Best Practices For Strengthening Medicaid-Covered School-Based Health Care Services Via Telehealth

School-based health services are essential for ensuring that students—especially those in underserved communities—have access to comprehensive health care, including physical exams, mental health counseling, and management of chronic conditions like diabetes and asthma.^{1, 2}These services help reduce absenteeism, support academic success, and address health disparities by eliminating barriers such as transportation and cost.³ Bolstered by the 2023 release of federal Medicaid school-based health services guidance,⁴ state Medicaid and education agencies have continued to explore ways to strengthen the delivery of school-based health services to increase access to care and address the youth behavioral health crisis.⁵

In recent years, technology companies have significantly increased their involvement in supporting states and local education agencies by providing digital health platforms, telehealth solutions, and electronic health record systems tailored to the needs of students. Technology companies have partnered with schools to deliver virtual medical and mental health care, allowing students to receive timely diagnoses and treatment without leaving school. This flexibility is particularly valuable in areas with limited health care access. In addition, the adoption of these tech-driven solutions was accelerated by the COVID-19 pandemic and is expected to remain a vital component of school health services.⁶ In recent years, numerous states have made substantial investments in their school-based telehealth programs. (See below.)

There is tremendous opportunity for both state Medicaid and education agencies, along with local education agencies, to partner with technology companies to address unmet physical and behavioral health needs for children and youth, particularly when it comes to increasing access to behavioral health services amidst growing shortages of providers. Building a successful school-based telehealth program takes careful planning and consideration and requires state agencies to release clear guidance and provide technical assistance support to technology companies that may not be familiar with the Medicaid regulatory structure. To advance transparency and support bi-directional feedback, state agencies and technology companies should also work to ensure there is close coordination and communication with primary care providers, school leadership, and the larger community.

To that end, the following are four best practices to help ensure successful implementation of Medicaid-reimbursed telehealth programs within school-based health care programs.

1. Release School Based Health Services' Medicaid Billing Guidance. With Medicaid and the Children's Health Insurance Program (CHIP) covering nearly half the children in the United States,⁷ and Medicaid being the primary payor of behavioral health services,⁸ Medicaid is an important source of financial sustainability for most school-based telehealth initiatives. Telehealth companies seeking to engage schools by providing health care services should understand what Medicaid services are covered and school-specific provider requirements, which can vary from state to state. For example, Individualized Education Plan-mandated services (e.g., physical or occupational therapy) are the sole Medicaid-covered services in some states, whereas, in other states, any medically necessary service (e.g., mental health therapy) can be provided by a school and be reimbursed through Medicaid. Also, the provider types allowed and specific modalities of telehealth that are reimbursed (e.g., live video or audio-only) varies by state. States should release clear Medicaid school-based health services billing guidance and provide technical assistance support to technology companies that are seeking to serve as Medicaid-reimbursed telehealth providers.
2. Ensure Coordination Between Telehealth and Primary Care Providers. Successful school-based telehealth programs should ensure coordination with the child's primary care provider. When primary care providers are made aware of the urgent care, mental health, and other services their patients are receiving via telehealth at school, they gain access to a more holistic picture of a student's health care needs. Coordinated care mitigates the potential for missed diagnoses, duplicated services, and potential patient safety risks. As such, states should establish clear Medicaid and school-based health service policies that require school-based telehealth programs to prioritize strong relationships with pediatricians, therapists, and others who may be involved locally with a student's health care. This can include, but not be limited to, requiring technology companies to: follow communication, collaboration and data sharing protocols (e.g., obtaining consent for information sharing and standardized referral and follow-up processes), including local providers as part of the school-based telehealth care team, using electronic health records to share information with community-based providers, and educating families and school staff on the importance of care coordination.
3. Engage with School Leadership, Staff and Families. In addition to working closely with local providers, building trust and buy-in from the local community and supporting bi-directional feedback is paramount to a school-based telehealth program's success. School leaders, such as superintendents, principals, and school boards, need to understand the school-based telehealth program's benefits, address potential concerns regarding privacy and liability, and see how a program aligns with educational goals and community values to provide necessary approval and support. State education and Medicaid agencies should partner to educate local education agencies about telehealth programs and services so that districts and schools can, in turn, provide this information to families and staff. States should work with technology companies to develop clear notices and other communication materials in multiple languages for families and staff that clearly describe the consent processes, data security protections, and the integration and coordination of telehealth with their children's existing medical providers. School staff, especially nurses or other staff who facilitate these services daily, require comprehensive training, clear protocols, and ongoing support to feel competent and comfortable coordinating use of the services.
4. Establishing Clear and Standardized Workflows: It is crucial to establish clear, documented workflows for any telehealth program, but this is especially true for school-based telehealth programs due to their additional complexities. State Medicaid and education agencies are uniquely positioned to lead the charge in establishing standardized protocols and cohesive frameworks for addressing issues including obtaining parental consent, as necessary; and ensuring compliance with federal laws such as the Health Insurance Portability and Accountability Act and the Family Educational Rights and Privacy Act, which protect the privacy of student health and education records, along with any state-specific laws, providing local education agencies with logistical support and guidance for creating designated private spaces for telehealth visits and developing efficient scheduling and facilitation protocols that do not overly burden already stretched school staff, and defining protocols for managing prescriptions and coordinating care with the student's local medical home. Additionally, state Medicaid and education agencies can collaborate to provide comprehensive training for both on-site staff and remote providers, ensuring everyone involved is comfortable and proficient in scheduling and facilitating visits. Without clear workflows—and the leadership of state Medicaid and education agencies in establishing them—even the most innovative programs may fail due to inefficiencies, miscommunication, and stakeholder frustration.

Conclusion

Embracing school-based telehealth offers a promising avenue for addressing unmet health needs and improving student outcomes. School-based telehealth programs are much more likely to thrive when state Medicaid and education agencies work alongside providers and technology companies to provide clear billing guidance, ensure care coordination with local primary care, foster engagement with local school leadership and families, and help establish standardized workflows and protocols. These strategies can help school-based health programs more effectively increase access to care for students and earn trust within local communities.

Footnotes

1. Knopf, John A, et al. "School-Based Health Centers to Advance Health Equity: A Community Guide Systematic Review." American Journal of Preventive Medicine, July 2016. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC5759331/.

2. Keeton, Victoria, Samira Soleimanpour, and Claire D Brindis. "School-Based Health Centers in an Era of Health Care Reform: Building on History." Current Problems in Pediatric and Adolescent Health Care, July 2012. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC3770486/#S1.

3. Supra note 1.

4. Centers for Medicare & Medicaid Services (CMS), "Delivering Services in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative Claiming." 2023. Available here.

5. Key policy changes encouraging school-based health care services include the CMS rescission of the free care rule in Medicaid in 2014, making it easier for schools to receive funding for school-based health care services and the passage of the Bipartisan Safer Communities Act in 2022, which contained provisions supporting the continued growth of school-based services.

6. Goddard, Anna, et al., "The Future of Telehealth in School-Based Health Centers: Lessons from COVID-19." Journal of Pediatric Health Care, May/June 2021. Available here.

7. American Academy of Pediatrics, "AAP Analysis: 49% of Children Insured by Medicaid or CHIP," February, 2025. Available at: https://publications.aap.org/aapnews/news/31491/AAP-analysis-49-of-children-insured-by-Medicaid-or?autologincheck=redirected.

8. The Commonwealth Fund, "Medicaid's Role in Mental Health and Substance Use Care," May 2025. Available here.

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