Equitable 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) bridges education and healthcare and delivers quality, cost-effective healthcare in the school setting that is vital to supporting student learning and academic achievement (Maughan et al., 2018). Ensuring sufficient funding so that all children have access to necessary healthcare services provided by a school nurse is a matter of equity (Department of Health and Human Services and Centers for Medicare and Medicaid Services, 2022a).
BACKGROUND AND RATIONALE
When there is a school nurse present in school, all students have access to healthcare without the need for an appointment, referral, fees, insurance, or transportation (Gratz et al., 2020). However, over half of public school students in the U.S. do not have access to a school nurse all day, every day (Willgerodt et al., 2018). Funding school nursing positions is not always a priority in educational budgets. However, the types of public health services provided by school nurses have demonstrated significant positive returns on investment ( McCullough, 2018; Minnesota Management and Budget, 2017). “Spending on school nurses ought to be viewed as an investment, not a cost … Supporting local school nurses is a sound investment not just for students and schools, but for the entire community” (Maughan, 2018, paras 17-18). Beyond a financial justification, evidence supports meeting the societal values of doing what is best for children, with benefits that are often realized over the lifetime of a child (McCullough, 2018).
For school-age youth, schools are an appropriate, safe, and least restrictive setting where school nurses can provide medically necessary care that will “improve health or lessen the impact of a condition, prevent a condition, or restore health” (National Academy for State Health Policy, 2021, para 4). However, both public and private insurer reimbursements for school nursing services are typically not commensurate with reimbursement for nursing services provided in other settings such as hospitals, clinics, and home care. For all students to have access to sustainable, quality school nursing services, sufficient funding for school nursing services should be supported by reimbursement through public and private insurers at levels equivalent to nursing services in other healthcare settings. The setting for the provision of needed healthcare should not determine payment or rates for a reimbursable service.
The Future of Nursing 2020-2030 specifically calls attention to the reality that school nurses are “inadequately supported by current funding mechanisms” (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021, p. 176). In order for all students to have equitable access to quality school nursing services, there must be sufficient funding to cover the cost of providing full-time school nursing services (Weeks et al., 2021). “School and public health nurses play a vital role in advancing health equity. Adequate funding for these nurses is essential” (NASEM, 2021, p.10). The American Academy of Nursing asserts that “all students must have daily access to a full-time school nurse who is part of a comprehensive health-care and education system and is supported financially by health and education dollars” (Maughan et al., 2018, para 1).
Decision-makers and stakeholders from education, health, and governmental sectors need to collaborate to create and sustain “adequate and equitable funding models at the federal, state, and local levels” (National Healthy Schools Collaborative, 2022, para 4). Efforts to achieve equitable standards of care for all school-age youth require sustainable and flexible payment mechanism reforms that support school nursing (NASEM, 2021). “Adequate funding would enable these nurses to expand their reach and help improve population health and health equity” (NASEM, 2021, pp. 176-177).
With over half of children in the U.S. enrolled in Medicaid and/or Children’s Health Insurance Program (CHIP) for children in families that do not qualify for Medicaid and cannot afford private insurance, these public programs provide health insurance for a significant number of school-age youth. Medicaid reimburses certain aspects of school health services for enrolled children when a qualified provider provides a service approved by Medicaid guidelines (Department of Health and Human Services and Centers for Medicare and Medicaid Services, 2022b). Complicating matters, each state has different methods for applying Medicaid coverage for school nursing services. In some states, regulations are misaligned, precluding these states from taking advantage of expanded Medicaid coverage to reimburse school nursing and other health services (Mays & O’Rourke, 2022; Weeks et al., 2021; Hoke & McGowen, 2019).
Economic fluctuations and multiple priorities create competition for limited financial resources in school district budgets. Sustainable payment systems to sufficiently support school nursing services are necessary to equitably help all youth address health barriers to learning, to be able to meet their full educational potential. Insurance reimbursement for school nursing services comparable to other nursing settings can provide additional funding to support and strengthen the provision of essential, quality school nursing care for all children.
Department of Health and Human Services and Centers for Medicare and Medicaid Services. (2022a). CMCS informational bulletin - Information on school-based services in Medicaid: Funding, documentation and expanding services (August 18, 2022). https://www.medicaid.gov/federal-policy-guidance/downloads/sbscib081820222.pdf
Department of Health and Human Services and Centers for Medicare and Medicaid Services. (2022b). CHIP turns 25. https://www.insurekidsnow.gov/sites/default/files/2022-08/chip-25-fact-sheet.pdf
Gratz, T., Goldhaber, D., Willgerodt, M., & Brown, N. (2020). The front-line health care workers in schools: Health equity, the distribution of school nurses, and student Access. CEDR Working Paper No. 12072020-1. University of Washington. https://www.cedr.us/_files/ugd/1394b9_509ab3f4cf2543c29a9fada638b3ef29.pdf
Hoke, K., & McGowen, K. (2019). Medicaid reimbursement for school nursing services. https://www.networkforphl.org/resources/fact-sheet-medicaid-reimbursement-for-school-nursing-services/
Maughan, E. (2018). School nurses: An investment in student achievement. Phi Delta Kappan, 99(7),8–14. doi: 10.1177/0031721718767853 https://kappanonline.org/maughan-school-nurses-investment-student-achievement/
Maughan, E., Cowell, J., Engelke, M., McCarthy, A., Bergren, M., Murphy, M., Barry, C., Krause-Parello, C., Luthy, K., Kintner, E., & Vessey, J. (2018). The vital role of school nurses in ensuring the health of our nation's youth. Nursing Outlook, 66(1), 94-96. doi: 10.1016/j.outlook.2017.11.002
Mays, A., & O’Rourke, L. (2022). Guide to expanding Medicaid-funded school health services. Healthy School Campaign. https://healthyschoolscampaign.org/dev/wp-content/uploads/2022/04/A-Guide-to-Expanding-Medicaid-Funded-School-Health-Services-2022-Update.pdf
McCullough, J. (2018). The return on investment of public health system spending. Academy Health. https://academyhealth.org/sites/default/files/roi_public_health_spending_june2018.pdf
Minnesota Management and Budget. (2017). Results first adult and youth substance use. https://mn.gov/mmb-stat/results-first/substance-use-report-summary.pdf
National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. The National Academies Press. https://doi.org/10.17226/25982
National Academy for State Health Policy. (2021). State definitions of medical necessity under the Medicaid EPSDT benefit. https://www.nashp.org/medical-necessity/
National Healthy Schools Collaborative. (2022). Healthy Schools Ten-Year Road Map. https://www.healthyschoolsroadmap.org/
Weeks, S., Smith, J., Birdsong, M., & Montgomery, L. (2021). State Medicaid & education standards for school health personnel: A 50-state review of school reimbursement challenges. Aurrera Health Group. https://healthystudentspromisingfutures.org/wp-content/uploads/2021/11/State-Medicaid-Education-Standards-for-School-Health-Personnel.pdf
Willgerodt, M., Brock, D., & Maughan, E. (2018). Public school nursing practice in the United States. The Journal of School Nursing, 34(3), 232-244. https://doi.org/10.1177/1059840517752456
Acknowledgment of Authors:
Wendy A. Doremus, DNP, RN, FNP-BC (retired), PHNA-BC (retired)
Carilyn Raines, MEd, BSN, RN
Linda Compton, MS, RN
Angella Hamer, BSN, RN
Andrea Ferguson, BSN, RN, CSN
Adopted: June 2013
Revised: January 2018, June 2023
Suggested Citation: National Association of School Nurses. (2023). Equitable reimbursement for school nursing services (Position Statement). Author.
“To optimize student health, safety, and learning, it is the position of the National Association of School Nurses that a professional registered school nurse is present in every school all day, every day”
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.