A child enters Nurse Smith’s* office wheezing, not feeling well. The school nurse speaks softly to the child, calming her breathing and talking her through a series of breathing exercises to help her control her asthma. She assists the child in taking her albuterol, a medication that helps control asthma attacks. After a quick conversation with the parent and a check-in with the local pediatrician, the child returns to the classroom. This is a typical interaction between Nurse Smith and her students at a small elementary school in rural North Carolina. The presence of a school nurse and her role in managing chronic conditions in collaboration with a local pediatrician is not only keeping children healthy, but also keeping them in school and out of emergency rooms, the costliest of care settings. Yet, in North Carolina, like many other states, school health services are limited and school nurses are overcommitted. In February, North Carolina received CMS approval to expand Medicaid school-based services, creating a new opportunity to support both school based providers like Nurse Smith and expand health services provided in school settings.
Recognizing that school-based services are an instrumental source of care for children, CMS issued new guidance in 2014 that reversed a longstanding rule that limited billing for school-based services to only those related to individual education plans (IEPs). IEPs are plans developed with parents and educators to support children in meeting educational goals. Often, health services are required for some students to achieve these goals. The new guidance allows Medicaid reimbursement for services provided to any Medicaid-enrolled child as long as their services and providers are included in the Medicaid state plan and there are appropriate billing mechanisms in place. Since 2014, there have been only a handful of states to take advantage of this new opportunity to expand Medicaid services for children in the school setting. While states may have different pathways to expand the provision of school-based services, most require a state plan amendment (SPA)—a change to their Medicaid state plan. North Carolina is the latest state to submit, and have successfully approved, a SPA to expand provision of school-based services for Medicaid enrolled children.
Prior to submitting its SPA, North Carolina schools could only seek Medicaid reimbursement for certain services if they were listed in a Medicaid-enrolled child’s individual education plan (IEP). With CMS’ approval of the SPA, North Carolina expanded the documentation requirements needed for Medicaid reimbursement of school-based services. Schools can now be reimbursed for services listed in a Medicaid-enrolled child’s IEP, a section 504 Accommodation Plan, an Individual Health Plan (IHP), or a Behavior Intervention Plan (BIP). In addition, the SPA also added vision services as being eligible for Medicaid reimbursement. With these changes, North Carolina is expanding the availability of school services to other students, rather than restricting services to only children who require an IEP. School-based providers will now be able to seek Medicaid reimbursement for Medicaid-enrolled children. This is a first step in expanding access to school services and a step towards integration of school services within the larger health care delivery system.
North Carolina’s SPA comes at a time of change for the state, which ranks 33rd in overall health. Recent initiatives in the state include value-based payment reform models and the establishment of a primary care case management program. While the SPA aligns with the transformative changes underway in North Carolina, there are still challenges. For example, schools and LEAs are not required to participate in Medicaid and they do not automatically qualify for Medicaid reimbursable services. Additional efforts are also needed to ensure that Medicaid eligible families are enrolling in Medicaid so their child can receive services. Finally, rural areas are strained, lacking school nurses and other providers; telehealth is not included in this expansion but has been shown to provide robust and timely access to care that keeps children in classrooms.
While North Carolina joins states like Massachusetts, South Carolina and Louisiana that have received CMS approval to increase availability of school-based services, it is imperative that other states also leverage current policies to accomplish this. States must engage stakeholders to advocate for expansion of school-based services to provide necessary care for children and support school nurses like Nurse Smith in delivering timely and effective care.
Our guest blogger, Andrea Chu, is an intern at Community Catalyst.
*We are not using real names in order to protect the identities of our storytellers