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New Report and 50-State Map: State Medicaid & Education Standards for School Health Personnel

November 8, 2021

By Stacie Weeks, JD, MPH, Principal, and Julia Smith, JD, Director, Medicaid Transformation and Financing

In partnership with the national Healthy Schools Campaign, Aurrera Health Group is excited to announce the release of State Medicaid & Education Standards for School Health Personnel: A 50-State Review of School Reimbursement Challenges, a report showcasing the findings of a comprehensive review of state Medicaid requirements for school health personnel. The findings provide new insights into the challenges faced by schools in seeking Medicaid reimbursement for the health care services that school nurses, social workers, psychologists, and counselors provide in the school setting. The report also discusses challenges related to billing for personnel who are authorized to work in schools but may lack the professional qualifications required by Medicaid, such as professional licensure by a state health care board, for reimbursement.

The report and a 50-state interactive map, State Data on Medicaid-Eligible School Health Services and Providers is available at Healthy Students, Promising Futures, a Healthy Schools Campaign initiative to help states and school districts increase funding for and expand access to Medicaid-funded school health services.


Background and Project Approach

To conduct this review, the Aurrera Health Medicaid Transformation and Financing team reviewed public information from each of the 50 states and the District of Columbia on Medicaid requirements for school-based health services and compared it to state education standards used to authorize health personnel to practice in the school setting, specifically for school nursing and behavioral health services. The review focused on school-based services provided in the school setting under which the school bills Medicaid – the report does not focus on community health clinics or school-based health centers that partner with schools to provide services to students, but bill Medicaid directly for services rendered. 

Schools can provide an accessible and reliable environment for connecting children to important health care and behavioral health services. Unfortunately, many schools lack adequate staffing to meet the needs of their students. The shortage of school health personnel — especially school nurses and behavioral health providers — has been amplified by the ongoing COVID-19 pandemic.

To address these challenges, it is critical that states ensure that school health personnel who are authorized to provide services under state education standards are also qualified to provide services that can be reimbursed through Medicaid. However, this is not the case in far too many states.


The Problem

When Medicaid provider rules are not aligned with state practice standards for school health personnel, schools are unable to receive reimbursement for Medicaid-covered services provided to Medicaid-enrolled students. Moreover, multiple requirements from various state agencies when hiring school health personnel can be confusing, if not overwhelming, for schools to navigate.

In rural areas, these challenges are exacerbated by workforce shortages. In some cases, schools may have no choice but to hire lower-level personnel who, under state law, may be authorized to provide student health services, but are not eligible for Medicaid reimbursement because they do not have the additional educational qualifications and/or licensure standards for traditional health care professionals.

When comparing information from state agencies, our team found that about a dozen states have misalignment between Medicaid reimbursement requirements and state standards used to authorize school nurses and other personnel to deliver nursing and related services in the school setting. Further, 20 states have misaligned standards for school-based behavioral health personnel, such as social workers and psychologists.

For school nursing services, the most common form of misalignment was a lack of clarity as to whether Medicaid reimbursement is available for services delegated by registered nurses to unlicensed personnel, such as school health aides.

Where school nurses are in short supply, it is critical that nurses be able to delegate tasks to lower-level personnel — as permitted by the vast majority of state scope of practice laws — and that those tasks be eligible for Medicaid reimbursement.

For school behavioral health services, the most common form of misalignment was a mismatch between state education agency and state Medicaid agency educational and licensure requirements for school psychologists, school social workers, and school counselors.

In many cases, state education agencies have established expedited certification or credentialing programs to authorize certain types of health professionals to practice in the school setting without requiring licensure by one of the state health care boards.

When state Medicaid programs do not recognize professionals certified by these programs for payment for services provided in school settings, access to care for students is compromised.  For example, in many states, a master’s level social worker can become certified as a school social worker but not a licensed clinical social worker (LCSW) or licensed independent clinical social worker (LICSW). State Medicaid agencies require, as a condition of reimbursement, that all social work services be provided by an LCSW or LICSW.  Some states permit health personnel to practice in the school setting with a temporary or provisional license to practice but the state Medicaid program does not recognize these conditional licenses.


Hope for the Future

Our report also outlines several promising practices states can implement to increase Medicaid reimbursement for school-based health services.  School districts have opportunities to leverage these strategies to expand access to school-based services for Medicaid-eligible children and youth and begin to achieve financial sustainability. These include:

  • Ensuring information about available school-based Medicaid health services is readily accessible to schools, parents, and other stakeholders;
  • Coordinating state agency oversight of Medicaid and educational standards for school health personnel and aligning requirements; and
  • Recognizing special state certification programs for school health personnel as qualified for purposes of Medicaid reimbursement.

Stacie Weeks and Julia Smith are available to provide additional information about their research findings. Send them an email here.

For more information on these findings and the report’s final recommendations for states, download the report here. Additional information is also available on an interactive online map.



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