Children and youth with special health care needs (CYSHCN) and their families face unique hardships in accessing school-based health services during COVID-19, especially children of color, those experiencing poverty, and those living in rural areas who have limited access to technology and acute socioeconomic needs. 

States are developing unique strategies to support the health needs of CYSHCN who lack access to their usual school-based physical, developmental, and mental health supports. 

These approaches include:

• Upholding requirements mandated by the Individuals with Disabilities Education Act (IDEA) and in particular, Individualized Education Plans (IEP);
• Holding or prioritizing in-person learning for specific populations of children (e.g., CYSHCN, children experiencing homelessness);
• Expanding Medicaid coverage of telehealth in schools; and
• Expanding Medicaid coverage of home health services.

How COVID-19 Impacts CYSHCN

CYSHCN require health care services and supports beyond what children normally require and account for about 20 percent (14.6 million) of US children and youth. Rates are higher across racial and ethnic demographics, with about 25 percent of non-Latinx Black children and youth reporting special health care needs, for example. This inequity is driven by a combination of systemic issues, including factors such as lower rates of access to robust medical homes and lower quality of received care among Black and Latinx CYSHCN. 

Recent data from the Centers for Disease Control and Prevention (CDC) shows that children who self-identified as Hispanic, non-Hispanic Black, and Native American/Alaska Native with underlying medical conditions make up nearly 80 percent of children who died from COVID-19. These racial and ethnic inequities are a result of a range of socioeconomic issues including: systemic racism; lack of access to healthcare; education, income, and wealth gaps; and crowded housing conditions. Inequities among CYSHCN have been heightened by the loss of school-based services that provide physical, behavioral, and developmental services and supports. 

A May 2020 survey conducted by ParentsTogether found that just one in five parents reported that their children received all the school support services required by their IEP as schools moved to virtual instruction. As school opening policies (in-person, virtual, hybrid) are changing on a weekly basis, it is important for states to closely monitor and improve the accessibility of school-based health services for CYSHCN both in-person and virtual settings.

The US Department of Education released guidance early on in the pandemic requiring local education agencies (LEAs) to provide students with disabilities access to the same educational opportunities provided to the general student population, including the provision of free appropriate public education (FAPE) during the COVID-19 outbreak. The guidance requires schools to uphold the services in a student’s IEP – a tailored education plan designed to meet the unique needs of children with special needs – and requirements under IDEA during any school changes, as a result of the pandemic. 

To support districts in their transition to virtual learning during COVID-19, the Georgia Department of Education was awarded $6 million in federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and IDEA funding. The Georgia State Board of Education allocated $3 million to supplement the state’s special education program, including the delivery of IEP plans. Pennsylvania is taking a similar approach, allocating $20 million from the Governor’s Emergency Education Relief Fund and the state’s federal IDEA funding to bolster remote services and supports for students with complex needs and provide services to students with disabilities who experienced a loss in skills or a lack of progress due to school closures. 

State Strategies

States have prioritized children with special needs for in-person learning due to their unique needs for access to services and supports, and the current challenges they face in accessing in-person learning. In late August, the California Department of Public Health issued rules to allow for opening of schools to small cohorts of students with “acute needs.” The guidance encourages  LEAs to prioritize students with disabilities who receive specialized services, such as occupational therapy, speech and language services, and other medical, behavioral, and educational support services. These cohorts are limited to 14 students and two supervising adults.

Oregon is taking a similar approach by allowing schools to bring a limited number of students (up to 10 per cohort) for up to two hours of in-person instruction daily. Students who receive special education services, are learning English, or lack reliable internet access, are prioritized for in-person learning. It is important for states that have already transitioned students back to in-person instruction to design and implement policies to protect the health of CYSHCN and other vulnerable students. A recent National Academy for State Health Policy (NASHP) blog, State Strategies to Safely Transition Children with Special Health Care Needs Back to School, highlighted additional state strategies to safely transition CYSHCN back to physical school settings.

States are also using telehealth and home health services to increase accessibility to care for CYSHCN that previously received these services in a school-based environment. Since the onset of the pandemic, 31 states have released guidance allowing Medicaid reimbursement of school-based telehealth services and nine are allowing reimbursement of school telehealth services for the first time. 

Pennsylvania, South Dakota, and Texas are newly allowing Medicaid reimbursement for school-based audiology, counseling, and occupational, physical, and speech therapy telehealth services. Other states, such as Ohio and Wisconsin, are working on making their telehealth-in-school Medicaid policies permanent post-COVID-19. Additionally, most states are allowing telehealth services to be delivered via audio-only format and with widely available tools, such as Zoom and FaceTime, to make services more accessible. 

States are also updating their Medicaid waiver rules to meet the health and educational needs of CYSHCN during remote learning sessions. The North Carolina Department of Health and Human Services recently worked with the Centers for Medicare & Medicaid Services (CMS) to allow families to use Medicaid waivers for home health services delivered at the same time that students are engaged in virtual learning. Families were previously prohibited from doing so because of restrictions on the use of federal funds from different programs (health and educational), as both home health and virtual school services rely on federal funding. North Carolina’s new Appendix K Waiver increases in-person physical health and therapeutic supports for CYSHCN who lost access to these services due to remote learning. 

As states consider new policies to better support the health needs of CYSHCN in virtual and in-person educational settings, it is important to consider: 

• What specific policies can be developed to support the unique needs of Hispanic, non-Hispanic Black, and Native American/Alaska Native CYSHCN who are disproportionately affected by COVID-19 and school closures? 
• Can policies such as expanding Medicaid coverage of telehealth in schools and increasing funding for special education services be leveraged beyond the COVID-19 public health emergency to strengthen care for CYSHCN? 
• What role will federal funding play in alleviating state budget pressures as they navigate COVID-19-related shortfalls?
• Can states continue to finance Medicaid-reimbursed home health services in supporting CYSHCN during remote instruction? 

NASHP will continue to monitor school-based health policies during the COVID-19 pandemic and the implications for CYSHCN and their families.