For children who face challenges accessing health care, school may be the most consistent — or only — place where they can receive essential health services. School-based health care, whether delivered in a school nurse’s office or through a school-based health center (SBHC), offers numerous benefits to all children. These services can be especially important for children served by Medicaid, who often face increased barriers to care and are more likely to have chronic conditions like diabetes or asthma. SBHCs primarily serve children from families with low incomes.
Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit or other state plan authority, Medicaid covers most school-based health services, including screenings. Medicaid agencies and their partners can leverage school-based settings to prevent disease and identify conditions at an early stage through screenings. This blog post explores five key strategies for states to strengthen pediatric screenings in school-based environments.
1. Align state priorities and actions across sectors.
To strengthen pediatric screening, state Medicaid agencies can establish formal partnerships with state and local education agencies, public health departments, and community organizations. These cross-sector collaborations help align priorities and share resources to prevent, identify, and manage specific health conditions. For example, many state health departments have action plans to address type 1 (T1D) and type 2 (T2D) diabetes. Medicaid stakeholders can enhance these efforts by incorporating strategies to engage school-based settings in screening and early identification of diabetes within their action plan recommendations.
Medicaid agencies can leverage legislative actions to support pediatric screening. For instance, Georgia is one of a number of states that enacted legislation requiring local school systems, grades six through 12, to provide information to families on both T1D and T2D. This includes guidance on when and how students should be connected to screening providers. Ideally, this information would highlight considerations for children covered by Medicaid to ensure they receive equal access to screening and other diabetes-related services.
2. Identify levers to maximize screening coordination and reimbursement.
Medicaid can serve as a stable funding source to provide screenings in school settings. Within schools, Medicaid can reimburse services provided to Medicaid-enrolled students regardless of whether those services are available to the broader student community. To date, 25 state Medicaid programs permit this type of reimbursement for school-based services. In Michigan, the Caring 4 Students program — authorized by a state plan amendment — expanded the state’s ability to use Medicaid funding for school-based services. This initiative focuses on providing nursing and behavioral health services through a partnership among Michigan’s Medicaid program, intermediate school districts, and the Michigan Department of Education.
Partnerships with managed care organizations (MCOs) can further support state efforts to increase access to screening services. For example, in New Mexico, the state’s MCOs, Department of Health Office of School and Adolescent Health (NMDOH OSAH), and Medicaid agency work together to better direct SBHCs in delivering EPSDT screenings, including for asthma, obesity, T2D, and depression. As part of these efforts, MCOs are contractually required to designate a staff member as an SBHC liaison. This liaison ensures that SBHCs are reimbursed through Medicaid for services provided to eligible students and that they meet the state’s quality standards for health care. Molina Healthcare, one of New Mexico’s MCOs, also provides SBHC sites with in-kind contributions (e.g., hygiene supplies) and grants to expand access to care.
3. Partner with provider organizations to support screening access, share educational resources, and promote best practices.
Medicaid can partner with local, state, and national organizations that work within school settings to increase access to screenings. For example, Medicaid agencies can partner with school nurse associations to increase school nurses’ ability to disseminate information to children enrolled in Medicaid. The National Association of School Nurses (NASN) created a toolkit to help school nurses share evidence-based guidance with families about T1D and available screening options. NASN trains school nurses on how to use the toolkit effectively — ensuring students and families receive accurate screening information and that students are referred to pediatric practitioners when further care is needed. In the case of the T1D screening, providers and families engage with considerations elevated by its experimental status, including differing levels of provider knowledge, connection to screening follow-up, and billing practices, and additional support from Medicaid agencies may be able to help smooth some of these challenges.
Additionally, the American Academy of Pediatrics (AAP) Training, Education, Assistance, Mentorship and Support to Enhance School Health Services program provides resources, training, and technical assistance at the school district and state level to strengthen school-based health policies, practices, and infrastructure. The TEAMS framework brings together clinical, public health, and education representatives to take specific steps towards achieving a set goal and evaluating their progress. Medicaid agencies can partner with national AAP or their local state chapter on these efforts.
4. Leverage the existing workforce to expand screening knowledge and delivery.
Innovative strategies like Project ECHO — which virtually connects primary care providers with specialists to build knowledge in specific clinical areas — can help train providers in school-based settings on best practices for screening protocols. This model is particularly useful in underserved areas, such as rural communities, where access to services is limited. There are several ECHO programs that train school nurses and providers at school-based health centers. Mountain Area Health Education Center’s ECHO program in North Carolina trained school nurses to identify and manage a wide array of conditions, including the use of screening tools like SBIRT (Screening, Brief Intervention, Referral to Treatment) and CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) for substance use. The New Mexico Alliance for School-Based Health Care partnered with University of New Mexico Project ECHO, NMDOH OSAH, and others to offer the SBHC ECHO. Over the past several years, this program has trained SBHC staff and partners on a range of physical, mental, and oral health topics. State agencies can support Project ECHO programs with a screening focus through Medicaid financing mechanisms.
5. Build trust with the community.
Building buy-in and trust with children and their families is essential to ensure that screenings reach their intended audience. Some families may be reluctant to screen their children due to various concerns, such as fear of discrimination or judgment based on screening results, worries about privacy and data security, conflicting cultural or personal beliefs, or skepticism regarding the accuracy of the screening, among other considerations. Medicaid agencies can support trust-building in school-based screening programs by involving families in decision-making processes, providing resources for school-based programs to use with their families, and thoughtfully communicating age-appropriate screening opportunities to relevant stakeholders, including school-based health centers and school personnel, families, local and state organizations focused on school health, community-based organizations, and more.
Additionally, Medicaid agencies can align their efforts with existing screening partnerships where buy-in has already been established, such as between SBHCs and their associated school system. For example, seven Native American Health Center (NAHC) sites in California conduct schoolwide dental screenings and have developed systems to pre-identify Medicaid-enrolled patients for billing, thereby maximizing reimbursement. NAHC’s success is rooted in the trust it has established between the school and the health centers to achieve buy-in with teachers and students. During one schoolwide screening, 17 percent of students required urgent follow-up care to address oral health conditions. NACHC implemented a system to notify caregivers regarding follow-up, including support to enroll students in health insurance when needed. Medicaid agencies can seek out SBHCs that have built trusted relationships to further explore what Medicaid screening supports would be impactful in their community.
Looking Ahead
Conducting screening activities to prevent and identify diseases and conditions is a powerful way to support children as they grow. However, children from families with low incomes often face hurdles to accessing screening services. Medicaid agencies and their partners can improve access by offering screenings directly where children spend most of their time — in school-based settings. Medicaid agencies can consider the above strategies to strengthen school-based screenings and more effectively support the health of children enrolled in their programs.
This blog post was made possible with support from The Leona M. and Harry B. Helmsley Charitable Trust.
