Colorado School Medicaid Snapshot

Expansion of School Medicaid Program
Colorado expanded its school Medicaid program to include all medically necessary services delivered to all Medicaid-enrolled students.

Coverage & Billing
Colorado covers the following school-based health services when medical necessity has been established:

  • Physician Services
  • Nursing Services
  • Personal Care Services
  • Psychology
  • Counseling
  • Social Work Services
  • Orientation, Mobility
  • Vision Services
  • Audiology Services
  • Speech Therapy
  • Occupational Therapy
  • Physical Therapy
  • Specialized Transportation – requires IEP/IFSP

Eligibility: Medicaid-eligible children under age 21 for covered medically necessary services provided pursuant to an IEP, IFSP, Section 504 plan, other individualized health or behavioral health plan, or Medicaid-eligible children under age 21 that have other medical plan(s) of care (outside of IEPs/IFSPs) of care where medical necessity has been established.

Billing: The billing providers are the Local Education Agencies (LEAs) and Boards of Cooperative Educational Services. Rendering providers do not enroll separately in Medicaid, but need to meet required registration, certification and/or licensure. School-based services are carved out of managed care contracts.

Reference Documents: State Plan Amendment #19-0021

Nursing Services

Nursing services are covered as:

  • Direct interventions – medically based services delivered within the scope of practice of an NP, RN, or LPN.

Provider types eligible for reimbursement:

  • NPs
  • RNs
  • LPNs

Unless exempt, all nurses must also have DORA licensure.

Nursing services may also be delegated to a Colorado-qualified:

  • Nurse Aide or Health Technician who qualifies as delegated staff per 440.130(d) and Colorado Nurse Practice Act

Any delegation must be in accordance with 42 CFR § 440.130(d) and the delegation clause in Section 12-38-132, C.R.S. of the Colorado Nurse Practice Act. Nursing services may be provided in an individual or group setting.

Reference Documents: School Health Service Program Manual

Behavioral Health Services

Behavioral healthcare is covered in schools as: Healthcare, diagnostic services, treatments, and other measures provided as health and behavior interventions that identify psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical and mental health problems.

Provider types eligible for reimbursement:

  • Licensed Psychologist (Doctoral)
  • Licensed Psychiatrist
  • Licensed Physician (MD or DO)
  • LPC
  • LMFT
  • Licensed School Psychologist (master’s level) under the supervision of a doctoral level Psychologist
  • Licensed Social Worker (master’s level)
  • LCSW (master’s level)

All providers required to have a Ph.D. must have a current DORA license.

Psychology, counseling, and social work services may be provided in an individual or group setting.

Reference Document: School Health Service Program Manual

Bright Spot
Colorado conducted a pilot study to better understand the financial impact of expanding its school Medicaid program and make data-informed decisions about how best to move forward with program expansion. The pilot found that expanding Medicaid to allow claiming for all Medicaid-enrolled students would lead to a significant increase in federal Medicaid revenue. Based on the results of the expansion study, the state moved forward with submitting a state plan amendment.

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.