School Medicaid Expansion: Interviews with State Medicaid Agencies

Background and Purpose

This qualitative study examines state-level implementation of school Medicaid expansion from the perspective of State Medicaid Agency (SMA) staff. School Medicaid expansion is defined as the ability of school districts to receive Medicaid reimbursement for school-based health services beyond a student’s Individualized Education Plan, which outlines disability-related services. Although the option to expand has been in place since 2014, several states have just recently taken up this opportunity to receive reimbursement for a wider range of services since the pandemic in the context of heightened health needs. Schools have become a primary site of health service delivery for children and youth, and a particularly important site of mental health service access for Medicaid eligible children whose mental health treatment options are often limited.

This study examines the implementation of school Medicaid expansion from the state-level Medicaid agency perspective. The SMA is responsible for approving changes to the Medicaid State Plan, including school-based services and providers. This study examines 1) how SMAs made decisions to expand Medicaid reimbursement of eligible school-based mental health services and 2) successes and challenges of current implementation efforts at the state level.

Methods

This study includes 25 semi-structured interviews between 2024 and 2025 with purposively selected SMA staff, reflecting the diversity of state expansion decisions. Qualitative interviews were designed using the literature on intergovernmental collaboration required to implement school Medicaid expansion, including the interagency collaborative capacity (ICC) framework (Bardach, 1998; Lasker et al., 2001). This ICC framework was employed to capture the coordination of activities, resources, and staff to implement SME between the SMA and state education agency. Thematic analysis was employed to analyze these interviews and followed the five-phase thematic analysis process (Nowell et al., 2017; Braun & Clarke, 2022). Interviews were deductively coded using the ICC framework and inductively coded with codes developed from the interview transcripts. Themes were developed from the codebook and finalized through research team consensus.

Results

Findings across the interviews with social workers and administrators include retaining institutional knowledge on the school Medicaid program, sharing motivation to meet student needs across the agency, strengthening multi-level communication between the SMA and state education agency, and enhancing the billing infrastructure for school-based health services to support the documentation and billing to receive funding.

Conclusions and Implications

Findings from this policy implementation study will build the evidence base for implementation successes and challenges to school Medicaid expansion by focusing on the different decision-making processes among states, such as why some states chose to adopt “full” expansion allowing reimbursement for all “medically necessary” services and some states chose to adopt “partial” expansion for some service categories. The findings provide concrete guidance about processes that improve interagency collaboration between education and health agencies to promote the use of Medicaid funds to increase student access to mental health services. This is an important study in the context of the child mental health crisis following the COVID-19 pandemic. Medicaid is a sustainable revenue source to expand mental health services for children and youth.