As one out of five children in the United States demonstrate some type of mental or behavioral health concern warranting additional intervention, federal policies have emphasized the need for school-based mental health (SBMH) services and an expansion of Medicaid reimbursement for eligible children and families. Most youth access mental health services at school; therefore, it is important to evaluate how staffing ratios, credentialing, and state Medicaid policies may influence school psychologists' involvement in the delivery of SBMH services. A survey of 192 school psychologists found that as practitioner to student ratios increased, the availability and provision of SBMH services decreased. As state Medicaid policies have been found to influence the provision of mental health services at school, current study results demonstrate an association between state level Medicaid policies and the number of school psychologists qualified to bill for Medicaid-reimbursable services. Implications for service delivery and policy development are discussed.