When occupational and speech therapies are provided to certain Medicaid-eligible students at Tulsa Public Schools (TPS), the district gets reimbursed. These are called school-based services, which are medically necessary and provided in a school setting.
The Centers for Medicare and Medicaid Services (CMS) describe them as a way to meet children where they are and deliver care where they spend most of their time.
Schools can only bill Medicaid for services provided to Medicaid-eligible students on Individualized Education Programs (IEPs), which are custom care plans to help students with disabilities succeed at school.
Gena Koster, TPS’ assistant superintendent of special populations, said the district is gradually moving toward billing for more types of services. It plans to begin offering physical therapy this school year and add nursing services during the following one.
Currently, Koster said TPS recoups around $150,000 annually, and she anticipates this could double amid these additions.
“The more opportunities we can make of the access to this program, it increases and improves our opportunity to serve students,” Koster said.
There are about 550 school districts in the state, including charters. Oklahoma Medicaid reimbursed approximately $3.8 million to 120 Oklahoma Health Care Authority-enrolled districts during fiscal year 2024. That’s compared to neighboring states like Arkansas and Colorado, whose districts recouped around $70 million each in recent years.
“I think Oklahoma just has not … taken the approach of being able to benefit from programs that other states have benefited from,” Koster said.
Oklahoma is taking steps toward enhancing its offerings through a state plan amendment, which the Oklahoma Health Care Authority (OHCA) is working to submit.
Pending federal approval, schools could recoup more Medicaid dollars from providing services like occupational and speech therapy, and behavioral health supports to eligible students. And, with a federal grant, the state hopes to help teach schools how to bill for Medicaid.
What a state plan amendment could do for Oklahoma schools
OHCA is working to propose a state plan amendment to CMS that would do two things.
First, it would allow Medicaid reimbursement for medically necessary school-based services provided to students on other plans of care, which organize a student’s health information. Beyond an IEP, that would include Individual Health Plans, 504 plans and Behavioral Health Plans, an OHCA spokesperson said.
Second, it would expand schools’ ability to bill for other services that parents consent to, like medication administration and additional behavioral health supports. Medically necessary offerings schools can currently bill for when serving eligible students include speech and hearing, physical and occupational therapy, nursing, personal care, and behavioral health services.
Oklahoma Medicaid Director Christina Foss said OHCA and the State Department of Education (OSDE) work closely on school-based services. OHCA helps draw down federal funds for school districts – which provide the state’s share – and offers training on how to bill Medicaid. OSDE provides connections to school districts and assists with training and supports.
Before 2014, Medicaid would only reimburse for services delivered to children with an IEP or individualized family services plan. That policy was reversed, allowing schools to seek reimbursement for covered services delivered to all Medicaid-eligible children.
More than two dozen states have expanded their school-based services as of 2023, including neighboring ones, like Arkansas and Missouri.
The Healthy Schools Campaign, a national nonprofit that provides guidance on expanding school-based services, has defined a comprehensive expansion as states permitting their school Medicaid plan to cover all medically necessary services for all Medicaid-enrolled students. A limited expansion would include expanding coverage outside of an IEP only for certain groups of students – such as those with a 504 plan – or only for specific services.
An OHCA spokesperson said in an email there are many reasons why Oklahoma is now choosing to work toward enhancing services. One is a document released in May 2023 by CMS, which offers new flexibilities and consolidates existing guidance to make it easier for all schools to receive payment for covered services.
The agency also received requests to explore school-based services beyond an IEP, and its spokesperson said many districts are already delivering services that could qualify for Medicaid reimbursement. OHCA and OSDE participated in an interim study on the topic last year.
Oklahoma has ranked 46th in overall child well-being for three years, placing 43rd in health and 48th in education. A report on school-based services from the Healthy Minds Policy Initiative suggests the state should take “urgent action” to invest in children’s well-being.
When schools are not billing Medicaid for services, they leave federal dollars on the table, causing districts and state taxpayers to bear the cost.
Both of these potential enhancements, Koster said, could be a big help to TPS by creating more opportunities to participate. She cited medication administration as an example.
“The number of students that we provide medication for that are on IEPs might be three percent of the total population of students that we provide medication management for,” Koster said. “So, if we were able to recoup funds on all of the students we provide medication management to, that would be huge.”
‘Is the juice worth the squeeze?’
Stormy Bullard is a licensed clinical social worker in Wilburton who works predominantly with children. She said in a rural, high-poverty area like hers, it’s important for kids to receive services where they are the most — at school.
Bullard said she supports the idea of the state plan amendment. But adding services and students to bill for is going to come with growing pains that may make participation unlikely in rural communities, which already have shortages of providers and lack the capacity to take on administrative functions like billing for Medicaid.
“The school may not even realize these are opportunities, because they’re trying to address all the other things they have to keep up with every year,” Bullard said. “This is a whole other thing that’s going to … add more to their plate to have to do. And so I think, it is just resistance with that – an already strapped system.”
Koster said TPS has taken a strategic approach in working to participate in more components of the program. She said, for example, it will take time for the district to become comfortable with billing for nursing services.
“Let's just say we just rip the Band-Aid off and say, ‘Hey, let's start billing for nurses next year.’ The likelihood that we're going to have non-compliant issues around the requirements for the billing is much larger,” Koster said. “So any time you get funds back, if you are uncompliant or your documentation is not adequate or anything like that, you have to repay those funds.”
Koster said there might be a perception that if the state plan amendment is approved, schools can automatically begin billing. That’s not the case, she said.
“There's a lot of procedural and administrative type of tasks or assurances that would need to be in place, and that takes time to train people to do it accurately so that we're not found out of compliance for specific things,” Koster said.
“The administrative part of it is not a small feat. And districts will have to decide: Is the juice worth the squeeze?” she added.
OHCA, in partnership with the OSDE, hopes to help schools tackle Medicaid billing with a new initiative funded by a federal grant. CMS sent out grants to 18 states last year to support them in designing and implementing changes to their school Medicaid programs. Oklahoma is receiving $2.5 million over three years.
Foss, Oklahoma’s Medicaid director, said it will be used to teach participating schools the ins and outs of billing for Medicaid. It will fund the development of billing manuals and guides for school districts.
“If you've never billed Medicaid before, it's a totally different process than what they're used to. And so our ability to help train and provide education around all of that is limited,” Foss said. “And so, using these grant dollars, we'll be able to provide a lot more technical assistance, and so will OSDE.”
Foss also said OHCA is also in the process of contracting with 10 “champion” school districts, which were identified as already successfully billing for school-based services. The plan is to divide them into regional support groups, where they can provide mentorship, training and support to other districts that may not have had the opportunity to bill for these services.
“Each district must decide whether to pursue Medicaid reimbursement. … This grant and the enhancement to school-based services aims to support districts in building the infrastructure needed to do so,” Foss said.
When school-based Medicaid services meet Oklahoma politics
The topic of school-based services garnered statewide attention this legislative session because of a bill filed by Sen. Dusty Deevers (R-Elgin). It would have disallowed medical services like occupational therapy and speech therapy from being written into students’ IEPs and pulled Medicaid coverage from those kinds of therapies, as well as services like eye and health exams.
Over 3,000 people signed a petition opposing the bill, which was pulled in February.
“It has become evident that the language of SB1017 needed to more precisely reflect my intent — protecting the necessary services for our special needs students while ensuring that parental rights remain intact,” Deevers said in a news release. “I regret any confusion or concern this has caused and sincerely apologize for the turmoil it has created.”
Deevers said he wants an audit of school-based Medicaid funds and, at the time, “secured a commitment” from OSDE to “take a closer look” at its audits. StateImpact reached out to Deevers multiple times. He did not respond before publication.
StateImpact also reached out to an OSDE spokesperson, requesting an interview to discuss the department’s partnership with OHCA on school-based services and role in efforts to enhance them. The spokesperson responded with a statement from State Superintendent Ryan Walters.
"Medicaid expansion is one of the vails [sic] that the radical Leftists use to deliver their anti-American playbook filled with indoctrination tactics. I do not support Medicaid expansion,” Walters said.
Deevers said the intent of his bill was to prevent Oklahoma from providing reproductive and gender-affirming care, such as in California, where students can access birth control without parental consent.
In Oklahoma, a parent, teacher, or primary care provider can refer a student for screening, according to an OHCA spokesperson. Parental consent must be obtained before the screening takes place.
If the screening shows a need, a full evaluation is conducted and, if appropriate, a plan of care is developed by a qualified provider and approved by the parent. Then, services can be delivered in the school setting, the spokesperson added.
“We require parental consent on all of these things, and that is included on every plan of care and updated if that plan of care ever changes,” Foss said. “So they're always kept in the loop.”
‘Totally change the scope’
Enhancing schools’ ability to bill for Medicaid services would “totally change the scope” of what TPS does, Koster said. It would allow the district to free up funds it’s currently eating when it provides services it doesn’t bill Medicaid for, she said. And that could mean more opportunities at TPS.
One would be getting more providers. She said TPS has had vacancies because it can’t provide a competitive salary.
More providers would create a lower caseload, she said.
“If we could increase our number of providers, then we could lower the caseload management of that service, which would also, in turn, better support our students,” Koster said. “Because right now, our providers are just overwhelmed.”
OHCA plans to submit the proposed state plan amendment in November, with implementation slated for March 1, pending federal approval.
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