The Future of School-Based Health Centers in New York
School-Based Health Centers (SBHCs) represent a relatively small but important component of the healthcare safety net in New York, providing access to services for approximately 250,000 mostly low-income students in urban and rural areas and areas where the majority of students’ health insurance coverage is Medicaid. New York’s investment in SBHCs is modest in the context of the State’s overall Health budget. The State provides grants of approximately $21 to $22 million annually directly to SBHCs and provides 50% of the funding for the roughly $30 million in total Medicaid reimbursement that SBHCs receive.
SBHCs are designed to address the health needs of students and reduce barriers to accessing care, such as lack of transportation, parental work schedules, lack of health insurance, or limited availability of local healthcare providers. SBHCs also provide an opportunity to reduce absenteeism by addressing health and health-related needs without requiring students to leave the school building. They serve students in elementary, middle, and high schools across New York and are required to serve all students in the school regardless of health insurance coverage or type.
The main purpose of this paper is to provide more transparency about the services SBHCs provide, who they serve, how they are regulated, and how they are funded. However, another purpose of this paper is to examine a policy initiative by the Hochul administration and the New York State Department of Health (NYS DOH) that could have a major impact on SBHCs.
In September 2024, NYS DOH informed SBHCs that as of April 1, 2025, their services would be “carved in” to Medicaid managed care (MMC), meaning those services would no longer be reimbursed through the Medicaid fee-for-service (FFS) system but instead through Medicaid managed care plans (MCPs) with which SBHCs would be required to contract. Just last week, Gov. Hochul vetoed proposed legislation, that would have made permanent the current “carve-out” of SBHCs from MMC. In response, Sarah Murphy, the Executive Director of the New York School-Based Health Alliance, said,
With this decision, the Governor has ignored the universally held position by all who provide and support SBHCs that forcing the field into Medicaid managed care, now in approximately 100 days on April 1, 2025, will decimate this highly unique and irreplaceable safety net for our most underserved children and their families.[1]
The SBHC sector and its supporters believe that a carve-in to Medicaid managed care will increase their administrative costs (due to contracting and billing with multiple plans and subcontractors) while reducing revenue due to lower reimbursement rates (after a transition period) or the elimination of reimbursement due to being designated as out-of-network providers, when not contracted. SBHCs fear that this policy change has the potential to decrease access to primary care services if as a result, some SBHCs are forced to close due to financial unsustainability or an unsupportable level of administrative burden. Such an outcome would certainly run counter to State policy goals that are focused on expanding primary care and reducing disparities in health outcomes for New York’s most vulnerable populations.
The campaign to keep SBHCs carved out of Medicaid managed care is supported not only by SBHCs, but also by hospitals and federally qualified health centers (FQHCs), both of which sponsor SBHCs, hospital associations, the healthcare workers union 1199SEIU, as well as the trade association for managed care plans. Moreover, although the State has had the authority since 2014 to carve SBHCs into Medicaid managed care, the legislature has on several occasions pushed for and passed legislation supporting the SBHC carve-out – and of this recent session just passed a bill that would have made that arrangement permanent.
Given the strong opposition to the MMC carve-in from affected stakeholders and the legislature, it is curious that the administration and NYS DOH are making the carve-in of SBHCs a priority now. The Governor’s veto message of the bill to permanently keep SBHCs carved out of MMC offered a general rationale, stating in part that,
[T]hese critical services [provided by SBHCs] do not constitute the full spectrum of care and coordination that a Medicaid managed care plan provides. Children will have better outcomes when school-based health centers become integrated in the spectrum of Care that Medicaid managed care coordinates.[2]
Since 2011, with the first Medicaid Redesign Team, “care management for all” has been the guiding principle of health policy in New York. However, the question for various special populations[3] (including individuals with traumatic brain injuries, children/youth in foster care or in the custody of the Office of Children and Family Service, and the much larger population of individuals with IDDs who are served by the Office for People with Developmental Disabilities), is whether MMC can more effectively advance the State’s health agenda than the traditional fee-for-service system. The opposition to the SBHC MMC carve-in by the managed care plans themselves should at least be a yellow flag that suggests the benefits the Medicaid managed care plans would bring to the SBHC sector could be outweighed by the drawbacks of the transition.
Given the strong feelings of stakeholders and the historical position of the legislature on this issue, it seems likely that the carve-in of SBHCs will be an important issue in the upcoming budget negotiations. It may be that rather than disrupting an existing care delivery system that provides access to essential healthcare services and opportunities for improving health equity across New York, the State should consider alternative policy and payment initiatives that support SBHC sustainability and coordination with the broader healthcare delivery system.
The hope is that whatever outcome results from this debate will promote a stronger, rather than weaker, structure for SBHCs. As part of that structure, the State should ensure there is a publicly accessible, all-payer data and information infrastructure to support the evidence-based evolution of SBHCs.
Introduction
SBHCs provide a range of services focused on serving students in low-income, urban, and rural areas where access to healthcare services may be limited and where the majority of students’ health insurance coverage is Medicaid. SBHCs are expected to collaborate with hospitals, community clinics, community-based primary care providers, and local health departments to ensure the provision of coordinated healthcare for students.
In New York, SBHCs have increasingly become integrated into the educational system, aligning with broader goals of improving student attendance and overall student well-being. They provide services directly within schools, in space provided by the school, adhering to requirements established by the NYS DOH. They were first established in the late 1960s and early 1970s in Cambridge, MA, Dallas, TX, and St. Paul, MN. The focus of the early centers was on “… family planning access, teen pregnancy prevention, and supports to adolescent parents.”[4] SBHCs have evolved to offer a broader range of services, including mental health services, dental care, health education, and facilitating access to social services.
To establish a SBHC, New York State requires a memorandum of understanding (MOU) between the SBHC sponsor, e.g., an Article 28 hospital, Federally Qualified Health Center (FQHC), or independent diagnostic and treatment center, and the school district that is renewed every five years. The SBHC is expected to coordinate the students’ care with the sponsoring Article 28 facility, the students’ primary care providers (if not limited to the SBHC), the local health and mental health departments, local departments of social services, and other providers delivering school-based health services to the student. Additionally, the SBHC must establish a Community Advisory Council, “… which is representative of the constituency and is oriented to SBHC services.”[5]
According to data from the NYS DOH from April 2023, SBHCs are distributed in the following types of schools:
· 25% of SBHCs are located in elementary schools.
· 9% are in middle schools and junior high schools
· 25% are in high schools
· 41% – The remaining centers are spread across combined schools (K-12, Elementary/Middle, Middle/High)
The table below, from the NYS DOH, provides additional information about SBHCs in New York:
Services provided by School-Based Health Centers
The services provided by New York’s SBHCs differ from those provided by a traditional school nurse. NYS DOH Principles & Guidelines for School Based Health Centers in New York State, explains that,
Comprehensive school-based health centers (SBHCs) provide primary and preventive care, acute or first contact care, chronic care, and referral as needed. They provide services for children and adolescents within the context of their family, social/emotional, cultural, physical, and educational environment.
The services offered by SBHCs in New York include:[6]
· Core Services
o Primary care that includes:
· age-appropriate reproductive health
· adolescent risk behavior assessment
· oral and dental health (referral if necessary)
· physical exams
· immunizations
o Diagnosis and management of minor, acute, and chronic conditions on-site, including prescription, in coordination with the student’s primary care provider if applicable
o Lab testing
o Mental health (on-site or by referral)
· On-site services of assessment, treatment, referral, and crisis intervention in individual and/or group settings
§ Primary prevention
§ Individual assessment, treatment, and follow-up
§ Crisis intervention
§ Short- and long-term counseling
§ Link to community-based counseling
· On-site or referral services for
§ Group and family counselling
§ Psychiatric evaluation and treatment
o Referral to specialty care
· Expanded Services (on-site or through referral)
o Health education and health promotion
o Assessments and referrals for social services
o Transportation to SBHC sponsor site or to a referral site
o Dental treatment
o Nutrition counseling
o Specialty care
o Well-child care for children of enrolled students
SBHCs are staffed by a multidisciplinary team, including at a minimum, nurse practitioners, physician assistants, a collaborating physician, mental health professionals, a medical/mental health assistant, and a program manager. When the related services are offered on-site, SBHCs must also be staffed with a mental health provider, health educator, nutritionist, dental hygienist, dental assistant, and a supervising dentist. They operate in partnership with the school administration, and students, unless qualified to provide consent on their own, must provide written consent from a parent or guardian to enroll in the SBHC. Students who are not enrolled in the SBHC may, on a limited basis, use the SBHC if the services are for first aid or emergencies, which might otherwise be handled by a school nurse.[7]
New York also authorizes school-based health center dental programs (SBHC-D). These programs still require an Article 28 facility sponsor and must establish an MOU with the school site, but the needs assessment, staffing requirements, care delivery models (such as an option for portable clinic[8] service delivery), and scope of services are all focused on oral and dental care. The SBHC-Ds may offer five different types of service programs per the Planning and Implementing a School-Based Health Center Dental Program guidance document from NYS DOH. They may offer interventions to 1) “create a healthy environment” through promoting regular dental check-ups, for example, or dental/oral safety measures to protect students from sports injuries; 2) provide “health education and promotion programs” that offer activities to promote dental health; 3) implement prevention programs such as offering dental screening, counseling, and referrals; 4) implement clinical prevention programs such as cleanings, applying sealants, and/or fluoride applications; and 5) dental treatment programs using either mobile vans, portable equipment, or fixed facilities within the schools.
Other school-based health services include designated mental health clinics regulated by the NYS Office of Mental Health (OMH). School-based mental health clinics (SBMHCs) provide assessment and psychotherapy services (individual, family, and/or group). They operate as a satellite, i.e., an extension of an OMH-regulated Article 31 clinic located within the community, and adhere to OMH oversight requirements. Additional services provided on-site or arranged by the SBMHC may include peer support, psychiatric assessment, medication treatment, and crisis intervention.[9]
At right, Findings from the 2022 National Census of School-Based Health Centers (p. 9), demonstrated the extent to which SBHCs nationally are helping students and their families address health-related social needs.
Regulatory Framework for School-Based Health Centers in New York
SBHCs are established as satellite clinics of an existing NYS Article 28-licensed hospital, independent diagnostic and treatment center, or FQHC. The SBHCs are added to the sponsor’s operating certificate as a “School Based Hospital Extension Clinic.”[10] While extension clinics are established within Article 28 of Public Health Law, SBHCs are intended to specifically “… provide health, dental or mental health services during school hours and/or non-school hours to school-age and preschool children…,”[11] and they are authorized to be on public school grounds by New York Education Law, Chapter 16, Title 1, Article 9, Section 414, subsection (j). That statute also provides for flexibility in the physical space requirements, operations, and provisions for State funding established in Education Law that permits the Commissioner of Health,
… to waive any provisions of the public health law and regulations, to enter into contracts with article twenty-eight facilities, to provide funds, and to issue appropriate operating certificates in order to establish, support and conduct projects to provide improved and expanded school health services for preschool and school-age children.
SBHCs must seek permission from the NYS DOH to open and close, and they have ongoing audits for compliance with relevant policies. The SBHCs have unique site codes and specific rate codes for billing purposes that the sponsors are required to enter into State or commercial claims processing systems. In some circumstances though, the sponsor may use a standard outpatient hospital clinic rate code that is not specific to the SBHC, so the billing and/or utilization data related to SBHCs could be incomplete.
The sponsor and the SBHC must have policies and procedures that address communication, coverage beyond the clinical coverage required during normal school hours, the proper handling of medical records, quality improvement, fiscal and billing procedures, the coordination of care, and appropriate security and supplies management.[12]
The NYS DOH, Principles and Guidelines for School Based Health Centers in New York State (“SBHC Guidelines”), includes recommendations and requirements for the SBHC physical space that depend on the number of students enrolled in the health center, the services provided, and the staffing plan. The document also addresses data management, quality management and quality improvement, and provides details on the expectations of the Community Advisory Council.
The SBHC Guidelines also address how the SBHCs should coordinate with students’ primary care providers (if not the SBHC or if the sponsoring facility is the PCP), local health and mental health departments, local departments of social services, and other school-based service providers. The SBHC guidelines emphasize the expectation of coordination of care, but implementing this care coordination may be a challenge, and it is a challenge that is not unique to SBHCs in New York.
Challenges with Coordinating Care
Coordination of care can become challenging when a student receives primary and chronic care services both at a primary care provider through their managed care plan and at an SBHC. As mentioned earlier, an abundance of primary care is not necessarily a problem, and many states are seeking to quantify increased access to and utilization of primary care services, and the resulting impact. The concern, however, is when the dual primary care systems are not communicating, and vaccinations, prescriptions, and/or lab work, for example, are duplicated for the patient. This could be mitigated for vaccinations, of course, by providers checking the relevant vaccine registries to avoid duplication.
Care fragmentation may also occur due to a lack of healthcare data sharing and integration related to both the delivery system and to clinical data. This challenge is not unique to SBHCs, and we have written several papers related to healthcare system data and information. SBHC utilization data is combined with the Article 28 sponsor’s data in the public datasets of New York’s Statewide Planning and Research Cooperative System (SPARCS), which is a core contributor to the State’s All Payer Database and provides important information to policymakers for evaluating and planning healthcare delivery and alternate payment models in the State. As mentioned above, SBHC sponsors do use particular site and billing codes when submitting reimbursement claims to State and commercial billing systems, but in the publicly available data they are represented as generic outpatient clinics. Billing data is retrospective and an important element in understanding utilization, spending, and value trends over time.
It is not at all clear the extent to which more current data related to clinical care is shared or accessed, whether through a shared electronic health record (which is common between the sponsor and the SBHC), or through the State Health Information Network for New York (SHIN-NY). For the SBHCs that use their sponsors’ electronic health record, which is a standard arrangement, this facilitates clinical information being available to providers in the same system. For different healthcare systems that have patient overlap, if they are both using Epic for their electronic health record, they can use Epic Care Everywhere, which permits clinical data exchange and access to patient records, with applicable patient consent, for the purposes of clinical care integration.
School-Based Health Centers and Medicaid Managed Care
Due in part to the concerns related to the coordination of care, the Department of Health has had a long-standing goal of carving school-based health centers into managed care. In addition to the goal of improving the coordination of care, DOH generally has a philosophy that nearly all services should be provided through managed care rather than a fee-for-service model. Although DOH has the administrative authority to require school-based health centers to be carved into managed care, this action has been regularly deferred for nearly a decade.
In late September 2024, the NYS Department of Health informed SBHCs that the long-delayed transition would take effect on April 1, 2025. Although DOH directed managed care plans to maintain current fee-for-service APG[13] reimbursement rates for two years, rates would likely decrease after that time. Moreover, the new administrative requirements (e.g., contracting with multiple MCPs as well as their vendors for behavioral health and dental care, rate negotiations, and provider credentialing) to be reimbursed by managed care organizations would need to be in place by April 1, 2024, for the SBHCs to receive payment by that date.
As a result of this direction from DOH, there is a great deal of debate and advocacy related to the appropriate standing of school-based health centers in New York’s healthcare delivery system. As mentioned above, on December 13, 2024, Governor Hochul vetoed a bill[14] that would have kept SBHCs out of MMC permanently. School-based health centers and their supporters argue that the administrative burden that would be imposed on them from being carved into MMC, the likely increase in claims denials from MCPs compared to State FFS, and the potential for reductions in reimbursement rates after moving on from a transition period with fixed reimbursement rates, will result in the collapse of many SBHCs. This outcome would further limit access to essential healthcare services for New York’s most vulnerable children and youth, particularly those for whom the SBHC is their only source of healthcare. Many students who are enrolled in SBHCs, however, are also enrolled in Medicaid managed care plans, and it seems that there could be some common ground where SBHCs are not burdened into oblivion and the MCPs could facilitate the coordination and integration of care and services, as originally intended.
The carve-in represents a significant policy change, but there is a limited pool of public data to understand statewide costs, utilization, and outcomes associated with SBHCs, much less to eventually assess the impact of the carve-in in the coming years. Total costs and spending statewide are not well understood because there is likely a significant volume of SBHC unbilled services, and the body of research demonstrating the positive impacts of SBHCs on students’ health and educational outcomes continues to grow. This is a clear illustration of how having a more robust health data and information infrastructure in New York would benefit policymakers and stakeholder analysts. Given that the State is not taking budget savings associated with the carve-in, it seems logical that this policy decision should at least be grounded in consistent and standardized data – both at baseline and ongoing.
Sustainability of School-Based Health Centers
The debate regarding the carve-in of school-based health centers to managed care has also brought to the forefront the larger question of the sustainability of school-based health centers. Of note though, SBHCs are generally not expected to be profit centers for the sponsors, and the expenses are often claimed on sponsors’ IRS Form 990s as community benefit spending, a responsibility of their tax-exempt status.
SBHCs in New York rely on a mix of federal, state, local, and private funding to operate. Nationally, SBHCs have relied on the sources identified in the graph below from the 2022 National Census of School-Based Health Centers (p. 4, Figure 2).
Funding for New York’s SBHCs includes eligible Medicaid reimbursement at the FFS Ambulatory Patient Groups (APG) rate, which will see a 10% rate increase equivalent to $1.4 million[15] retroactive to April 1, 2024 once CMS approves the plan; service reimbursement from other insurance coverage including NYS Child Health Plus and commercial plans; NYS DOH base grants to all SBHCs, which this year does not seem to incorporate some of the State’s federal Title V Maternal and Child Health Block Grant funds (although these may show up in subsequent budget figures); NYS DOH HCRA funds that are proportionate to the annual number of visits at the SBHC, as well as to the number of enrollees at the SBHC; NYS DOH funds to a segment of the SBHCs to compensate for previous reductions in grant funding; legislative additions to a segment of the sponsors to compensate for previous reductions in funding; and finally, some SBHCs receive grant funds from federal funders such as HHS and HRSA. For FY 25, State support for the approximately 252 SBHCs, excluding health insurance reimbursement and individual federal grants, is in the neighborhood of $22 million. This sum represents an increase of $1.2 million from previous years due to additions to support dental programs, training for community health workers, and other additional base grant funding of approximately $3 million, and reflects the subtraction of the separate Title V funding, which, in previous years, had been $1.8 million.
SBHCs generate revenue by billing health insurers for services provided when the students have coverage, but they may not be able to receive reimbursement for all services. For example, preventive services like health education or other counseling services may not be reimbursed, and other services may require prior authorization from a student’s managed care plan. SBHC services provided to enrolled students have no out-of-pocket cost. A small number of SBHCs in New York have qualified as NCQA-recognized Patient-Centered Medical Homes, which provides a per member per month add-on to the APG rate, but this designation is rare among SBHCs.
The cost of operating SBHCs varies depending on location, size, and the range of services offered. Key operational costs include, at a minimum, staff salaries; physical space renovations; billing, reporting, electronic health record systems, general administration; and medical equipment/diagnostic supplies/general supplies.
The OMH-regulated SBMHCs are included in MMC. Similar to the DOH-regulated SBHCs, they are reimbursed for billable services through health insurance, including Medicaid, CHIP, and commercial insurers. They also provide services that are not reimbursed, such as coordination, consultation, and education or training activities. Per the OMH SBMHC FAQ document, “[e]ven though providers may not be able to bill for these activities, all services provided through the school-based clinic are reimbursed at 25% above the standard rate.” This enhanced rate results from NYS statute and a federally approved State plan that requires Medicaid MCPs to pay “the equivalent of Ambulatory Patient Group (APG) rates for Mental Health Outpatient Treatment and Rehabilitative Services…, among other services.”[16] With this higher rate, “… providers will have greater fiscal flexibility to conduct these non-reimbursable activities.” The enhanced reimbursement is available for certain services and situations,[17] as described in NYS OMH’s, Enhanced Rate Reimbursement for Services Provided by OMH-licensed School-Based Mental Health Outpatient Treatment and Rehabilitative Services Program (MHOTRS/clinic): Frequently Asked Questions.
Fee for Service Versus Managed Care
New York’s first Medicaid Redesign Team recommended moving SBHCs from fee-for-service (FFS) reimbursement to MMC effective in 2014. With FFS reimbursement, SBHCs receive direct reimbursement from Medicaid for services provided to eligible students based on established rates for each service. Reimbursement comes directly from the state Medicaid program. Under Medicaid managed care, the State contracts with private managed care plans to provide services for Medicaid beneficiaries. SBHCs must then contract with these MCPs to receive reimbursement, which adds layers of complexity for providers and the State.
The NYS DOH provides an overview of the transition of the school-based health center benefit and population into Medicaid managed care. To implement the carve-in to managed care, SBHCs (or their sponsors) will need to contract with all of the Medicaid managed care plans and all the dental and behavioral health subcontractors in their service area and ensure that all of their staff are credentialed with each.[18] They will also need to share rosters of the enrolled students and work with the MCPs to ensure appropriate services are consented for and provided, and that the students’ health record information is reported to the MCPs for their required reporting to NYS, including the Quality Assurance Reporting Requirements (QARR) reporting.
There are challenges related to contracting with MCPs, particularly in urban areas of the State that have a significant number of plans overlapping in geography, and for students to designate the SBHC as their primary care provider. In some crowded markets, it is possible that the Article 28 sponsor may not be interested in contracting with a Medicaid MCP that has insufficient reimbursement rates for inpatient services, but nonetheless covers many of the SBHC students. They would then be out-of-network, and some hospitals have policies to not even attempt to bill an out-of-network plan, leading to a total financial loss on the SBHC services provided.
Credentialing of providers is also a lengthy and involved process that would have to be repeated for additional MCPs and for their behavioral health and dental vendors. The purpose is to verify and assess the qualifications of healthcare providers and conduct professional background checks to determine if a SBHC can become part of the MCP network, but the lack of a one-stop, centralized process adds a significant administrative burden. Credentialing can take many months to complete, and billing only has a window of 90 days from the date of service – this will result in the same provider at the SBHC being reimbursed by some MCPs and not others.
For SBHCs in more rural parts of New York, Article 28 SBHC sponsors may not need to increase contracting and go through additional credentialing processes because they already have established relationships with all the plans in their area.
Regarding the SBHC-D programs, it is not yet clear if students will need to designate those providers as their “dental home” to receive reimbursement for their services.
Policies to Support SBHC Sustainability and Integration
In response to the challenges some SBHCs face in Medicaid managed care, states[19] have recommended policy changes to ensure SBHCs are adequately supported. States across the U.S. have implemented various innovative strategies to improve SBHCs’ sustainability and integration with the broader healthcare delivery system.
The national School-Based Health Alliance (the “Alliance”) has identified three key policies that are effective in supporting SBHCs. These include, 1) defining SBHCs as a provider type, 2) waiving prior authorization for SBHCs, and 3) mandating Medicaid MCPs to reimburse SBHCs that are not in-network.[20]
At the time of the Alliance’s state survey in 2017, Delaware, Illinois, Louisiana, Maine, New Mexico, North Carolina, and West Virginia all designate SBHCs as a specific provider type. With this policy, it is possible to differentiate services provided at a SBHC from those of its sponsoring agency. This is important for understanding utilization and attributing quality outcomes.
Prior authorization for SBHC services is waived in Connecticut, Delaware, Illinois, Louisiana, Maine, Maryland, North Carolina, and West Virginia. SBHCs that are not the primary care provider are not required to seek prior authorization to be reimbursed for services provided at SBHC.
State policies in Louisiana, Maryland, Michigan, and New Mexico require Medicaid MCPs to pay for “self-referred” visits by SBHC enrollees, even if they are out of network. As the Alliance explains, “[s]uch policies do not necessarily obviate the need for a contract between managed care plans and SBHCs but assure compensation to the SBHC if none exists.”[21]
Promoting, or perhaps incentivizing, a tighter relationship between an Article 28 hospital sponsor and the SBHC is important for optimal performance of the SBHC. Ensuring the SBHC program is an established division of the hospital’s Pediatrics Department and aligning the program with other outpatient clinic resources (recognizing that, as with most primary care service lines, it will not be a hospital profit center but will provide an important service for the community), will lead to increased integration of goals, services, and funding.[22]
Strengthen Integration with Community Schools
Increasing overlap of SBHCs with New York’s Community Schools can form an important strategic partnership.
Community Schools are public schools that emphasize family engagement, strong community partnerships and additional supports for students and families. Community Schools are designed to counter environmental factors that impede student achievement. Fundamentally, Community Schools coordinate and maximize public, non-profit and private resources to deliver critical services to students and their families, thereby increasing student achievement and generating other positive outcomes.[23]
In New York City alone, there were 421 Community Schools in the 2022-23 school year. Community Schools across the State are funded through local, State, and federal funds. The presence of a SBHC within a Community School could be considered a gold standard that has the potential to enhance student success and improve health outcomes.
The Impact of SBHCs
National research demonstrates the positive impact that SBHCs have on students’ health outcomes and evidence also supports the positive impact of SBHCs on educational outcomes and academic performance.[24]
By providing a combination of primary care, reproductive health, mental health, vision, dental, and nutrition services, SBHCs improve the health, wellbeing, and academic achievement of the students they serve… SBHCs constitute an important safety net, and represent a critical point of access, for youth in underserved communities. Students with access to a SBHC are more likely to receive preventive services, less likely to lose valuable classroom time, less likely to visit the emergency department and be hospitalized, more likely to have access to confidential reproductive and sexual health services, and more likely to demonstrate improved educational and academic outcomes compared to students without.[25]
John A. Knopf and colleagues conducted a literature review that focused on data from SBHCs serving “urban, low-income, and racial or ethnic minority high school students.” They concluded that SBHCs “…can be effective in advancing health equity” because their utilization by students was associated with,
… improved educational (i.e., grade point average, grade promotion, suspension, and non-completion rates) and health-related outcomes (i.e., vaccination and other preventive services, asthma morbidity, emergency department use and hospital admissions, contraceptive use among females, prenatal care, birth weight, illegal substance use, and alcohol consumption). More services and more hours of availability were associated with greater reductions in emergency department overuse.
Research from January 2022 focused on the impact of SBHCs in rural New York on educational outcomes concluded that even among schools with lower than statewide-average rates of absenteeism, “[s]tudents in SBHC schools had significantly fewer absences than students in similar non-SBHC schools in the same rural area. SBHCs can provide onsite health care and mental health services that likely result in fewer student absences.”
Research from November 2024 involving the same system of SBHCs in rural areas of New York that have “high rates of economic disadvantage” found improved health outcomes related to asthma management for students in schools with SBHCs. The study compared patterns of healthcare utilization among students with asthma who had access to a SBHC and those who did not. They concluded that, “[r]ural students with asthma who have access to SBHCs have greater opportunities for preventive asthma care per national guidelines and use emergency departments and convenient care less.”
Performance Measurement and Quality Improvement
In New York, there is little State-level, publicly available data related to SBHCs. Their utilization data is merged with their sponsoring facilities’ data in the State’s publicly accessible SPARCS system, the publicly available Fact Sheet does not include information related to services provided or utilization, and the Medicaid Global Spending Cap Reports do not delineate SBHCs. For these reasons, it is difficult to ascertain the details of their care delivery.
SBHCs submit quarterly data to the NYS DOH that consist of:
There is a significant amount of quarterly utilization data that is being collected from SBHCs, yet very little of it is available publicly, or provided back to SBHCs for benchmarking purposes. If there is an issue with the measures, the collection process, the aggregation and analysis, or some other barrier to developing useful information from these data, the NYS DOH should consider simplifying/reducing the elements that are submitted quarterly. The submission of the quarterly utilization data is time-consuming for SBHCs, and it is not entirely clear how it is benefiting stakeholders in understanding the services of SBHCs, as well as the students’ outcomes.
In an effort to fill the gap in publicly available statewide data related to the work of SBHCs, the New York School-Based Health Foundation conducts surveys of SBHCs, and the most recent, the 2022-23 Survey, represents information from 52% of New York’s SBHCs that include 14 sponsoring organizations with 63,486 students and 250,805 visits. Of these respondents, 62% of all visits were for medical care, 26% were for mental health care, 4% were for dental care (although dental care was not consistently reported, so this could be understated), and 9% were unidentified. The top five reasons for visiting SBHCs were for illness and injury (25%), general wellness (20%), adjustment disorder (9%), chronic disease (6%), and anxiety (4%). SBHCs are integrating care as well – 21% of students making a medical visit also received mental health care, and 70% of students making a mental health visit also received medical care (p. 8).
From this partial view into the activities of SBHCs, we have these service snapshots for July 2022 through June 2023:
Connecticut provides a publicly available fact sheet related to school-based health centers. It includes some of the basic data that New York includes in their fact sheet but also includes a breakdown of medical, mental health, and dental services access and utilization that are similar to New York’s quarterly submitted measures. The Connecticut fact sheet includes two previous years’ data to display trends. This annual rolling representation of the SBHC data is something New York could reproduce, assuming they are also collecting data from the SBHC-D programs. Up until 2019, Connecticut also provided Results Based Accountability Report Cards that displayed SBHC-specific data related to financials, access and utilization, and performance evaluation.
The National School-Based Health Alliance provides an SBHC Quality Improvement Toolkit and recommends standardized SBHC performance measures to,
… help SBHCs monitor and improve care delivery and demonstrate effectiveness compared with other child health delivery systems. These data can help make a compelling case that the SBHC model is uniquely suited to support the broader health and education systems to achieve their objectives (p. 3).
Recommendations Moving Forward
With the Governor’s veto of the permanent carve-out bill on December 13, 2024, and barring a last-minute agreement with the legislature to delay implementation of the carve-in, it appears New York will forge ahead, within a compressed timeframe, to incorporate SBHCs into Medicaid managed care. The intent of this Policy Brief has been to take the opportunity to examine the role of SBHCs in New York’s healthcare delivery system, how they could be strengthened going forward, and what lessons can be learned from other states that have already carved SBHCs into MMC. Below is a summary of the important considerations from the discussion above that are important for New York’s SBHCs, stakeholders, and policymakers:
Improve the Publicly Available Data and Information About SBHCs
There is a limited pool of public data to understand statewide costs, utilization, and outcomes associated with SBHCs, much less to eventually assess the impact of the carve-in in the coming years. Total costs and spending statewide are not well understood, and this is a clear illustration of how having a more robust health data and information infrastructure in New York would benefit policymakers and stakeholder analysts.
· Existing public data sets should break out SBHCs from their Article 28 sponsors
· The NYS DOH should consider simplifying/reducing the frequency of the data submitted quarterly by the SBHCs. Very little of it is available publicly; if there is an issue with the measures, the collection process, the aggregation and analysis, or if there is some other barrier to developing useful information from these data, it should be addressed.
Make it Easier for SBHCs to Navigate Medicaid Managed Care
Of note, the OMH-regulated SBMHCs do not see all students in the school, as is required for the DOH-regulated SBHCs. If the DOH-regulated SBHCs do not have a contract with the Medicaid managed care plan or the service is denied, SBHCs will still be required to provide the care, they will just be uncompensated.
· Ensure that the unique site codes and SBHC-specific reimbursement codes are used by sponsors when billing to ensure a better understanding of utilization and outcomes.
· Remove the need for prior authorization to provide services if the SBHC is not the designated PCP.
· Require that all MCPs, even those with whom the SBHC is not contracted, reimburse for services SBHCs provide.
· Centralize the medical credentialing process to streamline and speed up the process. Consider a centralized entity with automated processes that would more efficiently perform the research and background checks for each MCP’s credentialing requirements.
Increase Reimbursement Rates
· Support SBHCs who seek PCMH designation, which provides enhanced reimbursement.
· Maintain State share Medicaid reimbursement at $15.4 million and reinvest the higher federal share of Medicaid funding into increased rates for SBHCs (continuing after the FFS rate maintenance has ended in two years). Because the federal matching rate for MMC is approximately 60% (as opposed to 50% for FFS), maintaining the current dollar amount the state provides for SBHC Medicaid reimbursement would increase total Medicaid reimbursement rates to SBHCs by approximately 20%. To ensure that the increased reimbursement rates are paid out by the Medicaid managed care plans, the State should mimic the process for the enhanced rates established by NYS OMH for their SBMHCs, by establishing a Directed Payment Template (DPT) or establishing a mechanism for an additional per member per month amount as occurs with the PCMH designation, perhaps a designation as a “safety net clinic.”
Carve out Dental Programs
· Given the severe challenges in accessing dental care and its critical importance in maintaining student health and well-being, in the absence of any other policy changes, it makes sense to keep SBHC-D services carved out of MMC.
Protect Patient Privacy
Ensuring the privacy of adolescents seeking and receiving reproductive healthcare services through SBHCs is of paramount importance. The managed care model uses explanation of benefits (EOBs) documents, which are sent to policyholders outlining the services provided and financial obligations.
· Given New York’s expansive minor consent provisions, MMCPs must implement billing processes that maintain the protections afforded under the law.
Establish an Optional Expansion of the Populations that SBHC can Serve
· For those SBHCs that want to, amend statutes to permit them to provide services to people other than the students after school hours or on non-school days. This could include school staff who are already authorized to be in the school buildings. If the SBHC has outside entrances, they could treat students’ family members or general community members. Some SBHCs will not want to do this, especially during school hours, because the care teams are pediatrics-focused and the SBHC is deemed as a trusted space for the students, without teachers or other staff in their space with their care team.
Sally Dreslin is the Executive Director of the Step Two Policy Project.
[1] Statement on Governor Hochul’s Veto A8862/S7840, Empire Report, December 14, 2024.
[2] See Appendix: Veto #81 Memo.
[3] Medicaid Managed Care: Exclusions and Exemptions, NYS DOH.
[4] H.E. Love, J. Schlitt, S. Soleimanpour, N. Panchal, and C. Behr. Twenty Years of School-Based Health Care Growth and Expansion, Health Affairs, Vol. 38(5), May 2019.
[5] Principles and Guidelines for School Based Health Centers in New York State, NYS DOH, August 24, 2017, p. 19.
[6] Principles and Guidelines for School Based Health Centers in New York State, NYS DOH, August 24, 2017.
[7] FAQ, Transition of School Based Health Center Benefit and Population Into Medicaid Managed Care, NYS DOH.
[8] This model utilizes portable dental equipment set up in school space. Dental providers treat students during the school day for several days at a time, then move the equipment to a different school to provide treatment there.
[9] School-Based Mental Health Satellite Clinic, FAQs for Schools, NYS OMH.
[10] Health Facility Certification Information, Health Data NY.
[11] SECTION 414, Use of schoolhouse and grounds, Education (EDN), CHAPTER 16, TITLE 1, ARTICLE 9, (j).
[12] NYS DOH, Principles and Guidelines for School Based Health Centers in New York State, August 24, 2017.
[13] NYS Mainstream Medicaid Managed Care and School Based Health Center Billing Guidance, NYS DOH.
[14] S7840/A8862 An act to amend the social services law, in relation to coverage for services provided by school-based health centers for medical assistance recipients. The veto message stated, in part, “[T]his is my third veto of legislation that attempts to take this step. Since taking office, I have prioritized tackling the youth mental health crisis including by investing $1 billion to transform the continuum of care and increasing the reimbursement rates for school-based health centers. However, these critical services do not constitute the full spectrum of care and coordination that a Medicaid managed care plan provides. Children will have better outcomes when school-based health centers become integrated in the spectrum of care that Medicaid managed care coordinates.” Veto #81, December 13, 2024. See the Appendix for the full veto message.
[15] If the 10% increase in Medicaid rates is scored at $1.4M, this indicates that the State share for Medicaid FFS SBHC spending is $14M for a total in FY 25 of $15.4M State/$15.4M federal ($30.8M gross) spending on SBHC Medicaid services reimbursement. Of note, the State/federal spending split for Medicaid Managed Care is 40/60 instead of the FFS 50/50, so there is a savings for the State during the first two-years of a carve-in, even with the maintenance of rates. The federal share would be approximately $3M more than under the FFS model, which likely explains the $3M increase in the State grants for FY 25, even though the funds are from different sources within the NYS DOH. It remains to be seen in FY 26 if the $3M State Medicaid savings will remain in grant funding, be shifted to increase Medicaid rates, or be taken as State savings.
[16] OMH/OASAS Behavioral Health Billing Manual for Medicaid Managed Care Plans, April 2024.
[17] “The enhanced rate is allowable for services delivered directly by the satellite and for specialty services by the main clinic through telehealth, in accordance with OMH billing guidance. Telehealth services provided by satellite staff on-site at the school, but the student is off-site due to temporary circumstances (e.g., when the child/youth is out of school for medical reasons, suspension, truancy/school avoidance, or during school breaks to address transportation challenges, as appropriate) are eligible for the enhanced rate when the student is enrolled in ongoing, on-site satellite services. Telehealth services provided by another clinic site while the student is not in school due to temporary circumstances are not eligible for the enhanced rate. During short-term school closures (e.g., spring and winter breaks) or unplanned events (e.g., snow days, emergency closures) in which the school building is closed, and satellite staff cannot access the clinic satellite, telehealth may be used to continue school-based clinic services. In these cases, the enhanced rate is also allowable.”
[18] FQHCs that are SBHC sponsors are exempt from this requirement since they are generally reimbursed utilizing the Prospective Payment System (PPS).
[19] State Policy Database, National Association of State Boards of Education [Note: public access to the database will be discontinued on January 17, 2025].
[20] Medicaid Policies that Work for SBHCs, School-Based Health Alliance.
[21] Ibid.
[22] Personal communication, December 2024.
[23] Community Schools. NYSED.gov.
[24] Realizing the Potential of School-Based Health Centers: A Research Brief and Implementation Guide, Harvard Graduate School of Education, Education Redesign Lab, September 2020.
[25] Improving Health Equity and Outcomes for Children and Adolescents: The Role of School-Based Health Centers (SBHCs), Current Problems in Pediatric and Adolescent Health Care, April 2024.
[26] Demographics include sex (M, F, X), ethnicity, race (including multiple sub-groups required in 2024 by statute), and primary language spoken at home (required in 2024 by statute).
[27] Visit reasons include SBHC-enrolled mental health, SBHC-enrolled first aid, non-SBHC-enrolled first aid, SBHC-enrolled reproductive health, SBHC-enrolled preventive oral health, and SBHC-enrolled telehealth visits.
[28] Optional reproductive health measures include the number of SBHC-enrolled students who received birth control, birth control counseling, and pregnancy tests.
