As pensions threaten school-nurse programs, schools can get new Medicaid money for both physical and behavioral health

Deputy Secretary Kristi Putnam

By Melissa Patrick
Kentucky Health News

Many of Kentucky’s school districts have long struggled to pay for school nurses, let alone professionals in behavioral health care. And now some health departments may no longer be able to provide nurses because they will have to pay more into their employees’ pension system.

But schools are about to get some help with their students’ health needs, under state officials’ plan to allow schools to use Medicaid funding to cover both physical- and behavioral-health services. More than two in five of the state’s children are covered by Medicaid.

Kristi Putnam, deputy secretary of the Kentucky Cabinet for Health and Family Services, who has spearheaded this effort, said that by the start of the next school year, schools will be able to use Medicaid to serve all students enrolled in the program.

“I’m a former school teacher and I know how valuable it is to have health services and behavioral health services for kids right there at your school,” Putnam said. Research shows that children who don’t get needed care can suffer academically.

What’s it all about? 

Until December 2014, schools could only bill Medicaid for students who were disabled or met other limited criteria. That’s when the Centers for Medicare and Medicaid Services changed the guidelines to allow states to provide services to any student who is enrolled in Medicaid, and get federal reimbursement for those services.

Only now has Kentucky decided to seek the money, a decision that seems largely driven by an increase of behavioral-health issues in schools.

Gaining access to these funds varies by state. In Kentucky, it requires an amendment to the Medicaid state plan and putting an appropriate billing process in place. Putnam said the amendment and fiscal analysis will be submitted May 1, with a request for an Aug. 1 start date and that they are still working on the billing aspect of the requirements.

She said the administration is working on the assumption that the funding will be approved and will start informing schools about it on May 1, because participation is optional.

States must provide matching money to get federal Medicaid dollars, 30% in Kentucky’s case. Putnam said existing school-based Medicaid expenditures can count toward the match.

“The state and local funding that is being used right now for any health and behavioral-health service can be used as the match to draw down additional federal funds,” she said. “So there is no increased costs to the state or to the school district.”

Putnam said the amendment will be broadly written, so the new money can cover both physical- and mental-health care, along with provisions for telehealth.

“You have to have both,” she said. “It’s just exciting because there has been limited funding for behavioral-health services . . . but this will allow us to expand both, and we need to expand both.”

Kentucky adults are strongly supportive of schools taking a more active role in helping families get health care services for their children, with 84% saying in the latest Kentucky Health Issues Poll that they favor such action.

So far, 14 states, including Kentucky, are either considering, actively pursuing or have already taken advantage of this additional Medicaid funding in their schools, according to a policy brief penned by three non-profits dedicated to health: Community Catalyst, Healthy Schools Campaign and Trust for America’s Health.

Why does it matter? 

For years, Kentucky schools have struggled to find funding for health care in schools. And while Putnam has pointed to the need for more behavioral health funding, school nurses have been on the chopping block for years as school and health-department budgets have decreased.

Kentucky Department of Education photo

These cuts have forced schools to find creative ways to provide health care to students. Some have moved to school-based health centers, which provide care to students through a public-private partnership; others have used fewer nurses to cover more students. Others have relied on health departments, but cuts in federal and state funding have forced the departments to ask for more money from schools to fulfill this role.

That said, health departments’ school-nurse programs could be at further risk because of the state’s pension crisis, which on July 1 will require health departments to increase their pension obligation from 49.47% to 83.43% of payroll — unless a special session of the state legislature changes that.

In the regular session, Gov. Matt Bevin vetoed a bill that would have offered some temporary relief to the health departments and has said he will call a special session to deal with the state’s pension system early this summer.

The Marshall County Health Department decided last week to end its school-nurse program, in order to help pay for its possible extra pension obligation of $566,200 a year. In a news release, local health officials called it an “agonizing decision.”

“The Marshall County Health Department school health program has been in our schools for over 25 years,” they said. “Our school nurses have truly made a positive difference in the lives of our children, their families, the school system, and our community. Discontinuing this program is a tremendous loss for all of us.”

Meanwhile, the need for health services in Kentucky schools is greater than ever, with students showing up at school with a long list of chronic physical-health and behavioral-health conditions, an electronic-cigarette epidemic that no one saw coming, as well as schools having to deal with issues around bullying, suicide, the drug epidemic and gun violence.

Mahak Kalra, the health policy director at Kentucky Youth Advocates, who has worked with the cabinet on this project, pointed to research that shows students with health problems, whether they be physical or behavioral, struggle to do well in school.

“So, providing those health services in the school setting can address their immediate health-care needs and can connect them to the services they need and really keep them learning,” Kalra said.

She added that it will also reduce many of the barriers parents have to get their children health care, like transportation, non-flexible work schedules or simply finding a provider who will accept Medicaid.

Kalra and Putnam both noted that this additional funding will help support the School Safety and Resiliency Act, or Senate Bill 1, that among other things calls for one trained school resource officer in every school and one guidance counselor for every 250 students by July 1, 2021 or as funds and qualified personnel become available. School-based mental health services providers fall under a subsection of the guidance counselor requirements and are listed as optional.The bill has no funding attached to it.

“This is one way to have those school-based mental health providers provide those services,” Kalra said.

Eva Stone, district health coordinator for the Jefferson County Public Schools, pointed out that Medicaid will only pay for licensed mental-health providers, not guidance counselors — unless they have a special certification, which most of them don’t.

Stone, who is also an advanced practice registered nurse, added that amending the state plan to define what this additional Medicaid funding will cover provides a great opportunity for Kentucky to meet all of the needs of the state’s children, whether they be physical, mental or social — like whether a child is homeless or has access to food or is being abused at home.

Stone has long said that school nurses are the best situated to coordinate all of these efforts because “that’s what nurses are educated to do.” Further, she said, making coordination of care reimbursable in the state health plan would allow for that coordination to happen.

“We have the opportunity to craft this in Kentucky in a way that would make all those players work together,” she said.

The state says Kentucky has 1,688 students for each school psychologist; the national standard recommends 500 to 700.

The 2018 School Health Profiles Report shows that 41% of all middle and high schools in Kentucky have a part-time registered nurse and 58% have a full-time registered nurse. The Kentucky Health Issues Poll found that 92% of Kentucky adults would support a law to require a nurse in every school.

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