Pop quiz: How many schools have a full-time nurse on staff? If you guessed anything above 40%, you would unfortunately be wrong. Only 39% of schools in the nation employ full-time school nurses. If you think the numbers on school behavioral health professionals would be better, you would unfortunately be wrong again. 8 million students do not have access to a school counselor, and 3 million do not have access to any other school support staff such as counselors, psychologists, and social workers.

We know that COVID-19 has taken a toll on the mental health of students, and with the COVID-19 vaccine approval recently being extended to children ages 5 to 11, school health professionals are more integral in addressing the complex physical and mental needs of students than ever before. While schools can be an essential setting for children to receive screenings and preventative services, funding often restricts capacity to administer these services. However, the expansion of Medicaid to reimburse for school-based health services provided to Medicaid-enrolled students has proven to be an important tool in overcoming issues of funding and staffing. Despite this, states have not been as quick to take up this option as we hoped.

Two new resources released by the Healthy Schools Campaign shed light on the state barriers to advancing Medicaid reimbursement in schools. First, the Healthy Schools Campaign has created an interactive map of school Medicaid programs, requirements for providers, and states that are putting best practices into action. This resource is available on the Healthy Students Promising Futures website here.

As shown by the map, to date, only 15 states have implemented the Medicaid free care policy reversal to expand Medicaid coverage to Medicaid-enrolled students in schools. As we’ve discussed here on Say Ahhh!, state implementation of the Medicaid free care policy reversal – a reversal made by 2014 guidance from the Centers for Medicare & Medicaid Services – is a critical first step to advancing Medicaid coverage in schools. The lack of state action to implement the free care policy reversal has left the majority of states and thus schools limited in their ability to bill Medicaid for services provided to most Medicaid-enrolled students in schools (i.e., students without an Individualized Education Plan or IEP). Schools in states that have implemented the Medicaid free care policy reversal, however, are able to bill for such services. In states like Michigan, which took advantage of the Medicaid free care policy reversal flexibility by submitting a Medicaid state plan amendment and implementing a program in 2019, findings have shown improved access to behavioral health services and additional funding for schools.

In addition to the interactive map, the Healthy School Campaign also issued a report, State Medicaid & Education Standards for School Health Personnel: A 50-State Review of School Reimbursement Challenges. Reviewing state Medicaid reimbursement standards for both states that have implemented the free care reversal policy and those that still limit Medicaid reimbursement to students with IEPs, the report identifies states where there is misalignment between standards for nursing and behavioral health personnel, and requirements that could negatively impact schools from receiving proper reimbursement for Medicaid-covered services. By analyzing regulations, state Medicaid plans, managed care contracts, provider manuals and billing guidance, and other publicly available information on Medicaid requirements, states were grouped into three categories: (A) Appears to be alignment; (B) Appears to be misalignment; and (C) Unclear/lacks clarity.

Overall, the report found that there are various types of misalignments between provider qualifications in Medicaid and standards used by other state agencies for school health personnel in states. For example, about a dozen states had some form of misalignment between provider qualifications for school nurses under Medicaid and the state education standards to qualify school nurses and other personnel to deliver school nursing services. For behavioral health personnel, the report found misalignment between Medicaid and state education agency standards in 20 states.

Across the states, the most common types of misalignments found were:

• Special certification for school health personnel not being recognized by Medicaid
• Provisional licensure program not being recognized by Medicaid
• Medicaid payments limited to fewer types of school health personnel
• More rigorous Medicaid requirements for school health personnel
• Medicaid restriction on payment for contract school health personnel 

So, how do we solve these issues? (No, this is not another pop quiz!) Though there is no easy answer to this question, however, the report highlights the following practices adopted by states that mitigate the risk of reimbursement being denied or unclaimed:

• Making Medicaid information easy to find and understandable for schools, including providing comprehensive manuals on well-organized state agency websites, such as in the example of Colorado, and easy-to-access online training in Iowa.
• Coordinating information from state Medicaid and education agencies. In Washington, DC, coordination comes by way of tasking the local education agency with helping schools with Medicaid reimbursement, including providing support with Medicaid-related compliance matters.
• Recognizing special certification for school health personnel in Medicaid to help address workforce shortages and create alignment in the 20 states that do not accept this type of certification for the purposes of reimbursement.

The report recommends that states that have not yet adopted these practices do so, in addition, it recommends that in addition to implementing the Medicaid free care policy reversal, states align their Medicaid rules with state education and other agency standards for school health personnel. Other recommendations include: establishing cross-agency workgroups with school officials, exploring ways to offer schools more flexibility in Medicaid, and clarifying whether Medicaid pays for services that school nurses delegate to unlicensed school personnel.

It’s been a long journey in school Medicaid reimbursement since the 2014 free care policy reversal, and that road continues ahead. We are grateful to the states that have started to pave the way!