As school-based health centers have established a track record in providing access to primary care services for underserved school-age populations, financial viability of these programs has become increasingly dependent upon revenues generated from Medicaid and other third-party payers. The introduction of managed care concepts into this situation has created great uncertainty for the future. The authors discuss the various types of managed care models that school-based health centers are being called upon to work with and summarize the key issues (communications, confidentiality, linkages, reimbursement, and quality improvement) around which those relationships are being developed.