School Health Services Matter More than Ever
Increasing access to school health services presents an important opportunity to reach vulnerable and underserved children and support children’s health and achievement.
The prevalence of chronic diseases—including asthma, obesity and diabetes—has doubled among children over the past several decades. Today, one in four American children have health issues that affect their ability to succeed in the classroom, double the number just 30 years ago. This has implications not only for children’s long-term health but also for their opportunities to learn and succeed at school.
Studies show that school health services can directly support the goals of the health and education sectors.
Why Are School Health Services Important to Educators?
School health services—including physical, mental, dental, vision and behavioral services—can serve as powerful supports for education. Student health problems are one of the leading causes of absenteeism and, as a result, can have a significant impact on academic achievement. For example, children with oral health problems and children with asthma are over three times more likely to miss school than their peers.
In addition, low-income minority students are at increased risk of health problems that hinder learning. Research continues to link health disparities to the minority achievement gap and suggest that unless we address these health disparities, efforts to close the education achievement gap will be compromised. Dr. Charles Basch of Columbia University Teachers College has pioneered research identifying seven health disparities that have a significant effect on education. He points out that health disparities and wellness have been largely overlooked in efforts to improve student success and learning. If health problems compromise students’ motivation and ability to learn, he shows, educational efforts such as teacher preparation, financing, and curriculum are jeopardized. He argues that an integrated and collaborative approach to addressing these disparities, including access to school health services, can bring about great results for learning.
Additional studies demonstrate the impact that access to school health services can have on student outcomes. For example:
- Multiple studies show that school nurses reduce absenteeism and a higher nurse to student ratio is related to better attendance.
- According to the American Public Health Association, school-based health center use is associated with gains in grade point average (GPA) and attendance; students without access to a school-based health center lose three times as much in-class time as students enrolled in a center.
- Studies show that a nurse in the school may provide a principal with nearly an hour each day allocated to their role as instructional leader.
- Teachers and principals spend on average 1 hour of the 6.7-hour school day on student health issues.
Why Are School Health Services Important to Health Providers?
With over 50 million children attending public schools across the country, partnering with schools presents an important opportunity for the health sector to reach vulnerable and underserved children.
Studies show that health care provided in school settings can reduce healthcare costs and improve access to and quality of care. For example:
- School health services have been shown to reduce students’ emergency room visits, resulting in significant healthcare savings.
- School health providers facilitate enrollment in public health insurance programs, including Medicaid and the State Children’s Health Insurance Program.
- Schools with school nurses have higher immunization rates than schools without, which results in a healthier student population and decreased rates of absenteeism for students and staff.
In addition, as the health sector increasingly prioritizes prevention, population health, care coordination and chronic disease management, it is critical for the health system to think about partnerships with those who can offer comprehensive health services. School health services can help health systems engage with otherwise hard-to-reach populations and meet many of the new metrics they are being held accountable for under the Affordable Care Act.
The Current Environment
At HSC, we believe that prioritizing health in schools will yield lifelong benefits for the more than 50 million children currently in America’s schools—and that our nation’s future hinges on giving all children a chance for a healthy, brighter tomorrow.
Providing students with access to school health services, including physical and mental health services, is a key component of a healthy school environment and a proven strategy for ensuring students are healthy and ready to learn.
Despite the clear connection between school health services and student success, more than half of public schools currently do not have a full-time school nurse or school counselor and only five percent of the nation’s students have access to a school-based health center. Significant disparities exist in access to school health services. Students in low-income schools are less likely to have regular access to a school nurse compared to their peers in higher-income schools.
Now, our country’s healthcare system is transforming and we have the opportunity to transform students’ access to health services in school, thereby supporting both health and learning.
With the passage of the Affordable Care Act, new opportunities exist for schools and school health providers to better integrate with a health care system that increasingly prioritizes prevention, population health, care coordination and chronic disease management. In addition, new financing arrangements, such as accountable care organizations, push the health system to think about partnerships with those who can offer comprehensive health services. Schools are well positioned to be a major part of this transforming health system.
Increasing access to school health services is a key strategy for ensuring students have regular access to the health care they need.
Increasing access to school health services presents an important opportunity to reach vulnerable and underserved children and support children’s health and achievement. That’s why HSC is committed to increasing access to school health services and ensuring that schools are better integrated within the transforming health care system. One of HSC’s key strategies for accomplishing this is supporting implementation of the recent change in federal policy which removes a major barrier to delivering school health services: the free care policy.
This section of HSC’s website focuses on HSC’s work to leverage the recent change in the free care policy to increase access to school health services.
The free care policy prevented Medicaid funds from being used to pay for services that are available without charge to everyone in the community. This policy had long been an impediment to allowing school health providers, including school nurses, to receive reimbursement from Medicaid for services delivered to non-special education students enrolled in Medicaid. As a result, the 2014 clarification of the free care policy removes a major barrier to accessing funding for school health services. The information that follows in this section is intended to provide school stakeholders, advocates and policymakers with the information and strategies needed to leverage this key opportunity to ensure children across the country are able to thrive.
The Free Care Policy
On Dec. 15, 2014, the Centers for Medicare and Medicaid Services (CMS), issued a State Medicaid Director letter that removes a key barrier to funding school health services: the free care policy.
This policy change provides an important opportunity to increase access to school health services. Since 1997, the free care policy has stated that Medicaid funds may not be used to pay for services that are available without charge to everyone in the community. This rule has presented a barrier to maximizing the role that schools can play in prevention, population health, care coordination and chronic disease management.
In order to support implementation of this change, it is critical to better understand the opportunities presented by the recent clarification of the free care policy. In doing so, we can help ensure that health and education stakeholders have the information and resources to leverage this opportunity to increase access to a system of comprehensive and coordinated health care services. HSC is working with partners across the country to accomplish this and ensure the full impact of this policy change is realized.
Overview of the Free Care Policy
While Medicaid has historically reimbursed health services included in a Medicaid-enrolled child’s Individualized Education Program (IEP), reimbursement for other services provided by school health providers have historically been subject to the free care policy. The free care policy states that Medicaid funds may not be used to pay for services that are available without charge to everyone in the community. Since school health providers serve the entire school community, many of the services they provide to Medicaid-enrolled children were considered not eligible for reimbursement due to the restrictions imposed by the free care policy. The free care policy did not apply to services included in a student’s IEP and services provided by the Title V Maternal and Child Health Services Block Grant.
The free care policy has been the subject of dispute for a number of state agencies. In 2004, the U.S. Department of Health and Human Services Departmental Appeals Board ruled that the free care policy, as interpreted by CMS and applied to school districts, has no basis in federal Medicaid law and that the policy, as applied to schools, is unenforceable. More recently, this ruling was affirmed when CMS agreed to reimburse San Francisco Unified School District for health services delivered to the general student population by school health professionals.
As a result, HSC and other advocates across the country have been working over the past decade to clarify that the free care policy does not apply to services delivered in schools.
State Medicaid Director’s Letter
The recent State Medicaid Director letter clarifies that the free care policy does not apply to school health services. The letter states, “We are issuing this guidance to ensure that Medicaid payment is allowed for any covered services for Medicaid-eligible beneficiaries. … The goal of this new guidance is to facilitate and improve access to quality healthcare services and improve the health of communities.” The State Medicaid Director letter removes one of the barriers that has made it challenging for schools to provide access to quality healthcare services for students.
The letter also clarifies that while schools are not considered to be legally liable third parties, they are required to pursue payment from legally liable third parties, such as private insurance plans. As a result, schools, like other Medicaid providers, must bill a beneficiary’s primary health insurer first (if a child has health insurance in addition to Medicaid), before billing Medicaid. It is important to clarify that the requirement to bill third party payers only applies to Medicaid-enrolled students who also have a third party insurer. Approximately 13 percent of Medicaid recipients have dual coverage at any given time and, as a result, the issue of third party liability does not apply to the majority of children who receive coverage through Medicaid.
The Free Care Policy and Medicaid Managed Care
Given the transformation that is taking place in the nation’s health care system, it is important to consider how implementation of the free care policy can align with managed care systems and capitated payments.
School health services can directly support many of the target goals managed care providers need to meet for children and youth and therefore recognizing school health services through the Medicaid managed care system should be a natural fit.
A number of states have recognized the important role school health services play in health prevention and promotion and disease management by ensuring that school health services provided to Medicaid enrollees are reimbursable, regardless of the way Medicaid services are delivered (managed care or fee-for-service). For example, a number of states have created carve outs for school health services and reimburse school health services under the “traditional” fee-for-service Medicaid program.
In addition, some school-based health providers have developed formal arrangements with managed care plans, including legal contracts and protocols for referral and treatment. For example, Los Angeles Unified School District has become a contracted provider with California’s Child Prevention and Disability Program, which allows them to seek reimbursement from Medicaid for nurse practitioners and physicians performing comprehensive physical exams.
A number of managed care organizations have also recognized the critical role schools can play in meeting their overall goals for improving the health of the populations they serve and have therefore either hired a school nurse coordinator for school districts or decided to cover a portion of the salary for a school nurse. In Madison, Wisconsin (a district which has had a long-term contractual relationship since the late 1990s with two local health maintenance organizations, or HMOs) the HMOs pay part of a school nurse’s salary with the specific goal of increasing the number of health screenings for their Medicaid members.
While the release of the State Medicaid Director letter was an important step towards addressing a long-standing barrier to schools seeking reimbursement for health services, there is still more work to be done.
One of the most important next steps will be supporting state-level efforts to implement the change in the free care policy. Implementation of the free care policy will vary by state. Each state must decide to allow school districts to bill for the health services delivered to students. In many states, this will require an amendment to the state Medicaid plan since most states currently do not allow schools to bill for health services delivered to students without individualized education programs. Since each state’s Medicaid plan is different, the amendments to each state plan will also be different. While there are states in which a state plan amendment will not be needed, it is important to better understand how school health services are currently recognized within each state’s Medicaid plan.
It is also important for stakeholders to continue to spread the word about the change in the free care policy and the potential impact of this change on student health and learning.
Many local and state stakeholders are unaware of this change and the role that schools can play in meeting both the goals of the health and education sectors. Raising awareness about the change in the free care policy and the need to implement it is an important step towards widespread implementation.
We do know that a number of states are working to make sure the opportunity presented by the change in the free care policy is not missed. For example, Louisiana passed an amendment to their state Medicaid plan allowing school districts to seek reimbursement for the school nursing services delivered to the general student population. In addition, California has submitted an amendment to their state Medicaid plan to CMS and additional states are beginning this process.
Schools and local health providers stand to benefit significantly from this change in the free care policy and should work together to ensure that schools have the infrastructure necessary to deliver health services to students and meet the health needs of students across the state.
Free Care Rule Convening
HSC and Trust for America’s Health hosted a convening in June 2015 to bring together stakeholders across the country to develop strategies for supporting implementation of the change in the free care policy. The discussions that took place at the June convening played an important role in informing HSC’s strategy for implementing the change in the free care policy. A summary of the June convening can be downloaded and a list of participants is available here.
Take Action to Support School Health Services
The change in the free care policy presents an important opportunity to increase access to and resources for school health services. The December 2014 state Medicaid director’s letter clarified that school health services delivered to the general student population are eligible for Medicaid reimbursement—not just those included in student Individualized Education Programs (IEPs). But action is required from states and school districts to implement this change. Below are some key steps you can take to support implementation of this change. Download the information included on this page, along with additional guidance on implementing the change in the free care policy, here.
Understand Your State Regulatory Environment
Understand your state Medicaid plan
Each state must decide to allow school districts to bill for the health services delivered to students. In many states, this will require an amendment to the state Medicaid plan. To learn more about how to implement the change in the free care policy in your state, we encourage you to start by familiarizing yourself with your state Medicaid plan by visiting your state Medicaid agency’s website. If your state Medicaid plan is not easily accessible via the state Medicaid agency’s website, you can reach out to your state Medicaid agency using the contact information provided here or your state school nurse consultant using the contact information provided here.
Understand your state legislative environment
It’s also important to look at any barriers to implementing the change in the free care policy that are created by state laws. A small number of states have codified the free care policy in state law, in addition to their state Medicaid plan. For example, the state of Maryland has a state law which limits school districts to billing for school health services included in a student’s IEP. While this is not the case in most states, it is important to reach out to state decision makers to determine if state law will present a barrier to implementation of the free care policy. This can be done by reaching out to your local legislator or the state committee that is responsible for issues related to Medicaid and children’s health.
Understand additional barriers or opportunities
Medicaid managed care
It is important to consider how implementation of the free care policy aligns with the ongoing transformation of the nation’s healthcare system, specifically the shift of Medicaid to managed care. More than 40 state Medicaid programscurrently contract with managed care organizations to deliver care to Medicaid enrollees. It is important to reach out to the managed care organizations serving your area to discuss the important role that school health services can play in helping managed care organizations deliver care to the populations they serve.
Under Medicaid law and regulations, Medicaid is generally the health payer of last resort. This means that Medicaid pays for healthcare only after a beneficiary’s other healthcare resources have been exhausted. It is important to clarify that the requirement to bill third-party payers only applies to Medicaid enrolled students who also have a third-party insurer. While the December 2014 State Medicaid Director letter clarified that schools are not considered to be legally liable third parties, it specifically stated that schools are not exempt from the requirement to bill legally liable third-parties prior to billing Medicaid for students with dual coverage.
Understand the Current School Health Services Environment
Understanding the current school health services environment is key in the development of a school district plan that will meet the health needs of students and ensure the appropriate infrastructure is in place to move forward with increased Medicaid billing and service delivery.
Assess student health needs
A key step toward developing a plan for increasing access to school health services and programming within a school district is assessing student health needs. Key sources of this data include student health information cards that are collected at the start of each school year and health and public health data systems. This data also can be used to make the case to both the health and education sectors for the important role that school health services can play in meeting the goals of the health and education sectors. The primary health conditions identified through this analysis can be linked to indicators that resonate with educators and health providers.
Understand the current school health infrastructure
It is also important to understand the current school health infrastructure within a given district. This includes the number and types of school health providers currently working within a district, a district’s billing infrastructure and the capacity of a school district to bill for additional health services. These are key factors to consider when determining what additional services a school district has the capacity to bill for under the change in the free care policy.
Develop a school health services model
Once student health needs have been assessed and there is an understanding of a district’s capacity to deliver and bill for school health services, a model for delivering school health services under the change in the free care policy can be developed. Key questions that should be considered and addressed when developing a school health services delivery model include
what services are currently being provided in the district, who is providing these services and what is the level of unmet need.
Engage Decision Makers and Allies
Identify key decision makers to engage
Identifying and engaging key decision makers throughout this process is important to the success and long term sustainability of efforts to implement the change in the free care policy. Building support from both health and education decision makers at the state and local levels will help ensure the success of efforts to change a state’s Medicaid plan or state laws related to school health services. Key decision makers might include state legislators and leadership within your state department of education, state Medicaid agency and Governor’s office.
Identify allies at the state and local levels
At the state level, state stakeholder organizations, such as state chapters of the teachers unions, the state school nurses association, the state PTA association and the state association for school based health centers, can play an important role in supporting state-level changes that are needed to implement the change in the free care policy. At the local level, key allies might include local health providers, local United Ways, public health agencies, the school district and school stakeholders, including school nurses, teachers, principals and parents.
Identify new opportunities for partnerships
The change of the free care policy presents a tremendous opportunity to create new and strengthen existing partnerships between health and education that support the delivery of school health services. Local health providers can work with schools to address some of the infrastructure needs that might prevent a school district from fully leveraging the change in the free care policy. For example, in Toledo, Ohio, ProMedica (a regional healthcare network) is partnering with Toledo Public Schools to put a full-time school nurse in all district elementary schools.
Build for the Long Term
Evaluate the impact
In order to ensure the long-term sustainability of efforts to expand access to and billing for school health services under the change in the free care rule, it is important to evaluate the impact of the new program. This evaluation should include an assessment of the impact on health and education outcomes. Key indicators to evaluate might include rates of chronic absenteeism (the percent of students missing 10 percent or more of school days for any reason, excused or unexcused), percent of students returning to class after visiting a school health provider and the number and type of health services delivered by school health providers.
Develop a plan for addressing additional student health needs
An assessment of student health needs should be conducted periodically to determine if additional health services need to be added to the school health service delivery model. In addition, if a school district decides to move forward with implementation of the change in the free care policy by billing for a smaller scope of services at first and then expanding to a larger scope of services, they should develop a plan to gradually expand the type of services being delivered.
Leverage opportunities presented by the broader transformation of the healthcare system
It is important to assess new and emerging opportunities for increasing access to school health services that are presented by the transforming healthcare system. For example, as new Accountable Care Organizations are established in a community, advocates should reach out to these entities to discuss the importance of school health services and role they can play in meeting children’s health needs. There are also state and local funding opportunities available through the Affordable Care Act which can potentially be used to support pilot efforts to increase access to school health services.
Health Policy Resources
Access related resources below, or go to our main Resource Center to access resources across all of our program and policy areas.
Healthy and Ready to Learn: Recommendations to the Next Administration
We can create a better future for our children and our nation by improving health in schools. The next President of the United States has the opportunity to support states, school districts and communities in creating the conditions of student health and wellness and giving all children a chance for a healthy, brighter tomorrow. This document outlines Healthy Schools Campaign’s recommendations to the next President for improving health and education for our nation's students.
How States are Leveraging Medicaid to Expand Health Services in Schools
The Healthy Students, Promising Futures Learning Collaborative includes a growing number of state teams from Departments of Education and Medicaid who are exploring ways to expand health services in schools and leverage funding through Medicaid. The Collaborative is supported by the U.S. Department of Education, the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services, in partnership with Healthy Schools Campaign (HSC) and Trust for America’s Health (TFAH). This webinar provides an overview of the Collaborative and highlight preliminary findings, successes and challenges that the state teams are facing.
Related Programs: National Collaborative
Medicaid’s “Free Care Policy:” Results from Review of State Medicaid Plans
This issue brief reports findings from the National Health Law Program’s review of state Medicaid plans (SMPs) for provisions that may impact states’ ability to implement the federal government’s recent reversal of the “free care policy.” Specifically, we reviewed SMPs for provisions related to Medicaid reimbursement for services provided in schools that are available free of charge to beneficiaries and others in the community. This includes SMP provisions that directly prohibit coverage of such services as well as those that might indirectly prevent coverage.
School Nurse Leadership Webinar: Tackling Absenteeism
The first of two important webinars focused on School Nurses celebrated two award-winning school nurses and kicked off our 2016 School Nurse Leadership Award. Kelly Graham is a school nurse from Colorado implementing data informed health interventions. An analysis of student data helped her identify students with asthma, implement effective interventions and assist these students in improving school attendance. Eva Stone hails from Kentucky and has also used student data to pinpoint the health reasons students were chronically missing school. In just one school year, all 10 schools in her district saw a decrease in the rate of chronically absent students. Both of these leaders demonstrate the power of school nurses and the importance of using data to improve student health. We’re excited to feature these two leaders and for them to share their strategies for tackling this very important topic.
Related Programs: School Nurse Leadership
COLORADO SCHOOL ASTHMA CARE PLAN
An example of Colorado's school asthma care plan that was presented during our Jan. 27 School Nurse Leadership: Tackling Absenteeism webinar.
Related Programs: School Nurse Leadership
CDC Professional Development E-Learning & Resources
CDC Healthy Schools is releasing four professional development resources! CDC Training Tools for Healthy Schools (TTHS) is a comprehensive set of professional development resources to help educators, school health professionals and administrators create school environments where students are healthy and ready to learn. Online modules offer a tailored learning experience through 1-1.5 hour (free CEUs!) courses on School Health Guidelines to Promote Healthy Eating and Physical Activity; School Health Index: A Self-Assessment and Planning Guide; Comprehensive School Physical Activity Program: A Guide for Schools.
Free Care Policy Fact Sheet
The December 2014 reversal of the free care policy has the potential to increase access to and resources for school health services across the country. While this policy reversal was an important step towards addressing a long-standing barrier to schools seeking reimbursement for school health services, states and school districts must now implement this change.
Free Care Policy Convening: Meeting Summary
The following document summarizes the Free Care Policy Convening which was co-hosted by Trust for America’s Health and Healthy Schools Campaign, with support from the W.K. Kellogg Foundation.
Related Programs: National Collaborative
Stakeholder’s Guide to Implementing Free Care
The change in the free care policy presents an important opportunity to increase access to and resources for school health services. While the December 2014 State Medicaid Director letter clarified that school health services delivered to the general student population, not just those included in student Individualized Education Programs (IEPs), are eligible for Medicaid reimbursement, action is required from states and school districts to implement this change. The following framework highlights key steps you can take to develop and implement a plan for leveraging the change in the free care policy to support increased access to comprehensive and coordinated school health services.
Related Programs: National Collaborative
National Prevention Strategy: America’s Plan for Better Health and Wellness
The nation’s first ever National Prevention and Health Promotion Strategy (National Prevention Strategy). This strategy is a critical component of the Affordable Care Act, and it provides an opportunity for us to become a more healthy and fit nation.
Related Programs: School Nurse Leadership