Children come to school with a variety of health conditions, varying from moderate health issues to multiple, severe chronic health illnesses that have a profound and direct impact on their ability to learn. The registered professional school nurse (hereinafter referred to as school nurse) provides medically necessary services in the school setting to improve health outcomes and promote academic achievement. The nursing services provided are reimbursable services in other healthcare settings, such as hospitals, clinics and home care settings. The National Association of School Nurses (NASN) believes that school nursing services that are reimbursable nursing services in other healthcare systems should also be reimbursable services in the school setting, while maintaining the same high quality care delivery standards.
Traditionally, local and state tax revenues targeted to fund education programs have paid for school nursing health services. School nurses are in a strategic position to advocate for improving clinical processes to better fit with community healthcare providers and to align reimbursements with proposed changes. Restructuring reimbursement programs will enable healthcare funding streams to assist in paying for school nursing services delivered to students in the school setting. Developing new innovative health financing opportunities will help to increase access, improve quality and reduce costs. The goal is to promote a comprehensive and cost-effective healthcare delivery model that integrates schools, families, providers and communities.
Historically, third-party payers have provided reimbursements for healthcare services, including Medicaid, the Children’s Health Insurance Program (CHIP) and private insurance companies. Medicaid, Title XIX of the Social Security Act, enacted in 1965, regulates the coverage and payment for many healthcare services. Medicaid is a federal-state funded partnership, and each state has a State Plan that defines the healthcare services covered (National Alliance for Medicaid in Education [NAME], 1997). School nurses should contact their state Medicaid agency to clarify which school nursing services may be reimbursable and to consider possibilities to amend or expand the definition. In order for Medicaid to reimburse the service, the child must be eligible based on family income or disability; the provider – or school nurse – must be qualified to provide the service; and the service must be a covered reimbursable Medicaid service. The place of service, such as the setting of a school district, should not preclude payment for a reimbursable service.
CHIP is a program designed to cover uninsured children in families who do not qualify for Medicaid. Private insurance companies often align the benefits of insurance coverage with the benefits of coverage paid for under Medicaid, and many private insurance companies have contracts with their state Medicaid agency to coordinate benefits for children enrolled in Medicaid. Medicaid sets the standard for coverage of benefits and reimbursement (Lowe, 2013).
IEP Health-related Nursing Services
Nursing services provided as a “related service” under the Individualized Education Program (IEP) are covered reimbursable services. Specifically, these are school nursing services provided to children in special education. The federal law, Individuals with Disability Education Improvement Act (IDEIA) (2004), stipulates that if a child is receiving a related service, the state Medicaid agency must assume the financial responsibility prior to the local education agency (LEA).
Some school districts provide nursing services under Early Periodic Screening, Diagnosis, and Treatment (EPSDT). EPSDT is a mandatory set of services and benefits for individuals under the age of 21 enrolled in Medicaid (Title XIX of the Social Security Act of 1965, Revised 1984). This is the only area in the current law in which Medicaid can reimburse for preventive services. Some school districts may offer EPSDT services to reduce barriers to healthcare disparities and ensure children have access to needed healthcare services. EPSDT provides for early identification, assessment and treatment of healthcare conditions.
To ensure immunization compliance, some school districts provide immunizations to Medicaid-eligible children under the federal Vaccines for Children (VFC) Program. The vaccines are offered free of charge; however, school districts receive reimbursements for the assessment and administration of the vaccinations. Some school districts provide influenza vaccinations, which are also reimbursable.
Nurse Practitioner Services
Many school districts hire advanced practice nurses as school nurses – or, in addition to school nurses – such as pediatric nurse practitioners and family nurse practitioners, to provide primary care services, including chronic disease management, EPSDT services and treatment of minor illnesses. School districts should be intentional in harnessing opportunities to include nurse practitioners in the school setting. This is a cost-effective way to expand access where children learn and play and to provide primary care in coordination with other health providers. Nurse practitioners can also manage and prescribe medication if allowed under their state nurse practice acts and coordinate with registered nurses in the school to reduce unnecessary healthcare utilization, such as emergency room visits. Providing these services in school also helps to reduce health-related barriers to learning, thereby improving overall outcomes.
School-based Health Centers
Many models exist for school-based health centers. Some school districts provide in-kind space for school-based health centers, and community agencies provide and receive reimbursements for the services. Other school districts may hire the providers for a school-based health center, and the district receives the reimbursements. There may also be a variety of hybrid models, which provide advanced practice nursing services. It is worth exploring innovative ways to complement the care provided by school nurses, by offering an additional comprehensive range of services through a sustainable mechanism.
Chronic Disease Management
School nurses provide chronic disease management to children during the school day for asthma, diabetes, attention deficit hyperactivity disorder (ADHD), hearing disorders and many other chronic health conditions. Management of chronic health conditions are healthcare services that are reimbursable in other healthcare delivery systems. The Healthy Learner Model is an evidenced-based model for chronic disease management, which promotes a healthy learner through the provision of quality evidenced-based practice nursing services; leadership to provide capacity building that includes training and mentoring for the school nurse; and collaboration between the professional school nurse, healthcare provider, and the family (Erickson, Splett, Mullett, & Heiman, 2006). Effective chronic disease management includes a key component of care coordination. Managing chronic diseases and coordinating care may lead to a reduction in emergency department visits, decreased absences from school, improved student health outcomes and overall cost savings.
School districts may claim “administrative activities” provided by school nurses under Medicaid, which are costs to administer the state Medicaid plan. This includes Medicaid outreach and facilitating Medicaid enrollment. School nurses in many states are participating in time studies for reimbursement for Medicaid administrative claiming (NAME, 2003). Examples of some school nursing services that may be eligible for reimbursement include, but are not limited to, assisting a student and/or family in completing and processing Medicaid enrollment forms; informing potential Medicaid eligible students and their families about the services provided by Medicaid; providing information about EPSDT; referring an individual or family to apply for Medicaid benefits; providing assistance in implementing health/medical regimes; coordinating health-related services; and making referrals for a student to receive necessary health/medical evaluations or examinations. School nurses should contact their state Medicaid agency for further information about administrative claiming in schools.
Affordable Care Act (ACA)
Schools and school nurses are in a unique position to engage in health reform implementation. The law, known as the Affordable Care Act (ACA, 2010), has three major goals: expanding access, improving quality and reducing costs. The ACA includes provisions, which will help more children obtain healthcare coverage, end lifetime and most annual limits on care, allow young adults under 26 to stay on their parents’ health insurance, provide children and adults access to recommended preventive services without additional costs, and prohibit insurance companies from denying coverage due to pre-existing health conditions. The ACA presents an opportunity to transform the way we deliver care in this country by exploring various models of integrated and coordinated care, which improve quality, expand access and save money – with a particular focus on investing in evidence-based strategies that promote wellness and disease prevention.
Section 504 of the Rehabilitation Act of 1973(34C.F.R. 100, 104, 106, 28C.F.R. 35) is a federal civil rights statute that assures individuals will not be discriminated against based on their disability. All school districts that receive federal dollars must comply with 504. The U.S. Department of Education, Office of Civil Rights (OCR) administers 504. A student with a physical or mental impairment that causes substantial limitation of a major life activity, such as caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. Related services must be provided without cost to these students, including medication administration, medication management and chronic disease management. Funds available from any public or private agency may be used to meet the requirement of providing related services. An insurer or similar third party, such as medical assistance, has a valid obligation to pay for services provided to a handicapped person (34C.F.R. 104.33). Many states have passed legislation related to chronic disease management of diabetes and anaphylaxis. Best practice in establishing reimbursement for these students is to follow the practice guidelines of the state Medicaid agency that is in compliance with other health care providers in the community. Reimbursement in a school setting should not be more restrictive than for community healthcare providers. The setting should not preclude a denial for reimbursement. The emphasis should be on the provision of quality healthcare services provided by qualified providers.
The responsibility of a school system is to provide quality education for our children. However, in order for children and adolescents to be successful learners, they must have their healthcare needs met. According to Julia Lear, author of Health at School: A Hidden Health Care System Emerges from the Shadows (2007), the time is ripe for school-community healthcare collaboration.
Local and state tax dollars often fund school health services. Although there is no comprehensive data that demonstrates actual healthcare spending at school, conservative estimates put annual expenditures around $10.4 billion (Lear, 2007). School nurses must take a leadership role in making the case that innovative health financing proposals, including restructuring existing reimbursement programs, will support, expand and promote access to health services. Harnessing healthcare funding to assist in paying for school nursing services delivered to students in the school setting is the only sustainable way forward. School nurses are keenly aware of the health needs of students and possess the expertise, assessment skills and judgment to provide direct, comprehensive health services for students. School nurses contribute to their local communities by helping students stay healthy, in school, and ready to learn and keeping parents and families at work. Ensuring that our children have a healthy and successful future will equip them to become productive citizens in society. This is the message that school nurses need to convey to their local, state and national policymakers, elected officials, school administrators and other stakeholders.
The Robert Wood Johnson Foundation publication, Charting Nursing’s Future – Unlocking the Potential of School Nursing: Keeping Children Healthy, In School and Ready to Learn (2010), aptly illustrates school nursing as a “hidden system” of health care. The reality is that school nurses serve on the frontlines as this nation’s safety net for our most vulnerable children. School nurses can help to address some of the nation’s most pressing health concerns while delivering quality, cost-effective health care. School districts that restructure revenue streams can use these dollars to support the delivery of health services, which ultimately will help to eliminate or reduce health-related barriers to learning and improve academic achievement.
Erickson, C., Splett, P., Mullett, S., & Heiman, M. (2006). The healthy learner model for student chronic condition management - Part 1. The Journal of School Nursing, 22, 310-318.
Individuals with Disability Education Improvement Act (IDEIA). (2004). 20 U.S.C.1412 (a) (12) and (e) 34 C.F.R. 300.154. U.S. Government Printing Office (GPO) Electronic Code of Federal Regulations (e-CFR). Retrieved from http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&SID=3fad6eeaff38fbbd5a0edb8e005a2b08&rgn=div8&view=text&node=34:22.214.171.124.126.96.36.199&idno=34
Lear, J. (2007). Health at school: A hidden health care system emerges from the shadows. Health Affairs, 26(2), pp. 409-419.
Lowe, J. (2013). Navigating the reimbursement maze to fund school nursing services. In Carol C. Costante (Ed). School nurse administrators: Leadership and management, pp. 433-457. Silver Spring, MD: NASN.
National Alliance for Medicaid in Education (NAME), Inc. (1997). Medicaid and school health – A technical assistance guide. Retrieved from http://www.medicaidforeducation.org/index.php?option=com_content&view=article&id=226&Itemid=260
National Alliance for Medicaid in Education (NAME). Inc. (2003). Medicaid school-based administrative claiming guide, 2003. Retrieved from http://www.medicaidforeducation.org/index.php?option=com_content&view=article&id=226&Itemid=260
Patient Protection and Affordable Care Act (PPACA) of 2010, Pub.L. No. 111-148. Retrieved from http://www.healthcare.gov/law/introduction/index.html
Civil Rights Act of 1964. 34C.F.R. 100-110. Rehabilitation Act of 1973, Section 504. 34C.F.R. 104, 106. Retrieved from http://www.ecfr.gov/cgi-bin/text-idx?SID+3aba8e58494814b734ea2c918f65114d&c=ecfr&tpl=/ecfrbrowse/Title34/34cfrv1_02.tpl
Robert Wood Johnson Foundation. (2010). Unlocking the potential of school nursing: Keeping children healthy, in school and ready to learn. Retrieved from http://www.rwjf.org/en/research-publications/find-rwjf-research/2009/01/charting-nursings-future-archives/unlocking-the-potential-of-school-nursing.html
Title XIX of the Social Security Act (Act) of 1965, § 1102, 42 U.S.C. 1302, 42C.F.R.441.50-441.62, 1984 (49 FR 43666, Oct. 31, 1984, as amended at 49 FR 45431, Nov. 16, 1984). U.S. Government Printing Office (GPO) Electronic Code of Federal Regulations. Retrieved from http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&SID=fbef42e6447325d4a95ef09628908c3c&rgn=div5&view=text&node=42:188.8.131.52.10&idno=42
Acknowledgement of Authors:
Janet Lowe, MA, RN, CNP
Joan Cagginello, MS, RN
Linda Compton, MS, RN
Adopted: June 2013
This document replaces the Issue Brief, The Role of the School Nurse in Third Party Reimbursement (2007)
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.