Medicaid school-based services (SBS) provide essential on-site access to physical and behavioral health care to support kids in an accessible, familiar environment. But implementing these programs isn’t always easy, especially when state leaders are working with small, under-resourced teams. Many SBS staff have little opportunity to exchange ideas with others and operate in isolation, making the navigating of complex regulatory and funding landscapes and compliance requirements feel even more overwhelming. Building on lessons learned from the National Alliance for Medicaid in Education (NAME) Annual Conference, experiences in the field, and supporting states through the SBS Technical Assistance Center, we share a range of options that states can use to move the needle and improve SBS.
Narrowing behavioral health treatment gaps through innovative, right-sized approaches
Day programs provide students with structured behavioral health treatment integrated into their school day, either on campus or at an offsite facility. However, the limited number of day program slots for students needing intensive behavioral health support often forces students to choose between receiving treatment or their education. At the NAME conference, attendees heard from leaders at the Cherry Creek School District in Colorado who pursued local fundraising, federal support, and creative problem solving to create Traverse Academy, a facility that integrates comprehensive behavioral health supports into the school environment. The impact has been profound: leaders shared that in its first year, Traverse Academy supported 48 students and saved lives. Simultaneously, they built a business case for Traverse by saving millions of dollars for the district by preventing out-of-district placements.
Not every school can dedicate an entire building to integrated behavioral health supports, but they can rethink and rightsize the space they do have. The bryt program originated in Massachusetts and integrates holistic supports—including Medicaid reimbursable offerings, like therapeutic services and integrated care coordination—into a dedicated classroom. The classroom serves as a safe space to support the transition back to full participation in school for students who have fallen behind academically due to a mental health disruption. Traverse Academy’s leaders worked with bryt’s executive director when building its program, illustrating the type of cross-state collaboration that is crucial for addressing kids’ health needs in schools. The bryt intervention is currently implemented in more than 250 schools across six states, impacting more than 6,000 families.
Using telehealth to address workforce shortages and improve access to services
Workforce shortages, especially in rural areas, continue to be a barrier to getting services to students.
SBS providers are typically directly employed by local education agencies (LEAs) or brought in from the community. Ideally, providers can be integrated into the school environment, enabling them to work as part of a cohesive care team for kids. However, this type of integration is not always possible due to the limited availability of providers, and LEAs may not have the resources to recruit from outside the community. To address this challenge, some LEAs use outside help and turn to staffing agencies.
At the NAME Conference, Gallup-McKinley County Schools (GMCS), a large rural school district in New Mexico, presented about their work with a staffing agency to fill pressing provider gaps. GMCS covers nearly 5,000 square miles, making in-person coverage difficult, so the district works with an agency that can provide behavioral health and other services via telehealth. Students need accompaniment and support to help them access telehealth services, which requires most LEAs to pull staff from other duties to help administer telehealth. At GMCS, students can safely and privately access services with the help of a “telefacilitator.” Telefacilitators enable schools to provide more health care without diverting nurses and other practitioners from other essential duties.
Balancing medical necessity and early and periodic screening, diagnostic, and treatment requirements
Federal requirements specify that to seek federal reimbursement, services must be medically necessary. While there are no federal requirements for a plan of care, to support medical necessity, most states require a plan of care to be established before Medicaid can bill for services. Some states have found a middle ground. For example, in Michigan, LEAs may bill for medically necessary services up to 30 days without a formal plan of care, citing the early and periodic screening, diagnostic, and treatment (EPSDT) requirements as the supporting federal authority. As described in the Center for Medicare and Medicaid Services’ recent State Health Official letter, EPSDT creates a higher standard of coverage for eligible children than adults, entitling children under 21 to medically necessary health care, screening, diagnostic services, treatment, and more regardless of whether the services are covered under the state plan. Michigan’s policy enables LEAs to continue providing students with and billing the state for medically necessary services while practitioners develop formal plans of care.
Reinvesting school-based services reimbursement to support student health
The Centers for Medicare and Medicaid Services encourages states to reinvest federal SBS reimbursement funds into health services for schools. Each state determines how to use SBS revenue; some states’ statutes and regulations allow the revenue to be used for any purpose, which can result in it being used for other school needs or local municipal services. Some states have also developed reinvestment plans. As highlighted in a recent webinar developed by Mathematica, a Colorado state statute requires each LEA to develop a five-year, community-driven local services plan to reinvest Medicaid reimbursement dollars into supporting student health. During the 2021–22 school year, participating districts in Colorado spent $16.7 million of their $69.7 million in Medicaid reimbursement on mental health treatment and well-being activities for students and staff. Colorado also uses the reimbursement to fund school-based practitioners such as school nurses, who can screen students and help refer them to treatment in school or community settings. Investing in these services can bring in more revenue and help scale SBS services.
Engaging with the school-based services community to find the right path forward
States that are navigating policy hurdles, implementing new services, or refining existing programs can tap the SBS community for ideas about how to effectively deliver SBS and promote positive outcomes for students across the country. State staff can attend conferences such as NAME, listen to webinars from the SBS Technical Assistance Center, join the Healthy Students Promising Futures Learning Collaborative, take note of lessons learned from technical expert panels, or participate in small group cohort sessions conducted by Mathematica and other members of the SBS community to identify promising practices and find the right path forward. Do you know of a promising practice you think other states could learn from? We’d love to hear from you.
