Strategies for Expanding School-Based Health Services Through Medicaid 

February 16, 2024

By Lisa Eisenberg, Child & Youth Health Financing Project Director, and Ruthie Caparas, Research Associate, at WestEd 

Many schools have expanded their school-based health services, particularly mental health supports, with short-term COVID-19 relief funds that are soon ending. An often-overlooked funding source that can help sustain such services is Medicaid.

Each state has a unique School Medicaid program but generally, the program can partially reimburse local education agencies (LEAs) for health services provided to students enrolled in Medicaid. In some states, services can be covered for all Medicaid-enrolled students—not just students with individualized education programs (IEPs)—and can include services like nursing, speech therapy, and mental health services.

Participation in school Medicaid requires substantive administrative effort and increased collaboration between two historically siloed entities–state education and Medicaid agencies–but providing access to health services in trusted school settings helps address the gaps in care that many students are facing, respond to overwhelming mental health needs of youth, and reduce health-related barriers to learning.

Here, we provide specific strategies for state education and Medicaid agencies to collaboratively serve the whole student by unlocking and expanding these federal funds together.

Five strategies state agencies can leverage to expand access to Medicaid-covered school health services.

To expand access to Medicaid-covered school health services, many state health agency leaders have first focused on submitting State Plan Amendments (SPAs) that either (a) expand access to additional students, such as those without IEPs, or (b) update policies that take advantage of the U.S. Centers for Medicare & Medicaid Services (CMS) agency’s new guidance, which offers some new flexibilities for schools seeking Medicaid reimbursement. New funding is also available to states to implement, enhance, and expand Medicaid school-based services. However, beyond pursuing these state-level changes, state agencies have the opportunity to take a more active role in promoting School Medicaid participation among LEAs.

State agencies can use the following strategies to expand School Medicaid participation among LEAs and foster collaboration between health and education leaders to increase access to school-based health and related services for students.

Use data to inform which LEAs to target for outreach and engagement with the state’s School Medicaid program. First, state Medicaid agencies and education agencies should collaboratively define the goals for the data analysis, such as identifying clusters of unenrolled LEAs or regions of the state that could benefit from enhanced outreach or technical assistance.

After matching LEA-level data with the state’s Medicaid provider data, state agencies can identify which LEAs are not participating in the program but should be—for example, LEAs with high proportions of Medicaid-enrolled students or LEAs in hot spots of weak community or pediatric health outcomes. The data can also be used to identify LEAs participating in the program that would benefit from technical assistance—for example, LEAs with comparatively low reimbursement rates.

Develop strategic communications for a comprehensive outreach approach. A recurring challenge within school-based health is that the Medicaid system and education system often do not “talk” to each other, although children and youth receive more effective support when healthcare and education systems coordinate services together. Accordingly, outreach strategies should leverage strategic communications for different audiences, using language that is clear, relevant, and comprehensible to LEA audiences.

Another key strategy for reaching LEAs or audiences that are unfamiliar or skeptical of School Medicaid is to engage trusted partners, such as education associations or student-serving organizations–who can serve as key messengers to promote interest in School Medicaid programs and advance LEA participation.

Improve the School Medicaid training and technical assistance available to LEAs. School Medicaid programs are complex, and complying with program requirements is challenging. While CMS is offering new flexibilities to address some of the barriers to participation, LEAs need training and individualized support to understand the new policies and requirements for program participation, and how to integrate them into their existing systems. Technical assistance can and should take many forms, from webinars and large group trainings, to learning collaboratives or cohorts, to individualized support.

Additionally, participating LEAs benefit from learning collaboratives or small cohorts that meet regularly to share best practices, identify high-friction points in their current Medicaid billing programs, and help each other integrate various School Medicaid policies into the LEA’s program.

In many LEAs, the special education department still manages the LEA’s School Medicaid participation; even years after School Medicaid program coverage expanded beyond special education, many LEA leaders still express the belief that “this is a special education program.” Beyond training LEAs about School Medicaid’s program expansion, LEAs need support breaking down siloes across departments, and often, their LEA peers can provide the best suggestions for how to do so.

Meaningfully engage LEAs and other key partners to inform policy decisions. LEAs participating in School Medicaid programs can provide key insight into making policy changes that address the challenges they face. States should facilitate input sessions that engage key partners throughout the SPA development and expansion decisions. Key partners include LEAs actively participating in the School Medicaid program, associations representing types of LEAs that are underrepresented in the program (such as small or rural districts and schools), and associations representing common school-health practitioners (such as social workers, nurses, and school counselors).

For example, in Michigan, following robust engagement with LEAs and education partners, the state Medicaid agency added Board Certified Behavior Analysts (BCBAs) and school counselors as eligible practitioners. Engaging LEAs and partners helped the state understand the diverse roles these practitioners play in school settings—which often goes beyond providing academic support and includes delivering Medicaid-covered mental health services.

Develop strong collaboration between state Medicaid agencies and state education agencies. Each of these strategies are more successful when state agencies identify a common agenda that advances policy, regulation, and implementation of school-based health supports. School-based health’s merging of two often siloed systems—health and education—presents both a challenge and an opportunity.

To build enduring cross-sector partnerships that can sustain these services, it is vital that education leaders and their health sector partners invest in both the necessary infrastructure (e.g., administrative routines, processes, and technical assistance to support school-based health services and Medicaid billing) and the necessary relationships (e.g., authentic, ongoing engagement between education and health leaders to build shared strategies to support students). Breaking down those silos at the state level can improve the integration of health and education systems at the local level, which ultimately improves the experience of students and families interacting with those systems.

Specifically, cross-agency collaboration can improve the “translation” between Medicaid language and the education system’s language; can connect School Medicaid programs with other school health initiatives, such as school mental health programs and/or community school expansion efforts; and can inform policy decisions through a more comprehensive perspective.

Examples of concrete ways to collaborate include, but are not limited to:

• bringing together a cross-agency state leadership team to review and provide input on policy changes, including SPA development;
• supporting statewide implementation efforts, including shared outreach and training efforts about program changes; and
• developing joint guidance for LEAs on effective program participation.

Integrating health services into school settings is not without challenges. It requires health partners and Medicaid agencies to adapt technical healthcare policies in ways that make sense and are digestible for education partners. And it requires LEAs and education partners to stretch and build their capacity to meet the policy and compliance requirements of the healthcare system. Yet the advancement of school-based health services is imperative, as it provides children and youth with access to the healthcare that they need to thrive at school and in life. Successful School Medicaid programs can be a cornerstone of this effort.