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Medicaid School-Based Services Can Help Prevent “Unwinding” Coverage Losses

The Centers for Medicare & Medicaid Services (CMS) kicked off the school year with a comprehensive informational bulletin reminding states and local school districts that Medicaid can help them ensure students have health coverage and get the health care they need. The bulletin’s emphasis on school outreach to keep kids covered is particularly timely: states are preparing to “unwind” the COVID-era prohibition against terminating Medicaid coverage for most enrollees, after which some 15.8 million people could lose coverage.

This continuous coverage provision is tied to the public health emergency (PHE), in effect until at least mid-October and widely expected to be extended though at least mid-January. Once the PHE ends, states will begin a massive effort to redetermine eligibility for their entire Medicaid caseloads.

Many of those losing coverage will still be eligible but may not receive or return renewal documents in time, or their Medicaid agency may fall behind in processing paperwork. Others could become uninsured if they’re no longer eligible for Medicaid and fall into a coverage gap (because their state hasn’t adopted the Affordable Care Act’s Medicaid expansion), or if they can’t navigate the enrollment process for marketplace coverage.

The disruptions to children’s coverage could be severe. For one, churning — when people lose Medicaid and then quickly re-enroll — has always been a challenge in Medicaid, affecting some 11.2 percent of children eligible for full Medicaid benefits in the year before the pandemic. These coverage disruptions are often due to administrative burdens, which disproportionately affect people of color, and to states’ failure to fully automate their renewal process as required. Even when short these disruptions can be harmful, resulting in interrupted treatment or medication access.

In 2019 about 2.3 million children (or 57.7 percent of all uninsured children) were eligible for Medicaid or the Children’s Health Insurance Program (CHIP) but were uninsured, the Urban Institute estimates. When the PHE ends, more than 3.8 million children (aged 0-17) are projected to be disenrolled despite being eligible for the two programs, according to the Department of Health and Human Services.

But there’s still time to get it right and schools can help. CMS’ guidance — which explains how to implement Medicaid school-based services and leverage Medicaid to pay for services that schools already provide — is a good place to start.

The CMS bulletin reminds states that the federal government can match state and local expenditures for administrative activities, like outreach and enrollment, at the applicable administrative matching rate — 50 percent in most cases. Local education agencies can use school registration processes and other regular contacts they have with families to help children (and their family members) enroll in Medicaid or CHIP. Obtaining Medicaid reimbursement for outreach and enrollment allows schools to expand health care services and programs.

Schools are natural places to help enroll uninsured children: they’re an easy place to identify children who are uninsured, they’re trusted places, they’re geographically accessible, they have experience communicating with their communities through established information-sharing methods, and they can collaborate with partners to help children and their families apply for coverage. In a 2017 survey, more than half of surveyed school superintendents reported that they had taken steps to increase Medicaid enrollment of children in their schools.

As states begin their PHE unwinding efforts, trusted school officials can support state efforts to ensure that kids don’t lose coverage. School-based outreach services could include:

  • Encouraging kids and their families to look out for renewal notices from states, in case they need to take action to provide the state with updated information;
  • Reminding kids and their families to update address information, if they have moved during the pandemic, so that notices reach them;
  • Supporting kids and their families in compiling updated paperwork (where needed) and materials that the state may need to complete an eligibility redetermination; and
  • Undertaking — where authorized — the presumptive eligibility process, which allows entities to screen individuals for Medicaid eligibility and temporarily enroll those who appear to be eligible.

School districts and local education agencies can work with their states to ensure that state Medicaid policies authorize reimbursement for these activities.

Beyond outreach, the informational bulletin outlines other ways states can leverage school-based services to ensure that Medicaid-enrolled children get immunizations, health screenings, oral health care, substance use disorder treatment, and behavioral health care. For example, CMS reminds states that Medicaid will pay for services delivered by a Medicaid-participating provider to a Medicaid-eligible child if the benefits are covered under a state’s Medicaid plan, even when the services are available without charge to the beneficiary and members of the community at large. Before 2014 Medicaid couldn’t reimburse these “free care” services. Since CMS clarified its position, some 16 states have gotten approval to allow Medicaid to pay for covered services furnished in a school setting.

Finally, schools can use Medicaid school-based services to help connect children to services they need outside school. Forty percent of surveyed school superintendents reported that they use Medicaid funding to facilitate outreach and coordination services to refer children to such services, including mental health services and food assistance.

There are also more school-based resources to come. The recently enacted Bipartisan Safer Communities Act requires the federal government to take several steps to help extend the reach of Medicaid through schools. And beyond its recent informational bulletin, CMS is planning to update its school-based services guide with more information about payment for Medicaid-covered services, including updates to the existing School-Based Administrative Claiming Guide. CMS is also collaborating with the Department of Education to create a technical assistance center to support Medicaid agencies, local education agencies, and school-based entities.

In the meantime, CMS’ Connecting Kids to Coverage initiative includes resources for schools to support outreach activities, including outreach guides and toolkits and a comprehensive guide to outreach, enrollment, and retention strategies. CBPP also has a Guide to School-Based Outreach for Health Coverage Enrollment.