OBTAINING PARENTAL CONSENT
TO BILL MEDICAID:
An Unnecessary, Time-Consuming and
Emotionally Fraught Process for Districts
and Parents
In December 2022, AASA, The School Superintendents
Association (AASA) along with the National Alliance for
Medicaid in Education (NAME) and the Association of
Educational Service Agencies (AESA) surveyed district
leaders and school-based Medicaid leads at the LEA
and ESA level to better understand the impact of the
U.S. Department of Education’s current parental consent
regulation on the school-based Medicaid program.
AASA, NAME and AESA were interested in
understanding whether there has been increased
difficulty in obtaining signed parental consent forms due
to the pandemic and the increased politicization of
America’s public education system and government. As
the Centers for Medicare and Medicaid finalize the
release of a new administrative claiming guide that will
simplify Medicaid billing for districts and ESAs, now is
the ideal time for the U.S. Department of Education to
also take steps to reduce the confusion and burden of
the parental consent regulation, so districts can adopt a
systematic approach to improving school-based
Medicaid documentation.
This is an analysis of the data collected and issues
identified by the survey, which was completed by 458
respondents in 43 states. Survey respondents had the
opportunity to share their varied experiences with
obtaining parental consent for Medicaid reimbursement
and we have collected and grouped a sample of the
responses to further illustrate the findings.
INTRODUCTION
PAGE | 1
January 2023
SURVEY FINDINGS
PAGE | 2
The first question asked respondents to identify barriers
to obtaining parental consent to billing Medicaid. The
top two barriers identified were 1) overcoming general
concerns by parents about signing any kind of release
form related to Medicaid and the impact it would have
on their child’s insurance and 2) the significant burden
on staff to obtain the signed consent forms.
Seventy percent expressed that there is
generalized concern by parents about signing
any kind of consent or release form related to
billing Medicaid.
Since 2005, district personnel have voiced concerns
that presenting a separate signed consent form for
Medicaid reimbursement has been confusing and
problematic for parents. While the U.S. Department of
Education attempted to improve the initial parental
consent regulation in the Individuals with Disabilities
Education Act (IDEA) for Medicaid reimbursement in
2013 for services that are delivered as part of a
student’s individualized education program (IEP),
there is still considerable confusion from parents
about why they should complete the consent form
and why the school needs a separate permission to
bill Medicaid for healthcare services they are
delivering to their child in schools. As districts around
the country begin to bill for non-IEP services the
confusion about signing a consent form has been
amplified. A parent with two children—one with an IEP
and one without—may only be asked to sign a
consent form for the child with the IEP even though
there is a separate requirement under Family
Educational Rights and Privacy Act to receive consent
for accessing Medicaid reimbursement.
“Parents/guardians do not understand what the form is
for, and they are hesitant to sign because of their
financial situation(s) becoming public/known to federal
officials.”
“Some parents just flat out refuse because they believe
there are strings attached; don't fully understand the
process despite trying to educate them.”
“Parents believe the school accessing these funds
reduce the amount of Medicaid funding that is available
over their child’s lifetime.”
“Despite reassurances, parents repeatedly have
expressed fear of how this will impact services outside
of school and they are concerned that the consent may
result in the sharing of information on logs/submissions
that they do not wish to share with ‘the government.’”
“We hear that some families do not wish to give consent
for fear of a stigma associated with Medicaid enrollment
and perceived discrimination.”
FROM THE FIELD
1
PAGE | 3
School-based providers are unique in that they have
roles beyond the healthcare services they deliver to
perform in schools. They are not bound to only
delivering Medicaid services to students with IEPs—
they provide healthcare-related students to 504 plans,
who may or may not be covered under Medicaid, and
who are not Medicaid eligible for other reasons. They
also act in other capacities: they supervise students
in the cafeteria or in homeroom, they may assist with
extracurricular activities, they attend school-wide
events and staff meetings. Moreover, many Medicaid
providers and specialized instructional support
personnel in schools lack the back-office
administrative support of other healthcare settings
where completing Medicaid documentation, IEP
documentation and other billing education and
medical documentation is their responsibility. This
means that chasing down consent forms also falls on
them and takes time away from their other student-
focused responsibilities. Given the national shortage
of these professionals in our schools, it is imperative
that their work being focused on serving the high
caseloads of students they see every week rather
than on obtaining parental consent forms.
“We have to spend a significant amount of time asking
staff to reach out parents to get the consent forms
signed. Staff already have their plates full and feel
overwhelmed with paperwork when working through a
student's IEP. We continually find students that are
receiving services will not have a consent form in place,
however everything else will be correct and they are
eligible for Medicaid billing. It is also very discouraging
to our staff to get all of the other pieces in place, and
then to find out that none of the services we provided
can be reimbursed because an initial consent from the
parent was never obtained.”
“Within a district where over 79 languages are spoken,
the explanation of this consent coupled with language
barriers has a significant impact on our consent
percentages. In addition, we have an extremely high
percentage of students entering the district from
elsewhere and it is typical for the consent to be missing
from the receipt of student records. This results in much
staff time being spent to track the form down or restart
the consent process.”
“Not all districts have the manpower to go after missed
opportunities to obtain consent, as most staff are
wearing many hats. I have even heard of employees
seeking work in districts that do not participate in
Medicaid, so they don't have to do the additional work
that is involved. This ultimately hurts the students.”
“My school district has a low percentage of lower social-
economic students and my staff spends countless
hours trying to obtain parent signatures. I cannot
fathom how much time must be spent by schools with
higher percentages of lower social-economic students.”
“Our Medicaid dollars have dropped significantly due to
our inability to obtain parent consents. Our staff call,
meet, text, message, etc. with parents to explain the
form and what we need, yet we cannot get signed forms
returned.”
FROM THE FIELD
2
Two-thirds of respondents described the burden
on staff to follow-up with parents to complete
forms was significant.
6-10%
51-75%
PAGE | 4
The second question asked survey respondents what
percent of their parental consent forms are not
signed or returned. The answers varied considerably.
“We currently have 37% of Medicaid eligible students
without signed consent. This is a significant amount of
revenue we are not receiving. Contacting parents,
sending and explaining consent forms takes time that
could be spent serving students.”
“Many parents think that by signing the consent it will
affect any outside services they receive. If 20-25% of
parental consents are unattained, then 20-25% of
reimbursement is affected. The need for medical and
mental health in schools has increased dramatically
over last 5 years. Schools cannot keep increasing costs
without reimbursement. This is not sustainable over
long term.”
“Chasing consents is a real problem and takes up many
hours of non-reimbursable time. Having a student or
several students with no parental consent show up in
the annual billing compliance review really hurts our
compliance percentage which in turn drastically reduces
our reimbursement.”
Almost a quarter of respondents said between 1-
10% of their forms are not signed.
Approximately a third said that between 26-50%
of their forms are not completed.
Eighteen percent said their over 50% or more of
their forms are not signed.
The inability to obtain signed consent forms can have
major implications for district finances. A student
with significant healthcare needs that requires a
personal care assistant, multiple services from a
variety of specialized instructional support personnel
and specialized transportation, can easily cost the
district a $100,000 per year to provide. If this student
attends a small or rural school with an operating
budget of $10 million and the parent is scared to sign
the consent form for the district, the district is forced
to spend one percent of their entire budget on
educating this student and are unable to receive any
financial support from Medicaid to cover the cost of
these Medicaid-reimbursable services.
As states look to expand their healthcare services,
particularly their mental health services for students,
Medicaid presents a critical funding stream that
enables districts to provide these additional
healthcare services. While by no means a dollar-to-
dollar match in reimbursement, AASA has found that
most districts utilize Medicaid reimbursement to pay
the salaries for specialized instructional support
personnel. The greater the reimbursement they
receive, the more personnel they can hire to support
students’ healthcare needs. The COVID-19 pandemic
highlighted the importance of the delivery of
healthcare services in schools and how critical the
expansion of these services is to ensuring students
can learn.
Percent of Forms Not Completed
5%
13%
11%
11%
32%
13%
76% or more
0-5%
11-25%
26-50%
FROM THE FIELD
3
PAGE | 5
“Every dollar counts. The inability to successfully
either obtain consent or have the appropriate
processes in place to document that consent has had
a significant impact on the Medicaid reimbursement
received in our county. I believe the reimbursement
received could have been about 50% higher if another
layer of consent was not required.”
“We have many parents in our district who are not
U.S. citizens and they are reluctant to complete any
forms. Even though we continue to provide quality
services, it is at a huge financial impact to our
district.”
“"For every consent form not signed and returned, we
do not receive reimbursement. We have
approximately 30% of our forms not signed or
returned, thereby losing 30% of our reimbursement.”
The third question asked respondents to describe
whether it has become any more difficult to obtain
parental consent now than five years ago.
Fifty-six percent of respondents report that it is
more challenging for districts and ESAs to obtain
parental consent to bill for Medicaid services
than it was in 2017.
Thirty-one percent report that there is no increase or
decrease in the difficulty in obtaining consent forms
while seven percent says it has decreased. The
answers as to why the challenge has increased can
be grouped into three buckets: 1) the increased
politicization of America’s public education system
during the course of the pandemic, 2) changes in
state Medicaid policy that allow districts to bill for
non-IEP services known as “free care” services; 3)
parents intentionally withholding consent as a way to
“punish” districts for what they believe to be
inadequate IDEA services or noncompliance with
IDEA.
FROM THE FIELD
“I’m thrilled our state has decided to expand school-
based Medicaid, but there is no reasonable opportunity
to engage a parent/guardian about the consent form
outside of an IEP meeting. Therefore, the recent
expansion of the program to allow claiming for services
unrelated to IEPs has been meaningless because there
is no realistic way to overcome the parental consent
barrier without an IEP meeting. This is most obviously
true for any unplanned medical and mental health
services and supports. Therefore, no claiming is
occurring for these medically necessary and important
services we are delivering.”
“Our State has now added free-care in our SPA and we
are finding it much more difficult to obtain Medicaid
consent from the general education population.”
“We live in an environment where it is becoming
increasingly difficult for parents to 'trust' signing any
consent form specific to their child, especially anything
involving their child's healthcare or mental health. Our
post-pandemic world has made it even more
challenging. On the heels of locally politically
contentious issues such as masking/not masking,
vaccinations or no vaccinations, parents are less likely
to provide any level of consent to school district officials
related to any access to data or information.”
FROM THE FIELD
PAGE | 6
“Our state is able to claim for ‘Free Care’ services, which
has increased the Medicaid enrolled students we
provide direct health and mental services to that we
could submit claims for. Students with other plans of
care that require parental consent for mental health
services often will not sign the Medicaid consent as it is
confusing to them. The expected reimbursement
increase we thought we would see with ‘Free Care’ is not
apparent at this time."
"We recently had a family revoke consent because they
wanted to file a state complaint related to IEP
implementation. They essentially made the decision out
of anger toward the district."
“Parental consent requirements make it more difficult
for our district to provide resources to support student’s
mental health and emotional needs. Parents refuse to
sign the consent for Medicaid billing, but the district has
the responsibility to provide those supports, which are
expensive. We have a high number of 504 students
receiving services now, but a very difficult time getting
parents to sign the consent form. Anything that could
make it easier for us to receive Medicaid reimbursement
for these services would be appreciated.”
FROM THE FIELD
CONCLUSION
A school’s primary responsibility is to provide
students with a high-quality education. However,
children cannot learn to their fullest potential with
unmet health needs. As districts are faced with more
children with critical health and mental health care
needs and increasing demands for school personnel
to provide those services, the federal government has
a duty to remove any administrative barriers that
stand in the way of districts receiving critical funding
that can support the expansion of these healthcare
services.
AASA, NAME and AESA hope that this new survey
data highlighting the increased challenges in
obtaining parental consent and the impact it has on
the ability of school-based providers to deliver
Medicaid reimbursable services to children, spurs
policy changes at the U.S. Department of Education
that will make it easier for districts to bill Medicaid for
these healthcare services.
PAGE | 7
REFERENCES
1.) The first IDEA regulation (§300.154(d)) requiring
districts to obtain parental consent before accessing
Medicaid reimbursement for school-based services was
issued in 2005 after the reauthorization of the IDEA in 2004.
A revised IDEA Part B regulation (§300.154(d)(2)(iv)) was
issued in 2013, which modified the requirements related to
securing parental consent to access Medicaid
reimbursement. The original regulation required school
personnel to obtain parental consent each time they sought
Medicaid reimbursement. The updated regulations made it
easier for school personnel to access public benefits by
only mandating that parental consent be acquired before
the school system accessed a child’s or parent’s public
benefits or insurance for the first time. It kept the
requirement that the LEA or ESA must send an annual
notice to parents informing them that school district is
billing Medicaid for the school-based services they are
delivering to their child and that the parent can opt-out of
having the school district access Medicaid reimbursement
for those services at any time.
2.) “About The Shortage.” National Coalition on Personnel
Shortages in Special Education and Related Services,
https://specialedshortages.org/about-the-shortage/.
3.) Pudelski, Sasha. "Cutting Medicaid: A Prescription to
Hurt the Neediest Kids." AASA, The School Superintendent's
Association (2017).
The Association of Educational Service Agencies (AESA) is a professional organization serving educational service agencies (ESAs) in 45 states; there
are 553 agencies nationwide. AESA is in the position to reach well over 80% of the public school districts, over 83% of the private schools, over 80%
certified teachers, and more than 80% non-certified school employees, and well over 80% public and private school students. Annual budgets for ESAs
total approximately $15 billion. AESA’s membership is agency wide and includes all ESA employees and board members.
The National Alliance for Medicaid in Education, Inc. (NAME) is a non-profit 501(c) (3) organization comprised of members from the nation's school
districts and state Medicaid and Education agencies who are involved in administration of Medicaid claiming for school-based services. Other
members are those with an interest in the Medicaid-in-education field such as businesses, consulting firms, non-profit organizations and federal
agencies.
AASA, the School Superintendents Association, founded in 1865, is the professional organization for more than 13,000 educational leaders in the
United States and throughout the world. AASA members range from chief executive officers, superintendents and senior level school administrators to
cabinet members, professors and aspiring school system leaders. AASA members are the chief education advocates for children. AASA members
advance the goals of public education and champion children’s causes in their districts and nationwide. As school system leaders, AASA members set
the pace for academic achievement. They help shape policy, oversee its implementation and represent school districts to the public at large.
