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The $2.2 million “bridge” money the Montana Legislature allocated to temporarily support mental health services for children in public schools has been exhausted, the Montana Department of Public Health and Human Services confirmed this week.
And with pressure mounting on multiple fronts, a plan to find a new way to pay for the Comprehensive School and Community Treatment program still isn’t set. Meanwhile, data from the state show fewer children are accessing the services even as the pandemic continues to take a toll on mental health.
“I absolutely cannot believe that we are in this position, that children and families are in this position,” said Rep. Mary Caferro, a Helena Democrat and longtime advocate for children and families. “OPI (the Office of Public Instruction) has had plenty of time to figure it out, and what they’ve done now is instead of resolving this, they have put families in a state of uncertainty.”
The problem arose long before OPI was asked to be part of the fix, though. In an email, OPI said it is working with its partners on the problem and is investigating one particular solution, and there’s positive interest in it.
“We will continue to work with our district’s partners, education advocate associations, mental health centers, the legislature, and DPHHS on more viable long-term solutions,” OPI said in an email.
Nonetheless, the clock is ticking on a new plan, and school districts still have unanswered questions about not only where the money is coming from, but how to get it to the right place.
Starting Feb. 1, for instance, public schools need to be able to submit a check into a new accounting system to pay for services, but how that happens still needs to be ironed out, and OPI has yet to provide training, as it announced it would do, said Denise Williams, head of the Montana Association of School Business Officials.
“If they’re going to be sending in checks, they need to know how to do that, and that’s not available to us yet,” Williams said. “That’s something that needs to be addressed really quickly.”
In 2020, CSCT served 4,556 children across Montana, but in 2021, it served 3,827, according to fiscal year data from the Health Department provided by a legislative committee chair. The labor shortage means fewer mental health care workers are available, and at the same time, fewer school districts are providing CSCT services — 50 as of December 6, 2021, compared to 77 for the 2021 fiscal year, according to data from the state.
The transition has been anything but smooth, and Micah Hill, superintendent of Kalispell Public Schools, said he believes bridge funding lasted longer than expected because fewer school districts are using the program. He believes at least one school district is hiring its own behavioral health specialist instead, and Hill himself is looking at other options and said it’s possible the district might be able to serve more students with a change.
However, Hill said the shift has put a sudden financial burden on schools that hadn’t existed before, and his district will need to find $375,000 to $400,000 in its budget with questions about reimbursements still up in the air.
“It’s really turned (the program) on its head, and at the end of the day, our response, our provider’s response, is we don’t want to see a disruption in the services we provide to our students or to the employees associated with CSCT,” Hill said.
Since 2005, the CSCT program has allowed school districts to contract with private mental health centers to provide $34 million in services to Montana children billed through Medicaid.
In the past, the Health Department certified that schools were providing an adequate “soft match,” but several years ago, federal authorities changed the requirement to a “hard match,” according to earlier information from the Montana School Boards Association. Montana had been the exception and had hoped to continue to appeal for reconsideration.
At one point, the Health Department paid the required $10 million because the money was available during the pandemic, but school officials and legislators didn’t know about the requirement change until the 2021 legislative session.
This year, the Legislature told the Health Department and OPI to figure out a plan, and it allocated “bridge” funding to pay for the services in the meantime. Permanent “match” funds for the program aren’t in the state budget, and more than six months after the Legislature adjourned, school officials still do not know how much cash they have to scrape out of their own general funds or how reimbursements will work.
Lance Melton, with the Montana School Boards Association, said the Health Department didn’t adequately apprise OPI or school districts of the looming problems because it was trying to negotiate with CMS, and in hindsight, it would have been helpful for the Legislature to have had a shot at sorting it out earlier. But he said he believes the plan to request OPI and DPHHS to collaborate made sense.
“I think it’s all going to work out,” he said.
Now on a statewide basis, school districts have to come up with $10 million to keep the Medicaid support. Melton said half of that amount can likely be established through approved indirect rates, and half has to be out of pocket.
“The fact remains that on a big ticket basis, school districts have to come up with money that they’ve never had to come up with before, and that’s in the millions,” he said. “And with everything else going on, including inflation clipping along at 7 percent, that’s not easy.”
Williams, with the School Business Officials, said school districts are likely concerned about the source of funds, but even more so about the process of paying the required match, the timing, the approvals required by trustees (an issue she later said appeared to be sorted out), and when the reimbursements will flow back.
“It’s been a long haul, and now we’re two weeks out,” Williams said.
In part, providers need to know the money will be available to pay their mental health workers going forward. The Health Department said it held back $55,000 to pay remaining claims from 2021, but the bridge funding is otherwise spent.
“In December 2021, DPHHS received CMS approval on our State Plan Amendment for CSCT program changes and authorization of an intergovernmental transfer (IGT) funding methodology,” said DPHHS spokesman Jon Ebelt in an email. “This means that CMS has authorized the use of the funds from local school districts to be utilized as the state match for the CSCT program. The new IGT process will need to be put in place for CSCT claims submitted during the month of January, with the intergovernmental transfer of state match occurring in early February.”
The messy process has taken place despite instruction in House Bill 671. The bill directed OPI and the Health Department to work together and said the transition should take place with as little disruption to schools as possible.
“The Legislature … intends that this collaboration minimizes to the greatest extent possible the administrative burden on school districts,” the legislation said.
Tuesday, Williams said she was reviewing a Q&A document intended to address questions her members might have, but the answers weren’t satisfactory. She said people working on the transition were making progress, and she was grateful to be included and hoped her comments would be helpful, but time was running short: “We’re getting up to the wire.”
“I’ll say it’s been very inefficient,” Williams said. “That’s my opinion. I hate to say that. I work with the OPI all the time on behalf of my members. It’s tough words to say. But I just feel like the whole thing has been very inefficient.”
Melton said the goal with the transition is to remove any uncertainty and ambiguity over a contract for services so school districts understand exactly how OPI is going to interpret and enforce it.
“The bottom line is that we want certainty for continuity of services for these kids, and the sooner that we get that done the better because the bridge funding has run out, and frankly, I’m really surprised it’s lasted as long as it has,” Melton said.
As the state sorts through administrative entanglements and school officials scrutinize general funds, Rep. Ed Stafman, head of the Children and Families Interim Committee, said it’s important to not lose sight of the bigger issue.
Suicide is a problem in Montana, and it’s a problem among youth. He said 86 percent of youth who commit suicide in the state are receiving no mental health services, and he believes that indicates the support children do receive is effective.
The Bozeman Democrat said the data also mean Montana needs to better screen students to get more of them the help they need, and his committee is studying children’s mental health in Montana. But one thing is already clear.
“CSCT is one of the major ways that we deliver children’s mental health,” Stafman said.
But Stafman pointed to the data that show a drop in the number of children and school districts using the CSCT program over the last couple of years. The number of children using those services fell to 2,029 as of the first week of December 2021 compared to 2,627 the previous fiscal year to date, according to data he provided from the state.
“If you look at the data, it’s pretty overwhelming what has happened,” Stafman said.
Low reimbursement rates for providers also contribute to the problem, although he said the Health Department recently raised the rate for some of the services.
Perhaps for a combination of reasons, school districts are seeing the staffing shortages with mental health workers, Hill said. In the past, his district had 12 CSCT teams, and this year, they have 9.5 teams, and providers are having trouble filling positions.
He’s looking at a model called School Based Outpatient Therapy, which would eliminate OPI and the Health Department from the equation altogether. Hill said the downside of CSCT is it only exists for students who can access Medicaid, but a lot of students aren’t eligible and can’t access the services, yet they need the support.
The new model would allow a therapist to work with any student on a sliding fee scale and with those who have insurance, he said. The district would charge the health provider rent, and the health provider would be responsible for billing and getting reimbursements for students who are eligible for Medicaid.
“We’re committed to providing these services,” Hill said. “They are essential for our student population, and if anything, we don’t have enough to serve all kids. And so we’re going to be working with providers, and whether we end up staying with CSCT, we’re still going to have to work with the providers to figure out how we make this work and function.”
This story was updated to include comment from the Office of Public Instruction received after publication.
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