Here’s a look at how seven states are using federal policy to improve access to and funding for school health services. Though each state took a slightly different approach, they all leveraged the opportunity to expand access to covered services and providers. An up-to-date state activity tracking sheet is available here.
In 2017, Massachusetts became the first state to receive approval from the Centers for Medicare & Medicaid Services (CMS) for a state plan amendment that expanded reimbursement for all Medicaid-enrolled students.
Massachusetts also added several specific services to the list of covered services and then added the provider types already qualified to deliver those services. This was an effective way to streamline the program and get reimbursement for services commonly delivered in schools.
In addition, the state figured out how to separate calculations based on a provider’s time spent delivering either IEP or non-IEP services, as well as Medicaid eligibility rates. This important development helped the state ensure appropriate reimbursement for each set of students. Massachusetts also has legislation pending that would funnel Medicaid reimbursement from school-based services back into school nursing programming and services.
For more information, view this presentation from MassHealth: Massachusetts School-Based Medicaid: Lessons Learned from Expansion/Free Care Preparations
Case Study: Expanding School-Based Medicaid in Missouri
Missouri’s state Medicaid agency, HealthNet, adopted a policy in 2018 that expands Medicaid reimbursement to include behavioral health services delivered to all Medicaid-enrolled students. Due to the way the state plan is written, Missouri did not need to apply to CMS for an amendment to make this change but rather was able to execute these changes through state rulemaking.
At the same time, Missouri also implemented guidance that allows community behavioral/mental health providers to deliver services in the school setting when a school district determines it appropriate to do so, and it clarified reimbursement policies. For more on the role of community mental health centers delivering services in schools, view guidance from the Missouri School Boards’ Association.
This Medicaid policy change did not add new types of qualified providers. Rather, it gave an existing group of providers the ability to bill for services delivered in schools. Though this is a different tactic than other states have used, the policy clarification resulted in an expansion of the types of providers eligible for reimbursement and may be a model for further enhancing access to school-based behavioral health services.
CMS approved Colorado’s state plan amendment in February 2020. In addition to expanding reimbursement to cover all Medicaid-enrolled students, the amendment added licensed applied behavior analysts and speech-language pathologist assistants as Medicaid-eligible providers.
Before applying to amend the state Medicaid plan, Colorado conducted a rigorous pilot project to examine how expanding Medicaid in schools might affect both large/small and urban/rural districts. Phase three of the pilot examined the financial impact of including school-based health providers not qualified to claim under Medicaid. The results were positive. The state now estimates it will receive $8 million in additional federal Medicaid funds per year as a result of expanding reimbursement to cover all Medicaid-enrolled students and adding more provider types.
When Michigan expanded its school-based Medicaid program via a state plan amendment in 2019 to allow billing for all Medicaid-enrolled students and for all EPSDT services, it also took the opportunity to clarify and expand the types of qualified providers. These changes were intended to harmonize the provider qualifications and scope of practice rules across state Medicaid.
Newly added provider types include nurse practitioners, physician assistants, clinical nurse specialists, marriage and family therapists, behavior analysts, school social workers and school psychologists.
The expanded school Medicaid program allows for more services to be reimbursed by Medicaid and provides a sustainable source of funding for school health services. Michigan estimates a $14 million increase from billing for services delivered by school psychologists alone. Read more about how Michigan is expanding access to mental health services.
California received CMS approval in April 2020 to expand its school Medicaid program to cover all Medicaid-enrolled students. California added additional services, including respiratory therapy, personal care services, and orientation and mobility assessment.
California also added additional types of school-based providers to its state Medicaid plan, including registered associate clinical social workers, personal care assistants, licensed occupational and physical therapy assistants and more.
CMS approved Kentucky’s SPA in 2019. In addition to Kentucky school districts being able to bill for services delivered to all Medicaid-enrolled students, the state is using funds for school counselors and mental health services mandated in the School Safety and Resiliency Act of 2019, which did not provide specific funding.
“Approval of this amendment is a game-changer,” said Adam Meier, secretary of the Cabinet for Health and Family Services, when the SPA was approved in 2019. “This will provide additional resources to support increased access to mental health services for students using money already being spent by school districts.”
Louisiana received CMS approval in 2015 to expand billing for school nursing services. As a result, federal Medicaid revenue jumped 35 percent. Based on this success, the state made another round of changes and received approval in April 2020 to expand school-based billing for licensed EPSDT providers.
Louisiana’s 2020 policy changes are noteworthy because the state expanded its school-based Medicaid program to include all EPSDT-covered services, as opposed to a specific list of covered benefits.
The state plan amendment includes language on licensure that can provide a model for other states considering a similar expansion:
Anyone providing EPSDT services must operate within their scope of practice license or certification under the supervision of a licensed practitioner. Licensed practitioners assume professional liability for unlicensed/certified practitioners under their supervision and within their scope of practice.