Before the ACA, about 10.5 million youth under age 18 were uninsured (Medical Expenditure Survey Panel, 2010), and community mental health services often weren’t readily accessible even for those with insurance. As a result, schools had been and remain the de facto mental health provider system for children and youth, with 70% to 80% receiving services directly in the schools (Farmer et al., 2003). ACA increases the number of families and children who can access health care insurance, including Medicaid. Schools can seek reimbursement for specific services delivered to Medicaid-eligible students; therefore, school districts may be able seek reimbursement for services already provided by school-employed mental health professionals.
Implications for school-based mental health centers
One of ACA’s primary goals was increasing health insurance coverage for more Americans. To ensure increased coverage for children and youth, ACA mandated expansion of the Children’s Health Insurance Program (CHIP) and provided financial incentive to states that voluntarily expanded eligibility to Medicaid. Schools and districts, especially those in high-poverty areas, will see an increase in the number of students who are Medicaid eligible.
Many states let school districts seek reimbursement for services to Medicaid-eligible students. Although each state establishes its own Medicaid plan, including covered services and eligible health care providers, the ACA explicitly recognizes school-employed mental health providers (e.g., school psychologists) as “qualified health professional(s)” for “children and adolescent mental and behavioral health” services. Reimbursing school districts that provide these services can be significant: The Council of New York Special Education Administrators estimates that school psychological services represent $100 million in Medicaid reimbursement for schools in New York alone.
ACA also authorized $200 million from 2010-13 to expand the capacity for services in existing school-based health clinics and to identify new clinic sites, prioritizing sites serving large populations of Medicaid-eligible children and families. Although various service models exist, the typical school-based health clinic is open every school day and staffed by health providers. Partnerships with community providers or school-based health centers can provide important resources for individual students but should supplement — not replace — the critical prevention and intervention services available to all students in the school.
Potential barriers
The ACA lets states expand insurance coverage to residents and provides financial incentives through “enhanced Medicaid funding” to defray expansion costs, but some states have chosen not to participate. These states maintain their current level of Medicaid funding but aren’t eligible for more funds. As a result, many low-income children and families still can’t afford comprehensive health care plans but also can’t access health care through CHIP or Medicaid.
In addition, Medicaid state plans differ from state to state, resulting in varying services covered by Medicaid and varying professionals being identified as “qualified providers.” Although ACA recognizes school-employed mental health professionals as providers of mental and behavioral health services, some states still don’t cover their services as qualified providers of Medicaid services.
Finally, while school-based health centers should benefit from expanding services to children and families, ACA funding is allocated only to build, renovate, and equip new or existing facilities. No funds are available for professional positions. Further, community professionals working in a school-based health center often need additional training because they aren’t familiar with or experienced with working in schools.
Promise for the future
Despite some challenges, the ACA offers potential for significantly expanding access to mental health services for children and adolescents at school. Become familiar with these opportunities in your state and advocate for state coverage of services provided in the school setting by school-employed mental health professionals in the following ways:
- Determine if your district currently seeks Medicaid reimbursement for eligible student health services (e.g. physical therapy, speech therapy, nursing services, behavioral and mental health services). Due to the documentation required to receive reimbursement, some districts only bill for certain services. Examine the cost-benefit of billing for behavioral and mental health services if your district is not already doing so.
- Identify the specific services eligible for reimbursement. These vary by state and can be found in each state’s Medicaid plan.
- Determine the provider qualifications outlined in your state’s Medicaid plan. In many states, school psychologists, school social workers, and school nurses are considered qualified providers of Medicaid services. If this is not the case, partner with state professional associations (e.g., school psychologists, superintendents, principals, PTA) to advocate that school-employed mental health providers recognized in ACA also be considered qualified providers of Medicaid services in your state’s plan.
- If your state doesn’t include school personnel as eligible providers, identify community mental and behavioral health agencies that are Medicaid-certified providers. Partnering with these entities could allow Medicaid-eligible students to receive specific, more intensive services from community professionals while giving school-employed professionals more time to provide broad mental health services to the greater student population.
- In collaboration with educators, families, and community members, encourage your local school board and district superintendent to increase support for mental health services, including improved partnerships and working toward staffing ratios that allow for a full range of prevention, early intervention, and more intensive intervention services.
Medicaid reimbursement can seem overwhelming. However, many districts use Medicaid funds as part of an overall financial plan to sustain school-based mental health services. Angeles, Tierney, and Osher (2006) offer additional guidance on how to obtain Medicaid funding for school-based mental health services, and contains contact information for each state Medicaid agency. State plans and policies can change frequently, so contact your state Medicaid agency for technical assistance and questions regarding the specific procedure for obtaining reimbursement for behavioral and mental health services in your district.
References
Angeles, J., Tierney, M., & Osher, D. (2006). How to obtain Medicaid funding for school-based health and mental health services. In C. Franklin, M.B. Harris, & C. Allen- Meares (Eds.), School Social Work and Mental Health Workers Training and Resource Manual. New York, NY: Oxford University Press. www.tapartnership.org/docs/obtainingMedicaidFunding.pdf
Farmer, E.M., Burns, B.J., Philip, S.D., Angold, A., & Costello, E.J. (2003). Pathways into and through mental health services for children and adolescents. Psychiatric Services, 54, 60-67.
Medical Expenditure Survey Panel. (2010). Health insurance coverage of the civilian noninstitutionalized population: Population estimates by type of coverage and selected population characteristics, United States, first half of 2010. http://meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&tableSeries=4&year=-1&SearchMethod=1&Action=Search
Citation: Vaillancourt, K. & Kelly, J. (2014). The Affordable Care Act and school-based mental health services. Phi Delta Kappan, 96 (4), 63.
ABOUT THE AUTHORS
John Kelly
JOHN KELLY is a school psychologist at Commack High School, Commack, N.Y., and the 2003 National School Psychologist of the Year.
Kelly Vaillancourt
KELLY VAILLANCOURT is a school psychologist and director of government relations for the National Association of School Psychologists, Bethesda, Md.
