Direct Certification With Medicaid and School Lunch Participation Among Maryland Public Schools

Importance: States may join the US Department of Agriculture Direct Certification with Medicaid (DCM) program, allowing schools to use Medicaid participation to automatically qualify students for free and reduced-price school meals (F/RP). DCM also informs the Identified Student Percentage (ISP), which determines eligibility for the Community Eligibility Provision (CEP). Pre-COVID-19 evaluations found mixed associations between DCM and school meal participation. Pandemic-era policies included free meals for all students, which has ended in most states. Therefore, a postpandemic evaluation of DCM is warranted. Objective: To examine the association of Maryland's DCM implementation in the 2022-2023 school year (SY22-23) with ISP, CEP eligibility and enrollment, and school lunch participation. Design, Setting, and Participants: In this cohort study, publicly available school-level data were used to examine annual ISP, CEP participation, and school lunch participation among public schools in Maryland. A school-level fixed effects model evaluated changes in school lunch participation before (SY18-19 and SY19-20) and after (SY22-23 and SY23-24) DCM implementation among non-CEP schools. A 2-way fixed effects model tested the association between CEP enrollment and school lunch participation among schools newly eligible for CEP due to DCM. Data analyses were conducted from July to December 2025. Exposure: DCM implementation. Main Outcomes and Measures: ISP, CEP eligibility and enrollment, and school lunch participation. Results: Among 1252 schools, 856 (68.4%) were elementary, 221 (17.7%) were middle, and 175 (14.0%) were high schools; 734 (58.6%) were suburban, 258 (20.6%) were located in rural or small towns, and 260 (20.8%) were urban. Mean (SD) ISP increased from 25.9% (17.5%) in SY21-22 to 37.3% (19.6%) in SY22-23 after DCM implementation. In SY23-24, CEP eligibility and enrollment increased by 26.7 and 22.2 percentage points, respectively. School lunch participation increased by 1.9 (95% CI, 1.1-2.8) percentage points (P < .001) among non-CEP schools post-DCM (SY22-23 and SY23-24). Among schools newly participating in CEP, school lunch participation increased by 6.5 (95% CI, 4.6-8.3) percentage points (P < .001). Conclusions and Relevance: In this cohort study of Maryland public schools, DCM implementation was associated with increases in direct certification for F/RP meals, CEP participation, and lunch participation. DCM implementation may support school meal participation in the post-COVID-19 pandemic context. Programs such as CEP and Medicaid may warrant policy attention to support school meal access and its benefits for student health and academic outcomes.