board of Education, Department of Health, and Department of Health Care Finance (the District’s Medicaid agency). The agencies collaborated to ensure compliance with the Family Educational Rights and Privacy Act and used the data to target outreach and resources to schools and students with the greatest unmet needs.
Research Methods & Limitations
The information provided in this analysis represents findings from a 50-state review of publicly available information, most of which was available online as of March 15, 2021. In general, state Medicaid programs require healthcare practitioners to be licensed or authorized in the state in which they are practicing, and services are typically limited to those within the practitioner’s scope of practice under state law. The review for this project did not account for changes that may have been made to Medicaid coverage in response to COVID-19. It also did not include information related to state Medicaid coverage for Applied Behavioral Analysis Therapy in school settings.
Contact your state’s Medicaid agency to verify specific program requirements related to reimbursement. State Medicaid requirements may change at any time, and the information in this document should not be considered as legal or compliance advice.
Prepared by Healthy Schools Campaign. For additional information, visit the School Medicaid Map.
