Overview of Medicaid and School-Based Services

The Medicaid program is a partnership between the state and Federal governments. CMS provides Federal Financial Participation (FFP) to states by matching eligible state program expenditures at a specified percentage through a quarterly grant award process. CMS also oversees state programs to ensure that they are consistent with federal requirements. Within federal statutory and regulatory requirements, states operate the Medicaid program and make decisions about program administration, eligibility, services, and covered services. States are also responsible for establishing methodologies to pay providers for furnishing health care services to Medicaid beneficiaries. The methods and policies that states use to determine how their Medicaid programs operate are described within a written Medicaid State plan, which is approved by CMS. In addition, states provide guidance to providers through program manuals and billing instructions that are generally available on state Medicaid agency websites.

School-based services (SBS) play an important role in the health of children and adolescents. Although schools are primarily providers of education-related activities, the school setting offers a unique opportunity to enroll children in Medicaid and facilitate access to coverage as well as provide health services directly to ANY Medicaid enrolled children. Schools provide a venue to enhance early identification of health needs and connect students to a broad range of health care services, including behavioral health resources. Specifically, SBS providers can help promote health and educational equity and increase school attendance by:

1. Helping eligible students enroll in the Medicaid program.
2. Connecting students’ Medicaid-eligible family members with Medicaid health coverage.
3. Providing Medicaid-covered health services in schools and seeking payment for services furnished. Health services can include any covered service, including EPSDT services, at the State Medicaid agency’s discretion.
4. Offering Medicaid-covered services that support at-risk Medicaid eligible students.
5. Providing Medicaid-covered services and performing Medicaid administrative activities to improving student wellness.
6. Providing Medicaid-covered services that reduce emergency room visits.
7. Providing Medicaid-covered services and performing Medicaid administrative activities that promotes a healthy environment and promotes learning.

It is important for SBS providers to receive reimbursement to cover costs associated with delivering and administering covered Medicaid services provided to children in school settings.
States and schools have long relied on Medicaid to fund covered services provided to children with disabilities under the Individuals with Disabilities Education Act (IDEA). However, more recently, schools have expanded SBS to include routine preventive care, on-going primary care, and treatment to enable children and adolescents’ access to care in the setting where they spend the most time.

Even if a school does not directly furnish medical services, schools can conduct and receive reimbursement for Medicaid and CHIP outreach and enrollment activities. Schools offer a unique venue for Medicaid and CHIP outreach to reach eligible but unenrolled children and to inform families about the programs. Schools can also be a catalyst for encouraging eligible Medicaid and CHIP children to obtain primary and preventive services, as well as other necessary treatment services.

In order for Medicaid to reimburse for health services provided in the schools, the services must be included among those listed in the Medicaid statute (section 1905(a) of the Act) and covered within the state’s Medicaid State plan or be available under the mandatory Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirement. Expenditures for direct SBS that are within the scope of Medicaid coverage and furnished to Medicaid enrolled children may be claimed. Additionally, expenditures for administrative activities in support of the Medicaid program, including outreach and coordination, may be claimed as costs of administering Medicaid.

For questions or comments regarding School-Based Services, please contact SchoolBasedServices@cms.hhs.gov.