Illinois School Medicaid Snapshot

Expansion of School Medicaid Program
Illinois expanded its school Medicaid program in 2023 to include all medically necessary services allowed under the state’s comprehensive EPSDT benefit delivered to all Medicaid-enrolled students. Eligible services can be documented in a student’s 504 plan, Individualized Health Care Plan (IHCP), or by other methods, such as a doctor’s order.

Coverage & Billing
Illinois covers the following school-based health services:

  • Audiology services
  • Developmental assessments
  • Hearing screening
  • Medical equipment
  • Medical services
  • Medical supplies
  • Nursing services
  • OT
  • PT
  • ST
  • Psychological services
  • School health aide
  • Social work services
  • Transportation
  • Vision screening

Eligibility: Medicaid-eligible children under 21 for covered services that are medically necessary for development of IEP/IFSP or fully documented in IEP/IFSP.

Billing: The billing providers are LEAs (school districts, special education cooperatives, schools administered by the Illinois Department of Human Services, Office of Rehabilitation Services). Rendering providers are not required to enroll in Medicaid. School-based services are carved out of managed care capitation payments.

Reference Document: Illinois Handbook for LEAs

Nursing Services

Nursing services are covered as: professional services relevant to medical and rehabilitative needs, provided through direct service intervention or consultation, including:

  • Medicaid administration and monitoring
  • Catheterization
  • Evaluations and assessments
  • Tube feeding
  • Suctioning
  • Monitoring health conditions
  • Providing information and recommendations care

Providers types eligible for reimbursement:

  • Licensed RN
  • Licensed Practical Nurse
  • School nurse (LSN) with a Type-73 certificate or ISBE-equivalent endorsement in school nursing
  • LPN under direction of RN or LSN

Reference Documents: Illinois Handbook for LEAs

Behavioral Health Services

Behavioral health care is covered in schools as:

  • Testing and evaluation
  • Behavioral evaluations
  • Therapy & psychological services
  • Crisis Intervention
  • Social work services (counseling, screenings, assessments, therapy, social development, crisis intervention)

Providers types eligible for reimbursement:

  • Psychologists with Type-73 certificate or ISBE-equivalent endorsement in school psychology
  • Licensed Clinical Professional Counselor (LCPC)
  • Licensed Clinical Psychologist (LCP)
  • Licensed Marriage and Family Therapist (LMFT)
  • Psychologist Interns with ISBE approval, under direction of qualified school psychologist
  • Registered Behavior Technicians (RBTs)
  • School Psychologist
  • School Social Worker
  • Social worker with Type-73 certificate or ISBE-equivalent, endorsed in school social work
  • Licensed Social Worker (Master’s)
  • Licensed Clinical Social Worker (LCSW)
  • Social Work Intern with ISBE approval under direction of qualified social worker

The state plan may list other practitioners not described above (e.g., APN with psychiatric specialty, “Qualified Mental Health Professionals”), including practitioners under supervision.

Reference Document: Illinois Handbook for LEAs

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