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Schools are places where health care happens, an essential part of the nation’s public health infrastructure. During COVID-19, schools across the country responded to the call to action to vaccinate students and community members and to provide nutritious meals and mental health counseling services to kids — despite shuttered classrooms. Even before the pandemic, schools were providing care that supports classroom learning to the 14% of public school children who have special health care needs, including those with chronic physical, developmental, behavioral or emotional conditions.

A recent study in JAMA Pediatrics found that schools are “the de facto mental health system,” providing services to 57% of adolescents who needed care before the pandemic. In 2019, the Centers for Disease Control and Prevention found 37% of high school students reported persistent feelings of sadness or hopelessness; 19% having seriously considered suicide; and 9% having attempted suicide. And the need is even more profound now. From April to October 2021, the proportion of pediatric emergency room visits that were mental health-related increased nearly a third for ages 12 to 17 and 24% for children aged 5 to 11.

As is always the challenge in public education, the need far outweighs the resources available. But changes in federal Medicaid payment policy have paved the way for schools to access millions of dollars to fund school nursing, behavioral health and other services in schools.

For example, in 2014, the Centers for Medicare and Medicaid Services broadened a longstanding policy to allow schools to be reimbursed for providing covered services to any Medicaid-eligible child. But only 17 states have taken advantage of this funding stream by amending their Medicaid state plans (the document that defines the types of services and providers that are eligible for reimbursement) to reflect the new policy.

Michigan altered its state plan to include behavioral health analysts, school social workers and school psychologists as covered providers, while the state legislature approved $31 million to fund behavioral health providers in schools. Since this change, there has been about a 6% increase in the amount of Medicaid reimbursement being directed to schools. Louisiana amended its Medicaid state plan in 2015 and saw a 30% increase in its Medicaid revenue as the school nursing workforce grew 15%. Last year, Georgia changed its plan to allow Medicaid to pay for more school health services. Half of Georgia’s kids are covered by Medicaid or the state’s PeachCare system, so this shift is dramatic and creates an opportunity to bring hundreds of millions of dollars to Georgia’s school districts to support the most vulnerable students.

More states can position themselves to leverage Medicaid funding for schools by clarifying and expanding the scope of covered school health services and providers in their state Medicaid plans. But, some schools face additional barriers, such as complex billing processes. That issue is being addressed in the Bipartisan Safer Communities Act, which directs federal policymakers to issue guidance, launch a help center and release $50 million in planning grants in the next 12 months to assist state Medicaid agencies and local educational entities in overcoming these challenges. These supports are likely to include strategies and tools to reduce administrative burdens for billing, especially for rural schools, and best practices that schools and state Medicaid agencies can use to amend state plans so the services students need, and the providers who deliver them, become eligible for reimbursement by Medicaid.

The National Healthy Schools Collaborative’s Ten Year Roadmap for Healthy Schools prioritizes optimizing the ability of schools to bill Medicaid for school health services and, importantly, recognizes that when health and education officials fail to collaborate, it makes it very difficult to achieve this end. School nurses, district administrators and state education officials must get ready to collaborate with state Medicaid agencies to take advantage of supports the act will provide — preparing data on the health needs of their school communities, the types of services provided in schools (and that schools could start providing if reimbursed) and the types of licenses and credentials required for personnel delivering services in schools. State Medicaid officials can then make sure state plan amendments reflect the exact types of services students need and that schools are capable of delivering.

How else can school nurses, district administrators, and state education officials prepare?

• Find out which states reimburse for Medicaid. Share information about the forthcoming supports for increasing access to Medicaid funds for school health services and providers.
• Engage with school or district Student Health Advisory Committees to collect community input on the health services they want to access, understand school communities’ unmet health needs and increase awareness of the availability of Medicaid services in school.
• Review the Community Health Needs Assessments from local hospitals to further understand the significant health needs of the community and the resources available to address those needs.
• Make connections at the state’s Medicaid agency and advocate for reimbursing school providers for specific services (e.g., counseling, personal care, case management, immunizations) that are a priority for students.