Katie Eklund, PhD, NCSP, Nathaniel von der Embse, PhD, NCSP and Kathleen Minke, PhD, NCSP
Approximately 20% of children in the United States experience significant mental, emotional, or behavioral concerns, yet there is often a lack of access to necessary mental or behavioral health services and supports to adequately address them (Costello, Mustillo, Erkanli, Keeler, Angold, 2003; New Freedom Commission on Mental Health, 2003). Furthermore, as many as one in seven adolescents have no health insurance and therefore cannot reasonably afford to receive third-party reimbursable mental health services in the private sector (Crespi & Howe, 2002). However, there is compelling evidence to suggest that providing mental and behavioral health services in schools is an effective strategy for connecting with at-risk or hard to reach youth (Sklarew, Twemlow, & Wilkinson, 2004: Zirkelback & Reese, 2010). In fact, 70-80% of children who receive mental health interventions access these necessary supports in schools (Farmer, Burns, Angold, & Costello, 2003) and students are more likely to seek out help if such supports are available at school (Juszczak, Melinkovich, & Kaplan 2003). Additionally, mental and behavioral health services provided at school are significantly related to utilization of services within the community, suggesting that schools offer an important point of access for facilitating a connection with critical services (Tegethoff, Stalujanis, Belardi, & Meinlschmidt, 2014).
Expansion of Medicaid Eligibility
State Medicaid plans provide comprehensive health coverage for low income students and their families, including mental and behavioral health services, and allow school districts to seek financial reimbursement for certain services provided to Medicaid eligible students in the school setting. Since its enactment, the Patient Protection and Affordable Care Act (ACA, 2010) increased the number of children and families who have access to health insurance by 16.4 million, according to data from the U.S. Department of Health and Human Services (2015). Additionally, the ACA provides funding for states to voluntarily expand their Medicaid programs to reach families that had previously been ineligible for government health programs such as Medicaid or for those that had difficulty affording private insurance.
The expansion of Medicaid eligibility under the ACA could result in a larger number of Medicaid eligible students receiving reimbursable services in the schools, thus increasing the amount of monetary reimbursement provided to school districts for psychological services (e.g., assessment, therapy, consultation). School-mental health professionals, including school psychologists, already provide such services to children regardless of their Medicaid eligibility status. However, a potentially larger population of Medicaid eligible children could subsequently result in a greater funding stream being returned to the school, enabling more comprehensive service delivery.
Notably, Title V of the ACA contains specific provisions intended to increase access to mental and behavioral health services and improve the mental and behavioral care workforce. Further, Title V specifically recognizes school psychologists as “qualified health professionals” of child and adolescent mental and behavioral health and “mental health service professionals” at the licensed and certified level without distinguishing degree. As a result, doctoral and specialist level school psychologists who have a valid and current credential from the state in which they are employed are considered mental health service professionals by the federal statute, and therefore are recognized within this statute as an eligible provider of reimbursable services.
Opportunity and Caution
One particular opportunity of this change in Medicaid eligibility relates to the funding of important school-employed mental health professionals. Despite the apparent need and benefits for increased access to school-based mental and behavioral health services, schools continue to experience difficulties in ensuring sustained funding for appropriate personnel to deliver those services. Specifically, many states continually experience shortages of school-employed mental health professionals (e.g., school psychologists, school social workers) that have specialized training in the provision of a range of services within the unique context of a school (Rossen & von der Embse, 2015). As an example, the National Association of School Psychologists (NASP, 2010) recommends a ratio of 500 to 700 students per school psychologist to provide a full comprehensive range of services; whereas the reported ratio in a national sample far exceeded that recommendation at 1:1383 (Charvat, 2011). As ratios increase, the role of the school psychologist tends to focus more on legal compliance with the Individuals with Disabilities Education Act (IDEA) and less on prevention, indirect or systems-intervention, and early intervention. One important advantage of recognizing school psychologists as eligible providers, therefore, is the potential to provide additional funding to ensure improved ratios and access to those services, as reimbursed funds would go directly to the district. Conversely, given that state Medicaid plans typically provide reimbursement only for specific services associated with an Individualized Education Program (IEP), there is a risk that districts may opt to limit psychological services in schools to those providing an additional funding source through Medicaid. Such a narrow scope of services may preclude a broader range of services made available to other students in need, such as prevention and early intervention services.
Differing Medicaid Coverage, Eligible Services, and Definitions of Qualified Providers
Although federal legislative language has provided clear definitions of qualified service providers (e.g., school psychologists) in addition to a range of eligible services as covered in Medicaid policies, states are not required to recognize federal definitions within state-specific Medicaid policies. As a result, state regulatory agencies differ substantially in the interpretation and implementation of Medicaid policies.
Currently, school psychologists are considered qualified providers of Medicaid services (i.e., schools can seek reimbursement for specific services they provide) in 34 states (National Association of School Psychologists, 2014). However, a range of exclusions and limiting factors contributes to inconsistency even within these 34 states. For example, several states require an additional level of supervision for service providers based upon licensure and/or graduate preparation while other states limit billable services to a single activity (e.g., assessment for special education decision-making).
In a recent survey of 31 states conducted by the National Alliance for Medicaid in Education (NAME), 63% reported that local school districts maintain eligibility to claim reimbursement for direct services (NAME, 2014). Newly eligible services reported included special transportation, interpretation, behavioral and psychological counseling, audiology, and case management. However, states also reported several other service domains not eligible for reimbursement including assistive technology devices and personal care assistance. Some states reported conflicting eligible services (i.e., not eligible for behavioral/psychological counseling, interpretative services, audiology).
School Psychological Services
School psychology maintains recognition as a specialty by the American Psychological Association (APA, n.d.), in large part due to a unique skillset for providing a comprehensive range of psychological services in school settings. School psychologists receive broadly focused preparation to provide academic, mental, and behavioral health services within schools’ organizational and cultural contexts. School psychologists partner with families, teachers, school administrators, and other professionals to create safe, healthy, and supportive learning environments that strengthen connections between home, school, and the community. In this vein, school psychologists provide services using a multi-tiered system of supports (MTSS) approach that provides prevention, early intervention, indirect and systems-level interventions, and direct and individualized interventions using data-based decision making. Within MTSS, students are provided with increasingly intensive supports based on need.
States that provide reimbursement for school-based services, however, can generally only bill for services provided to those identified on a student’s IEP once identified as having a disability under the Individuals with Disabilities Education Act (IDEA, 2004). While this often ensures reimbursement for individualized assessment and direct, face-to-face intervention, it does not reimburse for other important related services. In some states, this also may not cover indicated direct interventions despite lack of an identified disability (e.g., bereavement, stress over military-deployed parent), even though school-employed mental health professionals provide ongoing supports for these students on an as-needed basis.
This reality highlights the critical need to have school-employed professionals, such as school psychologists, providing this range of services, while also recognizing them as qualified providers within state Medicaid policies. This would ensure that all students receive a comprehensive range of services using an MTSS approach while also providing necessary funds for services that are already provided.
Schools and Settings for Integrated Care
Professional psychology is in the midst of a “rebranding” process as “health service psychology” (HSP) as outlined in the Blueprint for Education and Training (Health Service Psychology Education Collaborative, 2013). The HSP Blueprint provides guidance for preparing psychologists to work within the health care system as it is evolving in the 21st century. The HSP Blueprint does not eliminate professional distinctions among the core applied specializations of school, counseling, and clinical psychology, but it does provide an integrated framework for preparation and practice that may promote collaboration among psychologists and other health service providers both within and outside schools. Similarly, SAMHSA is promoting the development of fully integrated health care sites in which there is a seamless system of supports for physical and mental health with the aim of treating the “whole person” in a single health care system (Heath, Wise, & Reynolds, 2013).
In a parallel fashion, school psychology practice continues to move toward a population-based model of service delivery, grounded in multi-tiered systems of support (Doll & Cummings, 2008). In this approach, all youth are served as needed through universal, targeted, and intensive levels of intervention. Although school psychology practice has always been more consistent with a population-based model than other professional psychology specialties (Short, 2003), schools are not always recognized as sites for fully integrated care and academic success is not always considered a central health-related outcome (Hughes & Minke, 2014). Indeed, schools’ necessary primary focus on education makes them different from other health care settings. The federal and state regulations that govern school practice are different from and do not always fit neatly with those that govern community-based providers. The different requirements of FERPA vs. HIPAA for protecting client privacy offers just one example of this disconnect (Vaillancourt & Amador, 2014). However, schools have a number of defining features as sites for integrated care, particularly for Medicaid-eligible youth and families who may face barriers to accessing care in more traditional settings.
"States that provide reimbursement for school-based services... can generally only bill for services provided to those identified on a student's IEP once identified as having a disability under the Individuals with Disabilities Education Act."
Beyond the simple advantage of co-located services eliminating some transportation issues for youth, schools are familiar settings for most families, and there may be less stigma associated with seeking and accepting help in a school context (Eklund & Dowdy, 2014; Tegethoff et al., 2014). In addition, because schools must serve all youth, there are often supports available to assist families for whom English is not the first language. Schools often have family-school collaboration projects in place that can further bridge cultural and language differences, allowing more informed family decision making about a host of health-related areas.
School psychologists are specifically trained in collaboration and consultation skills, which are often applied at the systems level. That is, unlike in traditional medical models where consultation often means gathering expert opinions on particular aspects of treatment, consultation within the school context involves a non-hierarchical, problem-solving process in which the consultant’s role is to facilitate and elicit the expertise of all concerned stakeholders (Hughes & Minke, in press). These skills may be particularly applicable when trying to build an integrated system of care across diverse existing structures. In addition, because school psychologists and other school-employed mental health service providers are not bound by strict fee-for-service limits, these professionals can provide universal supports and early intervention services to students not meeting diagnostic criteria for mental health problems (Vaillancourt & Amador, 2014). The increased availability of Medicaid funds will enhance the provision of services to students requiring more intensive supports.
There are a number of developing programs that illustrate the possibilities for greater collaboration between school and community providers. The Comprehensive Behavioral Health Model (CBHM) was developed by school psychologists and other staff in the Boston Public Schools, in partnership with Boston Children’s Hospital, and the University of Massachusetts – Boston. It was designed to restructure school psychology services in alignment with the NASP Practice Model (See NASP, 2010) and to provide comprehensive multi-tiered supports to all youth. The initiative recognizes the need for a strong leadership team, professional development for all staff, and comprehensive resource mapping that allows greater coordination and collaboration with existing services provided by community partners in school settings. Resources have also been deployed for systematic data collection and evaluation, which will be instrumental in improving the program as it moves forward. Data from the first three years of implementation show substantive decreases in problem behavior, increases in prosocial behavior, and improvements in math and reading scores in implementing schools (Amador, Dennery, Pearrow, & Snyder, 2015).
Similar efforts are underway in the Cincinnati Public Schools. At Ethel M. Taylor Academy, serving pre-K to 8th grade students, there is a school-based health center with a school nurse, nurse practitioner, school psychologist, and social worker providing services (http://taylorhawks.cps-k12.org/resources/health-resources.aspx). Although most existing models focus on the integration of mental health, educational, and behavioral outcomes (e.g., the integrated systems framework; Barrett, Eber, & Weist, 2013), this model illustrates the possibility of combining the focus on mental and behavioral health with physical health outcomes in the context of supporting academic success. Schools already address some physical health outcomes through universal supports (e.g., health and physical education classes, vision and hearing screenings); these exist alongside universal supports for academic outcomes (e.g., routine progress monitoring and intervention for core academic areas) and for social-emotional and behavioral outcomes (e.g., schoolwide positive behavior supports, universal screening for depression). Increasingly, school nurses are being recognized as members of the school mental health team, with an important role in supporting students with a variety of physical and mental health challenges (Bohnenkamp, Stephan, & Bobo, 2015).
It is clear that a new infrastructure will be needed to support fully integrated and seamless academic, mental, and physical health models and, as noted above, many difficult details need to be addressed. School psychologists, in partnership with other school-based mental health service providers, are well positioned to provide leadership in building the necessary connections among providers and families to support optimal developmental outcomes for all youth.
Since the passing of the Patient Protection and Affordable Care Act (ACA), which includes a significant expansion in the number of students eligible for Medicaid, states have demonstrated inconsistencies in the interpretation and implementation of Medicaid eligible services in schools. In particular, despite clear definitions in federal statute identifying school psychologists as qualified health professionals, states differ in whether school psychologists can provide Medicaid reimbursable services. School psychologists are ideally positioned to provide these services to youth as they exist “in the biopsychosocial system where children spend 35 hours or more a week,” (Hughes & Minke, 2014, p. 29) and in many cases already provide those services within their comprehensive role. Further, school psychologists can help connect students and families with additional supports in the community in order to ameliorate barriers to accessing care. Increased communication and additional advocacy efforts are needed among all health service providers to more clearly align state Medicaid policies with federal statute.
Dr. Katie Eklund is an Assistant Professor in the School Psychology Program at the University of Arizona. Dr. Eklund has worked in public education for 12 years as a school administrator, school psychologist, and school social worker. She is a National Certified School Psychologist and licensed Psychologist. Her research interests include early identification and intervention for behavioral and emotional concerns, school climate, and school safety.
Dr. Nathaniel von der Embse is an assistant professor of school psychology at Temple University and co-chair of the NASP Government and Professional Relations Workgroup. Dr. von der Embse has authored over 35 peer-reviewed publications, practitioner-focused articles, and book chapters, and has presented nationally and internationally on high-stakes testing and internalizing disorders.
Dr. Kathleen M. Minke, is professor and coordinator for the PhD in Education and EdS in School Psychology programs at the University of Delaware. She is a licensed psychologist in Maryland. Her research interests include parent-teacher relationships, family-school collaboration, and professional issues in school psychology.
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