Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is the child health benefit covered by Medicaid. Children under age 21 who are enrolled in Medicaid are entitled under federal law to EPSDT which includes all necessary preventive, dental, mental health, and developmental, and medical services. EPSDT requires that children receive the right care, in the right place, and the right time.
A requester contacted the Network to inquire whether school-based mental health services would be covered under EPSDT.
The EPSDT and IDEA (Individuals with Disabilities Education Act) statutes both make it clear that services included a student’s Individualized Education Program (IEP) can be covered by Medicaid. To the extent that any mental health services are part of a child’s IEP, if the school district or provider is approved by the state Medicaid agency to provide those services, then they can be covered.
In some circumstances, there may be barriers to reimbursement for services performed in a school setting. An example would be services that aren’t provided by the school district but by a provider, like a peer aid, who accompanies a child to school. Or, services, like school counseling, or other services provided by an employee or contractor of the school that aren’t covered by an IEP.
Beginning in the mid-1990s, the Centers for Medicare & Medicaid Services (CMS) had a policy that services provided “free of charge” to others in the community could not be covered by Medicaid. That included many of the services provided in schools. Consequently, many schools did not develop policies or other infrastructure enabling them to bill for these services.
In 2014, CMS reversed the policy; however, because the policy had been in effect for nearly two decades, many states and school districts had other policies and procedures that reflected this barrier to charging for services. For example, some states had regulations that prohibited coverage for services provided in schools. Other states’ Medicaid plans, which govern the services that can be provided, excluded coverage for school based services.
Notably, CMS has historically been supportive of school-based health centers, which are sometimes federally qualified health centers attached to a school. These SBHCs centers are generally approved as Medicaid providers and can provide mental health services that would be reimbursed under EPSDT. Thus, states that make use of SBHCs may find it easier to overcome barriers to reimbursement for school services.
The Healthy Schools Campaign is an organization whose work focuses on removing the barriers to Medicaid coverage for in-school services. More information about this organization can be found on their website.
Network attorneys are available to answer questions on this and other public health topics at no cost to you, and can assist you in using law to advance your public health initiatives. Contact a Network Attorney in your area for more information.
The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.