Access to health care is impacted by a range of social determinants, such as access to safe housing, transportation, job status, and level of education. For children, the ability to access care is also impacted by the stability of their home life and their caregivers’ physical and mental health status and ability to take time off work. These challenges are acutely felt by people living in rural communities, where an estimated one in four report being unable to access health care when they needed it, as well as people from racial and ethnic groups who experienced historical racism by the medical system, which fostered well-founded distrust of seeking care from providers in traditional office settings. When we add the COVID-19 pandemic, which contributed to a 40 percent decline in health screenings and a 75 percent decline in dental services among American youth enrolled in Medicaid and the Children's Health Insurance Program (CHIP), the importance of accessible care becomes even more clear. Thankfully, schools are uniquely positioned to help make health care more accessible and equitable… if given the right support.
School-based care isn’t new, but new guidance and funding present a unique opportunity for schools to help provide accessible, equitable care.
Schools understand the value of healthy students and are places where health care happens. For decades, schools have been providing health services that support classroom learning to the 14 percent of public school children who have special health care needs, including those with chronic physical, developmental, behavioral, or emotional conditions. Moreover, about 37 percent of all school-age children and 79 percent of school-age children living in poverty receive health coverage through Medicaid and CHIP. Despite the need, there is a shortage of school nurses, and those working in schools are spread thin, often working at multiple schools on different days. However, schools can work to reverse this trend by seeking federal reimbursement for the Medicaid services provided in school and using the funds to pay for more school-based providers (for example, school nurses, therapists, social workers) that serve children covered by Medicaid.
We’ve worked together to support the National Association of School Nurses’ (NASN’s) Champions for School Health (CSH) initiative— a grant program that empowers school nurses and community-based organizations to deliver equitable access of COVID-19 and routine immunizations to young children and adolescents. At one of the CSH grantee’s vaccine clinics, 90 percent of the kids in attendance were enrolled in Medicaid. School nurses understand the health-related social needs of their community. For example, a school nurse grantee in Washington planned a mobile vaccine clinic in her rural community because she “knows that she needs to meet people where they are at, literally.” We also know that people access health care services when it’s more convenient to do so and when they trust the provider. That creates unique opportunities for school nurses to serve as an accessible, trusted provider in many underserved communities.
In August, the Center for Medicaid and CHIP Services (CMCS) released an informational bulletin affirming the importance of school-based health services to children on Medicaid and CHIP. They also committed to issuing additional guidance and resources for states, including the release of an updated Medicaid and Schools Technical Assistance Guide and Administrative Claiming Guide that will provide more detailed information regarding reimbursement for Medicaid-covered services provided in schools, the creation of a technical assistance (TA) center, and $50 million in grants in conjunction with the Department of Education to support state Medicaid agencies and local educational entities implementing or enhancing school-based services.
Taking advantage of this moment will require overcoming persistent challenges.
Complex reimbursement processes deter many schools from participating in Medicaid’s provider network, especially rural districts where accessibility is critical. A survey from the American Association of Superintendents noted 84 percent of school districts that said they do not seek Medicaid reimbursement were rural, and more than 20 percent of these rural districts were high poverty. Respondents noted the costs and time involved with tracking services for reimbursement. Similarly, NASN’s 2022 workforce study shows that only 42 percent of school nurse respondents noted billing Medicaid.
Only 17 states have amended their Medicaid state plans to explicitly cover school-based health services and providers since the reversal of the 2014 free care rule (a policy that prohibited schools from being reimbursed by Medicaid unless a child had an individualized education program [IEP]). States in the Healthy Students, Promising Futures Learning Collaborative experienced consistent challenges related to state Medicaid plans that did not recognize school-based health providers (such as school nurses, school psychologists, and school social workers) as eligible for reimbursement and still included outdated restrictions on reimbursing care for Medicaid-enrolled students who did not have an IEP.
To get it right, keep it simple.
As CMCS prepares the additional school-based health services guidance and launches the TA center, policymakers should keep these resources simple and actionable, while helping state Medicaid agencies and local educational entities learn from states that are successfully using schools as access points. Specifically, we recommend that the guidance and additional resources help:
Codify school nurses and other school-based health care staff as eligible for Medicaid reimbursement. CMCS should issue state plan amendment processing tools and templates to help states remove outdated restrictions on who is eligible for services and ensure that services like behavioral health, immunizations, and Early and Periodic Screening, Diagnostic, and Treatment services are covered. The TA center should be prepared to help state Medicaid agencies think through involving state and local educational entities in the process so that state plan amendments cover the services students need most and schools are best equipped to provide.
Both Kentucky and Louisiana offer examples of how a state Medicaid program can be amended to increase access to school-based services. Kentucky’s School-Based Health Services Program allows schools to enroll as Medicaid providers so that school-based health providers may provide and be reimbursed for medically necessary services for all Medicaid-eligible children, not just those with an IEP. The program notes that expanding reimbursement collects more federal Medicaid dollars for schools and reduces the burden on state taxpayers. Louisiana’s School-Based Medicaid Program covers physical and mental health care, routine screenings, and occupational and behavioral therapies. Receiving services during school doesn’t limit students from receiving care after school or on weekends from another contracted provider, because the state treats school-based services as carved out of the beneficiaries’ comprehensive health plan.
Share best practices about how states can incorporate school-based health services with its managed care program. As of 2020, more than 80 percent of all Medicaid beneficiaries were enrolled in some type of managed care. Any expansion of school-based health services should consider how managed care organizations can leverage schools to provide health care.
California and Colorado both implemented incentive programs with managed care entities to increase access to preventative care services. California’s Medi-Cal managed care program funds the Student Behavioral Health Incentive Program, which fosters collaboration between managed care organizations and school districts to increase access to preventative care through early intervention to behavioral health services. One benefit of providing mental health services for children during school is reducing students’ out-of-classroom time and parents’ time off work. Colorado’s Boulder Valley School District partnered with Colorado Medicaid’s Regional Accountable Entities to improve care coordination and increase well visits for elementary-age children. A care coordinator was placed in select schools to assist families in accessing health care, and a mobile van came to the school to provide physical exams to Medicaid-enrolled children and incentives to participating families.
Use tools and compile best practices to support state and local educational entities in implementing the soon-to-be-updated Medicaid School-Based Administrative Claiming Guide. The TA center should provide simple tools for school-based providers that ease the administrative burdens associated with adhering to Medicaid billing standards. Most school nurses operate without a clerk to track the services delivered to students and assist with seeking reimbursement from Medicaid. This reality increases the workload for school nurses to provide services to students and manage billing operations.
States like California and Michigan have attempted to streamline the reimbursement process with centralized billing, such as at the school district level, that allows all school-based providers to bill under a single provider ID. School nurses in the Sacramento area only have to submit a service tracking form to the centralized biller, rather than seek reimbursement as an individual provider, giving school nurses more time to care for students.
Failure to act deepens health inequities for students enrolled in Medicaid.
Implementing these recommendations will expand access to health care in schools, especially underserved rural and high-poverty communities. Schools will be positioned to provide mental and physical health care services for children, as this is where children spend 180 days each school year, removing the need for transportation, caregiver time off work, and missed classroom learning. When local educational entities are empowered to navigate the Medicaid reimbursement process, there will be more funds for hiring school nurses, social workers, speech language pathologists, and countless other providers to meet the health needs of students. Also, schools that are already providing in-school services to Medicaid-enrolled children but are unable to seek reimbursement will no longer be leaving money on the table. Health inequities are perpetuated by a variety of factors, including poor access to care, and failing to act on these recommendations means state Medicaid agencies will miss an opportunity to ease the long-lasting health and social impacts children face when their health needs remain unmet.
