Here are some preliminary questions to ask when trying to understand the role that Medicaid plays in school health services:
1. What are the highest-priority student health needs in my school and community?
Understanding the health issues that affect students in your school, school district and community is a key step toward identifying the changes you want to make to your school Medicaid program. This can be accomplished by examining student-level data collected via health information cards, Individualized Education Program (IEP) and 504 plans for children with disabilities, and school health provider records.
In addition, aggregate-level data available at the school and community level can be helpful in better understanding the health issues in your district. For example, all nonprofit hospitals are required to complete community health needs assessments and make this information publicly available. These assessments usually draw on public health data and present a snapshot of the leading health issues affecting all populations in the community, including children.
2. What health services do students have access to in schools? How are those services being provided?
Many students receive physical and behavioral health services in schools. Some services, like vision screenings and vaccination programs, are made available to the entire student population. These serve an essential public health function as well as provide access to preventive care that the students may not otherwise receive. Other day-to-day health services, such as bandages and ice packs, are widely available to the general student population.
For students with special needs, medical and behavioral health services that are listed in a student’s IEP must be provided in school to help with learning preparedness. These services often include physical therapy, speech therapy, occupational therapy and mental health counseling. These services also may be available to students without IEPs, but schools often have limited staffing and capacity to meet the needs of all students.
Most school districts (also known as local educational agencies, or LEAs) hire some combination of medical and behavioral health providers to deliver school-based services. These providers may be hired directly by the LEA or contracted through an external staffing service. They include school nurses, counselors, social workers, psychologists, speech-language pathologists, occupational therapists, physical therapists and others.
The makeup and quantity of the LEA-employed workforce depend on many different factors and are often driven by the district’s budget and priorities. For example, some districts have a school nurse in every school, but in many districts, a school nurse serves more than one school.
There are also health care delivery systems that provide services to students. For example, school-based health centers play a growing role in supporting student health. Some LEAs also partner with community-based providers to expand student access to services. Partnerships with local hospitals, universities, community health centers and public health departments, along with mobile clinics (such as oral health vans), provide invaluable services and expand access.
3. Can LEAs seek Medicaid reimbursement for health services provided to all Medicaid-enrolled students?
LEAs can seek Medicaid reimbursement for health and behavioral health services included in the IEPs and Individualized Family Service Plans (IFSPs) of Medicaid-enrolled students. Some states have expanded their school-based Medicaid programs to include services provided to Medicaid-enrolled students without IEPs or IFSPs.
For more information about Medicaid eligibility in your state, view the HSPF school Medicaid map with state-by-state data.
4. What types of health services does Medicaid cover in a school-based setting?
All states are required to offer comprehensive physical and behavioral health services for children, including prevention and diagnostic services, but not all of those services are covered in a school-based setting. Services Medicaid will commonly reimburse for include in-school nursing services, physical therapy and counseling.
In some states, all health services are eligible for reimbursement if they are deemed medically necessary and can be delivered in a school-based setting by a qualified school-based provider.
It is important to note that many more physical and behavioral health services may be offered in a school-based setting other than those covered by Medicaid. These services would not be eligible for Medicaid reimbursement and funding would need to come from other sources.
Identifying which services are covered in the Medicaid state plan can reveal potential health gaps — along with opportunities to pursue state policy to expand the menu of covered services in schools.
For more information about Medicaid-eligible school health services in your state, view the HSPF school Medicaid map with state-by-state data.
5. Are there restrictions on the types of providers that can be reimbursed for delivering Medicaid-eligible services?
Schools can bill for services covered in the state plan only if the services are delivered by qualified providers. The state plan will list the types of providers eligible to deliver services in school-based settings, as well as the scope of those services. Those providers, including both LEA and contract employees, might include school nurses, counselors, psychologists, speech-language pathologists, physical therapists and occupational therapists.
For more information about Medicaid-eligible school health providers in your state, view the HSPF school Medicaid map with state-by-state data.
6. What systems are in place to support your state’s school health services program?
There may be a wide range of supports and systems already in place in your state. For example, many LEAs have developed an infrastructure to help link school health services with Medicaid, including electronic case management and data collection tools. Vendors can be an important source of information and play a critical role in supporting billing and data sharing between agencies.
Building on existing tools and supports can be an effective and efficient way of strengthening and expanding your state’s school health services program.
