By leveraging federal Medicaid funding and state investment while simultaneously clarifying complex billing procedures and enhancing engagement with providers, Arizona has made remarkable progress in increasing student access to critical school-based behavioral health services.
Arizona’s efforts to improve school behavioral health services began in 2018 when its state legislature allocated $3 million from the state’s general fund to expand these services. The state’s Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), and the Arizona Department of Education (DOE) used $1 million of this funding to provide schools with mental health training, and the remaining $2 million was matched with federal Medicaid funds, resulting in a total $10 million in Medicaid funding to increase the number of behavioral health providers in schools.
To obtain Medicaid reimbursement for school-based services under the Medicaid School-Based Claiming (MSBC) program, Arizona’s local education agencies (LEAs) use two school-based claiming programs, the Direct Service Claiming (DSC) program and the Medicaid Administrative Claiming (MAC) program. LEAs seek Medicaid reimbursement through the DSC program to cover the cost of providing medical and behavioral health services to Medicaid-eligible students with an Individualized Education Program (IEP). The MAC program provides LEAs with reimbursement for administrative outreach services for Medicaid that are conducted in school settings. The state contracts with a third-party administrator, Public Consulting Group (PCG), to process Medicaid school-based claims.
In addition to claims processed through the MSBC program for students with IEPs, Medicaid services delivered by behavioral health providers contracted through one of AHCCCS’ managed care organizations can be reimbursed by Medicaid regardless of whether the student has an IEP.
Challenges and Solutions
Improving partnerships and coordination between schools and providers: While Arizona provided school behavioral health services before 2018, the additional state funding helped prioritize these services and facilitated the development of new relationships between behavioral health providers and schools. State officials reported that prior to the initiative to promote school-based behavioral health services, there were some challenges related to establishing relationships between schools and providers.
For example, some school administrators were skeptical if they could bill for school-based services or were concerned about the logistics of providing appropriate space to conduct behavioral health services without interrupting usual school activities. Many of these issues have been addressed through extensive and ongoing training sessions with both school administrators and provider groups. State officials also credited the cross-sector workgroup meetings that are held on a regular basis with helping improve interagency relationships.
Another key factor in Arizona’s success was incentivizing partnerships between schools and behavioral health provider agencies to create a differential adjusted payment for behavioral health providers. The enhanced payment became effective in October 2019, and provides a 1 percent rate increase for providers that have a memorandum of understanding with three or more schools to provide behavioral health services, and a 3 percent rate increase for providers that are autism Centers of Excellence.
State officials at AHCCCS also are in the process of improving data sharing with the DOE. By matching school identifier numbers on claims for services provided on a school campus, or as the result of a referral from an educational entity, the state will be able to obtain a better understanding of where and which services are delivered. Improving these data-matching processes will also provide information about where students are being referred for additional services and help identify where future focus should be directed within the state to enhance school-based behavioral health services.
Another key partnership to support students’ behavioral health needs is AHCCCS’ collaboration with the Arizona DOE on several grants, including Project Aware, which is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Project AWARE works with three school districts to provide suicide prevention and behavioral health resources.
Addressing lack of behavioral health providers and service delivery challenges: Arizona state officials identified the lack of behavioral health providers, particularly in rural regions, as an issue faced by many states. However, Arizona officials are pleased and encouraged by the number of providers who are participating in the state’s expansion of school-based behavioral health services. One factor that likely incentivized greater provider engagement was the implementation of the differential adjusted payment, although state officials indicated that there had already been a growing interest among behavioral health providers to develop new school partnerships to reach more students due to the statewide focus on the issue.
School districts in Arizona have also developed creative solutions to connect their students to behavioral health services. One school district in Arizona responded to provider shortages and space limitations by setting up a dedicated mobile unit in the school parking lot for behavioral health services. Prior to bringing in the mobile clinic, providers did not have financial incentives to travel to the school because it was difficult to secure an appropriate office during the school day. With the mobile unit, the district can provide consistency for their providers as well as a private space for students to receive behavioral health care. However, because the care is not technically provided in the school building, the district needed to work with the state Medicaid agency to find a way to appropriately bill under school-based behavioral health services.
Clarifying qualifying services and billing procedures: The state’s increased focus on the provision of behavioral health services in schools also helped to improve the accuracy of billing code processes. When efforts to expand school-based behavioral health services were initially launched, state officials at AHCCCS actively worked to address some of the existing misunderstandings about the allowability for those services to be provided at a school campus outside of the MSBC program. State officials recognized that due to errors in coding related to where services are provided, some school-based behavioral health services were not being correctly captured, resulting in the state not having a clear picture of the scope of services being provided to students.
To address these issues, AHCCCS coordinated and led many informational learning sessions throughout the state for both educators and provider agencies, including trainings about billing procedures. Once providers learned how to assign the correct place of service code, state officials reported a notable increase in the quantity of behavioral health services provided. State officials attributed the increase not only to the coding improvements that more accurately captured completed work, but also due to new services provided as a result of the state’s overall emphasis and investment in school behavioral health services.
Like many states, Arizona uses a Random Moment Time Study (RMTS) to assess the amount of time providers spend engaged in Medicaid-reimbursable activities. Each LEA has a RMTS coordinator who facilitates the administration of the program. As the third-party administrator, PCG manages the overall RMTS process, and provides program-specific introductory trainings for new coordinators and LEAs as well as recurring trainings to provide program updates and address areas of concern. AHCCCS coordinates with PCG to improve the RMTS process, and at present, AHCCCS consistently meets RMTS compliance standards, despite having to transition to virtual trainings during the COVID-19 pandemic.
Effect of COVID-19: The transition to mobile learning due to COVID-19-related school closures has presented an opportunity for schools to provide behavioral health services through virtual platforms. State officials report there has been a reduction in the number of claims that use place-of-service codes, which indicate when services are provided at an educational institution, most likely due to the decrease in the number of students attending school in person because of the pandemic. However, officials indicated that they have observed a dramatic increase in the amount of behavioral health services currently delivered through telehealth as more students have had to operate within a remote learning environment.
For districts without local providers, the ability to work with students without travel has helped connect more children to care. According to one Arizona state official, many behavioral health providers have gone above and beyond to connect with children whose need for care has been exacerbated by stress and isolation resulting from the pandemic.
State officials said there is anecdotal evidence that the pandemic has caused an increase in the number of parents expressing concern that their children are exhibiting depression and/or suicidal tendencies. However, officials also noted they have observed a greater willingness among parents to discuss issues concerning mental health, which could result in parents more actively advocating to ensure that schools continue to offer behavioral health services.
Since the start of the state’s efforts to expand behavioral health services in schools in 2018, officials report progress has been remarkably successful throughout 2019 and into early 2020, and there has been a substantial increase in the number of students who have received behavioral health services from an educational entity or institution. While declines in the number of youth suicides cannot be directly correlated with the state’s expansion of behavioral health services — and data from the effect of the pandemic is not yet available — there was a 41 percent decrease in youth suicides from 2018 through 2019.
State officials report their efforts have been so successful that in 2020 the state legislature passed SB 1523, which established and allocated $8 million to a new Children’s Behavioral Health Services Fund that will further enhance school-based behavioral health services. The fund will be administered by AHCCCS and provides behavioral health services to students who are not Medicaid-eligible but are uninsured or under-insured and who receive a referral for services from an educational institution.
In reflecting on lessons from Arizona’s expansion of school-based behavioral health services that might be used by other states, officials explained that determining how to handle nuanced billing situations, such as telehealth and the state’s mobile unit, was an important factor in ensuring that all provided services were accurately captured and reimbursed. They commented, “If Arizona can do it, anyone can do it — we are ranked 51st in [the nation for] education funding, and we have the poorest counselor-to-student ratio in the nation…that said, we have this great state Medicaid agency, and we’ve been able to figure out how to reach more kids with the dollars given to us. And so, if Arizona can figure out how to do this sort of work and get these partners on school campuses, then any other state can do this.”
The National Academy for State Health Policy (NASHP) would like to thank state officials from Arizona for their time and contribution to this publication. Support for this work was provided by the David and Lucile Packard Foundation. The views expressed here do not necessarily reflect the views of the foundation.
The COVID-19 pandemic has negatively impacted the mental health of many children and adolescents and reduced students’ access to comprehensive school mental health systems (CSMHS) as schools shifted to remote learning.
In recent years, states have implemented policies that have successfully expanded access to CSMHS. Lessons learned from these initiatives can help address students’ growing mental health needs and may help reduce states’ health care costs by decreasing mental health-related emergency department visits, which have escalated during the pandemic.
The availability of a comprehensive behavioral health system is critical to a child’s health and well-being. Nearly 17 percent of children and adolescents have a mental health condition, yet almost half of these children do not receive needed treatment. This is more pronounced among children and youth who are Black, Latinx, and come from other racial and ethnic minority groups, which disproportionately face barriers to accessing quality mental health care. These disparities have been amplified by the COVID-19 pandemic. A lack of regular, accessible mental health programs, services, and supports may lead to greater use of emergency departments, which are costlier and often lack appropriate policies to serve children with mental health needs, such as how to transition children and adolescents to other services and provide appropriate care coordination.
Schools are a primary source of mental health services for children and have been shown to improve students’ access to mental health programs, services, and supports. This is true for an increasing number of students, as the percentage of adolescents receiving mental health services and supports in educational settings has grown from 12 percent in 2011 to 15 percent in 2019.
A CSMHS approach is a best practice identified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare & Medicaid Services (CMS). Schools can use this approach to support:
- Prevention of mental health needs among all students;
- Early identification of students and intervention for those who are at risk; and
- Services and treatment for those who have mental health needs.
A CSMHS also supports adherence to treatment, decreased stigma, and improved educational attainment. Implementing and expanding a CSMHS may also help to reduce racial and ethnic disparities in school responses to students’ behavior by encouraging mental health services over punishment. Children and youth with mental health needs who are Black and Latinx are more likely to receive punishment instead of mental health care services in comparison to White children.
A CSMHS is one component of a system of care for children and youth with special health care needs (CYSHCN) and behavioral health needs, and can be considered within a broader framework of policies to support mental health of children and adults.
There are a variety of federal initiatives that support state efforts to develop and expand these critical school programs, including:
- The Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health (DASH) provides funding at state and local levels to promote health and well-being through schools, including programs and services to support students’ mental health;
- SAMHSA’s Project Advancing Wellness and Resilience in Education (AWARE) provides funding to state education agencies to partner with state mental health agencies to increase awareness of mental health in schools, provide training to school staff, and connect students with behavioral health needs to services; and
- The School-Based Mental Health Services Grant Program, authorized by the 2020 Department of Education budget, provides $10 million to six states to increase the number of mental health service providers in schools.
The Biden Administration has underscored the importance of behavioral health services for students by setting a goal to double the number of mental health professionals in schools. The day after his inauguration, President Biden issued an executive order stating that the federal government will support states in promoting mental health and social-well-being in schools, and the American Rescue Plan Act of 2021 that was signed into law in March 2021 allocates more than $120 billion in grants to states through the Elementary and Secondary School Emergency Relief Fund. The majority of this funding will be distributed to local education agencies, which could use these subgrants to provide mental health services and supports and to implement interventions that address learning loss while responding to students’ emotional needs, among other purposes.
State Policy Considerations
Schools have adapted to shifting priorities over the past year and continue to implement innovative strategies to meet students’ growing mental health needs. During the pandemic, several states have introduced legislation to support schools in various ways to enhance their mental health programs during and after the pandemic.
- Implementing statewide task forces. Schools face a variety of barriers to developing CSMHSs for students, including allocating adequate funding, adhering to data privacy regulations, and identifying and implementing best practices. To support school districts’ diverse needs, states are forming committees to review existing approaches and make recommendations to improve mental health programs. This process may be particularly helpful to identify and address emerging challenges and strategies during and after COVID-19.
In 2017, North Carolina created the Superintendent’s Working Group on Student Health and Well-Being to produce recommendations to support students’ mental health, which were released in a report in May 2018. In October 2020, Illinois introduced legislation that would create a similar mental health task force consisting of mental health providers, school nurses, state General Assembly members, school board members, principals, parents, and students to produce recommendations in 2021.
- Developing mental health policies in schools. Clear policies at the state and local level can support comprehensive, consistent, and appropriate approaches to addressing students’ mental health needs in schools. State policies can provide guidance for local school districts regarding expectations and best practices, while allowing flexibility for schools to meet their students’ specific needs while considering the local context.
On June 8, 2020, North Carolina enacted SL 2020-7 S476, which implemented recommendations from the state task force. This law requires the Department of Public Instruction to adopt a statewide, school-based mental health policy, and requires each school to adopt its own policy following task force recommendations.
- Supporting universal screening practices. Widespread screening for children’s behavioral health needs is a recommended best practice. While schools have a unique opportunity to screen a high proportion of their students for behavioral health needs, less than 15 percent of schools have implemented a universal screening process. States are supporting schools by issuing recommendations for schools to increase mental health screening among students and guidance for funding for these services.
New Mexico requires in its administrative code that schools screen all students for health and well-being, including behavioral health needs. The state has developed guidance on funding sources for screening services, which may include operational funds, Title I and Title III funds, and Coordinated Early Intervening Services funding through the Individuals with Disabilities Education Act. In January 2020, New Jersey introduced legislation that would require schools to provide annual depression screening for students in grades seven through twelve.
- Expanding the availability of mental health services in schools. Few schools meet the recommended student-to-staff ratios for counselors, psychologists, nurses, and social workers due to a lack of funding and workforce shortages. States are enhancing CSMHSs through policies that provide funding to increase the availability of mental health professionals in schools and support partnerships with community-based behavioral health agencies.
Washington, D.C. has made significant efforts to support the expansion of behavioral health services to all students by earmarking local and federal funding and increasing funding over time for schools to develop partnerships with community-based mental health services. In October 2020, New Jersey introduced legislation that would require all public school districts to have at least one school counselor and to meet a maximum student-to-school counselor ratio of 250 to 1 – the national recommended ratio.
- Improving mental health training and education. School staff who are frequently in contact with students are an important resource to support students’ mental health. States are providing guidance and support to train these staff to identify indicators of mental health needs among students and facilitate appropriate referrals. States also advise on school curricula and education that support mental health awareness among students.
North Carolina’s SL 2020-7 S476 requires the state’s mental health policy to include a model mental health training program for school staff that local school districts must adopt. All school staff who work with students in grades K-12 must be trained in youth mental health, suicide prevention, and other mental health-related topics. Pennsylvania introduced similar legislation in September 2020 that requires schools to train school staff in identifying signs of depression and referring students and their families to mental health services.
Comprehensive school mental health systems are an important component of systems of care for CYSHCN and behavioral health needs. The National Standards for Systems of Care for CYSHCN, which were developed by a national work group of state and national health policy leaders, is a valuable resource that states can use to guide improvements to systems of care for CYSHCN, including considerations for mental health systems. States can implement systems based on the following standards to improve care for CYSHCN during and after COVID-19, including:
- Improve mental health care access, especially for marginalized communities;
- Increase the use of medical homes serving individuals with chronic and complex conditions;
- Improve coordination of care across behavioral health, social and health systems; and
- Improve access to CSMHS.
Schools have played an important role in supporting students’ mental health, but often face challenges in implementing CSMHS. Mental health needs among children and adolescents have been rising for several years, and this trend has been exacerbated by the pandemic. One way that states can address this is through policies that strengthen CSMHS to support students during and after the pandemic. The National Academy for State Health Policy will continue to track state policies that support CSMHSs during and after the COVID-19 pandemic.