School-Based Health Care: State Policies and Funding, FY2017

Executive Summary

The School-Based Health Alliance surveys state public health, education, and Medicaid offices triennially to assess state-level public policies and activities that promote the growth and sustainability of school-based health centers (SBHCs).[1]  The fiscal year (FY) 2017 survey found that 16 states and the District of Columbia  reported investments explicitly dedicated to SBHCs – one fewer than the previous survey in FY2014. More detailed findings from the survey are provided below.

State Investment in SBHCs (n=17)

Sixteen states and the District of Columbia allocated funds totaling $91.3 million to SBHCs for school year 2016-17—a slight increase of seven percent from 2013-14 (link to Map 1). California was the first state in more than a decade to establish an office for school-based health centers, but has yet to appropriate any public funds for their operations.

The states’ investments ranged from $20 million (supporting 100 SBHCs in MI) to $500,000 (supporting 3 SBHCs in TX). The average amount of state funding and number of supported SBHCs was $5.3 million and 57, respectively. Seven states (DC, IL, MI, NC, NY, OR, TX) increased their SBHC funding allocation between 2014 and 2017 (link to Map 2). Another seven states (CO, CT, DE, LA, MD, WV) experienced decreases in financial support since FY2014.

Table one and chart one highlight key findings across eight data collection points between 1996 and 2017.  Over the last two decades, the number of state public health or education departments that fund SBHCs (“state SBHC program offices”) has decreased 54 percent, from 37 to 17. Despite the decline in the total number of states with state SBHC program offices, the total funding for SBHCs increased 118%, the number of SBHCs supported by states has increased 76%, and the total number of SBHCs across the U.S. has increased 187%.

One of the best illustrations of the positive effect of state-level investment in SBHCs is represented in the 21-year growth of SBHCs in states with SBHC program offices compared to states without (link to Chart 2).

Allotment Strategy (n=16)

The states vary in their approaches to a funding allocation strategy. The majority of state SBHC programs date back to 1996 (and earlier); many of the funded SBHCs have been grantees since the creation of the program. With few exceptions, most of the state programs operate under a noncompetitive renewal process, with disbursal of funds to SBHCs contingent upon provision of progress reports and performance data. Funding amounts are dictated by annual appropriations; increases to state program funding levels are used to augment existing grantees or put out for competition to support new SBHCs.

States use a mix of criteria for establishing funding priorities and award levels, including number of SBHCs operated by a sponsoring institution, complexity of patient demographics and population needs, staffing and service models (i.e. primary care, mental health, specialty care), and school size/number of SBHC enrollees.

Eligibility (n=16)

We asked the states to describe the types of school-based delivery models that are eligible to receive state-directed funds (link to Table 2).  They include:

  • Traditional SBHCs (16 states): clients access care at a fixed site on a school campus and providers are physically onsite, and may deliver some services remotely.
  • School-Linked SBHCs (5 states): clients access care at a fixed site near a school campus and providers are both physically onsite and may deliver some services remotely.
  • Mobile SBHCs (5 states): clients access care at a mobile van parked on or near a school campus and providers are physically onsite, and may deliver some services remotely.
  • Telehealth Exclusive SBHCs (2 states): clients access care at a fixed site on a school campus and providers are available remotely for 100% of primary care services.

Collecting/Reporting Performance Measures (n=16)

All state SBHC program offices collect data from their SBHC grantees, including processes and outputs such as enrollment, number of visits, types of diagnoses, billing revenue, and financial accounting. They also collect data on quality measures such as annual well care visits, depression screening, and immunizations. The periodicity of collection varies, ranging from monthly, quarterly, semi-annually, or annually. The reporting format differs across states, as well: some extract the required data elements directly through electronic health records, while others require SBHCs to submit through an online data portal or excel spreadsheet (see Table 3).

The Alliance, which launched a first-ever voluntary national SBHC performance data set in 2016, asked the states to identify which of their respective quality measures align with the Alliance’s national measures [see measures definitions here]. Five states (DE, DC, LA, MI, and NM) currently collect all five measures using definitions that align with the Alliance’s national measures. Several of the states are committed to making progress towards adapting their measures to align with the national initiative (see Chart 3).

Medicaid Policies that Support SBHCs (n=16)

In general, states adopt one of two approaches to Medicaid and school-based health centers:

  1. Reimburse SBHCs based on the provider (physician, nurse practitioner, etc.) or sponsor type (hospital, FQHC, health department) that submits claims to Medicaid; or
  2. Recognize SBHCs as a unique provider type and set up conditions or requirements for reimbursement by Medicaid.

States that afford special status to SBHCs under Medicaid typically:

  • Require SBHCs to undertake a certification or credentialing process as an assurance to Medicaid that the site meets the state’s operating standards for quality of care—typically delineated in a joint memo of understanding between Medicaid and the state program office (IL, LA, MI, NC, NM).
  • Provide financial protection for SBHCs seeking reimbursement within a managed care environment, such as waiving the SBHC from securing prior authorization from the patient’s primary care provider or health plan (IL, MI), allowing adolescents to self-refer to the SBHC (MD), requiring contracts between managed care organizations (MCO) and SBHCs (MI), or allowing SBHCs to circumvent the MCO and bill the state Medicaid agency directly (NY).
  • Establish fee schedules specific to SBHCs, excluding SBHCs that bill under the sponsorship of FQHCs (ME, NC).
  • Require SBHCs to use a distinctive billing or locator code to more readily identify claims by SBHCs (OR).

Examples of these state policies can be found here:

[1] Some version of this survey has been administered to states very 2-3 years since 1993, first by Making the Grade, a national program office of the Robert Wood Johnson Foundation housed at George Washington University, and subsequently by the School-Based Health Alliance starting in 2005.

Map 1. State Dedicated Funds for SBHCs, FY17 (in millions)

Map 2. Percent Change in State Investment From FY14 to FY17

Table 1. Survey Highlights Summary, 1996-2017

Table 2. SBHC Models Eligible for State Directed Funding

Table 3. SBHC Performance Data Collection Process

Chart 1. Percent Cumulative Change, Number of SBHCs and Amount of State-Directed Funding (FY96-FY17)

Chart 2. Percent Cumulative Change: Total Number of SBHCs in State with and without dedicated funding (since 2004-05)

Chart 3. Alignment of State SBHC Performance Measures with the Alliance’s National Measures