Reimbursement for School Nursing Services
The National Association of School Nurses (NASN) believes school nursing services that are reimbursed in other healthcare environments should also be reimbursed in the school setting. The registered professional school nurse (hereinafter referred to as the school nurse) provides the health services in the school setting to improve the students’ ability to remain in the classroom and increase their opportunity for academic achievement. Healthcare services provided by the school nurse are reimbursable services in other healthcare settings, including hospitals, clinics, and home care settings.
Historically, local and state tax monies targeted to fund education programs have paid for school health services. School nurses are in a unique position to advocate, encourage, and facilitate improving clinical care to students. This care matches the services provided by community healthcare professionals and as such school health programs should be able to apply for to reimbursements just like their community counterparts. Restructuring reimbursement programs will enable healthcare funding streams to assist in paying for school nursing services delivered to students in the school setting. Developing innovative health funding opportunities will help to increase access, improve quality, and reduce costs. A goal of NASN is to promote a comprehensive and cost-effective healthcare delivery model that integrates schools, families, providers, and communities while at the same time keeping students healthy, safe, and ready to learn.
Historically, third-party payers--including Medicaid, the Children’s Health Insurance Program (CHIP), and private insurance companies--have provided reimbursements for healthcare services. 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 approved through the Centers for Medicare and Medicaid services that define the health services covered (National Alliance for Medicaid in Education [NAME], 1997). For Medicaid to reimburse health services, a child (student) must be eligible based on family income or disability; the provider (school nurse) must be qualified to provide such service; and the service must be reimbursable according to Medicaid guidelines. The place of service, such as the setting of a school district, should not preclude payment for a reimbursable service (Medicaid.gov., 2014).
CHIP is a program designed to cover uninsured children in families who do not qualify for Medicaid and those who cannot afford private insurance. CHIP is administered by individual states but is jointly funded by both the federal government and states (Medicaid.gov, n.d.). Individual states may choose how CHIP funding is used through one of three options: Medicaid expansion, as a separate children’s insurance, or as a combination of the two (Medicaid.gov, n.d). Medicaid sets the standard for coverage of benefits and reimbursement (Lowe, 2013). The majority of children enrolled in CHIP are covered through Medicaid (The Commonwealth Fund, 2017).
Individualized Education Program (IEP) Health-related Nursing Services
Covered reimbursable nursing services include both direct and case management services as long as the student receiving services is in special education, has a current IEP, and qualifies for Medicaid. 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).
Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
Some school districts provide nursing services under 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, making needed health services available to children. EPSDT provides for the early identification, assessment, and treatment of health conditions.
To promote 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, such as pediatric or family nurse practitioners, as school nurses or in addition to school nurses to provide primary care services, including chronic disease management, EPSDT services and treatment of minor illnesses. 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 (SBHC)
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. Although the majority of SBHC are privately funded, approximately one-third rely on school districts for financial support (Price, 2017). Price (2017) adds that, while fee-for-service produces the largest revenue, some centers receive monthly or annual capitated payments and reimbursement for care coordination. NASN believes that 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 (NASN, 2017).
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 is a health service that is reimbursable in other healthcare delivery systems. 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 nurses often have the tools necessary to link school staff, students, families, community, and healthcare providers to promote a healthy school environment for students with chronic health conditions (Leroy, Wallin, & Lee, 2017). 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 healthcare providers in the community. Reimbursement for nursing services is not restricted to only those services provided in community healthcare centers but is available for nursing services provided within the school setting as well (Medicaid.gov., 2014).
Medicaid allows for the provision of administrative activities, including Medicaid outreach and facilitating Medicaid enrollment. These administrative activities are reimbursable through state Medicaid programs. 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 regimens, coordinating health-related services, and making referrals for a student to receive necessary health/medical evaluations or examinations.
Patient Protection and Affordable Care Act (PPACA)
Schools and school nurses are in a unique position to engage in health reform implementation. The law, known as the Patient Protection and Affordable Care Act (PPACA) (2010), has three major goals: expanding access, improving quality, and reducing costs. The PPACA 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 PPACA presents an opportunity to transform the way care is delivered 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 (2000) is a federal civil rights statute that grants to individuals legal protection against discrimination on the basis of disability. All school districts that receive federal dollars must comply with Section 504. The U.S. Department of Education Office of Civil Rights administers Section 504. For a student with a physical or mental impairment that causes a substantial limitation of a major life activity, or major bodily function, related services must be provided without cost, 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 person with a disability (Civil Rights Act of 1964, 34C.F.R. 104.33).
The responsibility of a school system is to provide quality education for children. However, in order for children and adolescents to be successful learners, they must have their healthcare needs met. The school setting provides a unique opportunity to enroll eligible children in the Medicaid program and to assist children who are already enrolled in Medicaid to access the benefits available to them (Medicaid.gov, n.d.). This is one example of reimbursement of professional school nursing services from a third- party payer. When reimbursement programs are restructured, revenue will be available to support essential school nursing services.
The position of NASN is school nurses must take a leadership role in making the case for innovative health financing proposals, including restructuring existing reimbursement programs to support, expand, and promote access to school 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 by keeping parents and families at work. Providing services that will enable children to 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, Why School Nurses Are the Ticket to Healthier Communities (2016), points out that, because school nurses are integrated into their schools and communities, they can address unmet health needs so that students can focus on learning. This statement highlights the reality that school nurses serve on the frontlines as the nation’s safety net for our most vulnerable children and is also a position that is valued by NASN. School nurses are uniquely equipped to address some of our most pressing health concerns while delivering quality, cost-effective health care.
School communities must recognize that school nurses are providing comparable, quality care to students as other healthcare providers. It is NASN’s position that school nursing services should be reimbursable through third-party payers, such as Medicaid or private insurance companies; and, in turn, those monies can provide needed revenue to support the delivery of essential school health services. This proactive thinking will ultimately help to eliminate or reduce health-related barriers to learning and improve academic achievement.
Civil Rights Act of 1964, 34C.F.R. 100-110. Free and appropriate education. Retrieved from https://www.ecfr.gov/cgi-bin/text-idx?SID=a0776dddb23e3264e9f94527cf3ca185&node=34:220.127.116.11.18.104.22.168&rgn=div8
Leroy, Z. C., Wallin, R., & Lee, S. (2017). The role of school health services in addressing the needs of students with chronic health conditions: A systematic review. The Journal of School Nursing, 33(1), 64-72. doi: 10.1177/1059840516678909
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.
Medicaid.gov. (n.d.). CHIP state program information. Retrieved from https://www.medicaid.gov/chip/state-program-information/index.html
Medicaid.gov. (2014). EPSDT – a guide for states: Coverage in the Medicaid benefit for children and adolescents. Retrieved from https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf
National Alliance for Medicaid in Education (NAME), Inc. (1997). Medicaid and school health – A technical assistance guide. Retrieved from http://www.medicaidforeducation.org/filelibrary-name/webcommittee/PDF/CMS_Manuals/Medicaid_and_School_Health_Technical_Assistance_Guide_.pdf
National Alliance for Medicaid in Education (NAME). Inc. (2003). Medicaid school-based administrative claiming guide. Retrieved from http://www.medicaidforeducation.org/filelibrary-name/webcommittee/PDF/CMS_Manuals/2003_Adminstrative_Claiming_Guide.pdf
National Association of School Nurses. (2017). Whole school, whole community, whole child: Implications for 21st century school nurses. Retrieved from https://schoolnursenet.nasn.org/blogs/nasn-profile/2017/07/28/whole-school-whole-community-whole-child
Patient Protection and Affordable Care Act (PPACA) of 2010, Pub.L. No. 111-148. Retrieved from http://www.healthcare.gov/law/introduction/index.html
Price, O. (2017). Strategies to encourage long-term sustainability of school-based health centers. American Journal of Medical Research, 4(1), 61-83. Retrieved from https://www.addletonacademicpublishers.com/search-in-ajmr/2995-strategies-to-encourage-long-term-sustainability-of-school-based-health-centers
Rehabilitation Act of 1973, 29 U.S.C. § 504
Robert Wood Johnson Foundation. (2016). Why school nurses are the ticket to healthier communities. Retrieved from http://www.rwjf.org/en/culture-of-health/2016/05/why_school_nursesar.html
The Commonwealth Fund. (2017). Extending the children's health insurance program: High stakes for families and states. Retrieved from http://www.commonwealthfund.org/publications/issue-briefs/2017/sep/extending-chip-high-stakes-families-states
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).
Acknowledgment of Authors:
Pam Allsbrook, MSN, RN, NCSN
Teresa Cowan, BSN, RN, CSN
Doreen Crowe, MEd, BSN, RN
Acknowledgment of 2013 Authors:
Janet Lowe, MA, RN, CNP
Joan Cagginello, MS, RN
Linda Compton, MS, RN
Adopted: June 2013
Revised: January 2018
Suggested Citation: National Association of School Nurses. (2018). Reimbursement for school nursing services (Position Statement). Silver Spring, MD: Author.
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.