State Policy Focus: School Mental Health Programs
October 2007
Legislation re. School-Based Health Centers and Psychotropic Medications in Schools
OverviewSchool-based health centers
Psychotropic medications in schools
CMS proposed rules regarding transport and administrative activities
Current and pending state legislation
Overview
This State Policy Focus discusses state legislation regarding both School-Based Health Centers and Psychotropic Medications in schools, as well as the proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) that would end federal funding available for school-based transportation for children and youth with disabilities.
States have filed a variety of bills that provide funding and/or establish school-based substance abuse and mental health programs. A few states have also filed pieces of legislation relating to recommendations for and refusals of the use of psychotropic medications by school children. In addition, CMS has issued a rule currently available for public comments that, if put into affect as proposed, would end federal funding available for transportation from home to school and back for disabled school-aged children.
The research team at KSE Focus has analyzed legislation filed and enacted in 2007 by 21 states for this report.
School-Based Health Services
The 2007 sessions for many states ended positively with bills passed that recognized the critical need to expand school mental health programs by providing essential funding. Of the eight bills enacted, seven appropriate funds for school-based health centers to help expand and increase access to mental health and substance abuse services offered to students. The remaining bill, Illinois SB 715 not only authorizes 20 new school health centers to be established subject to appropriations, but also provides that all students younger than 18 are eligible for school health center services with parental consent or by consent on their own behalf as permitted by law, and that these services must be listed by the school health center. California, Illinois and Massachusetts are still in session and have six bills relating to school-based health centers that are pending while Minnesota will carry-over two bills to 2008. California’s final bill signing deadline is October 12.
The pending bills follow the theme of increasing services offered by school health programs. California SB 564 for example expands the definition of a “school health center” to include routine physical, mental, and oral health assessments and allows these centers to provide services not offered onsite or through referrals. It will also require centers receiving funds to outline a plan to show how the center will strive to provide these services in response to community needs. Illinois SR 90 and four bills in Massachusetts, HB 4000, HB 4001, SB 3 and SB 2250 all appropriate funds for mental health services, and additionally, the Massachusetts bills require that a minimum of $300,000 be expended for mental health and substance abuse services. Minnesota will carry over two bills, HB 1575 and SF 1399 that, like the enacted bill in Illinois, would create a program to support new school-based health clinics that would provide mental health services.
While the pending and enacted bills appropriate funding for mental health services, the 12 bills that died this term would have set out more specific guidelines of what services school-based health centers provide and would have allocated percentages of funding for targeted populations. The bills sought to expand access to these clinics and to require states to assess the functionality of the clinics. For example, bills in Connecticut would have allowed all public school children to have access to these clinics, and two Florida bills would have mandated the types of services to be provided. In terms of targeting populations, New Mexico HB27 would have allocated funds to increase the hours of service at school-based centers with at least 15% Native American students and that 98% of funds go directly to mental health services or provider training. Similarly, Texas HB 2893 would have assessed the availability and assistance to children who are at risk of disciplinary action or juvenile justice involvement. Identical concurrent resolutions in West Virginia, HCR 53 and SCR 48 asked a Legislative Oversight Commission on Education Accountability to study and assess the means needed to create a school health system.
Psychotropic Medication
Restricting school personnel from recommending or compelling parents to submit their children to psychiatric or psychological treatment—specifically, psychotropic medication—was another major trend in school legislation filed in 2007. Many of the bills protect children from being denied access to school programs and services and also allow parents to decide whether they want to place their children on medications or submit them for psychiatric testing. Although only one of 10 bills filed was enacted, there are two pending bills in New York and New Jersey as well as five bills in Georgia, South Carolina, and Tennessee that will carry over to 2008.
Utah’s HB 202 was the only bill enacted. This bill will prohibit school personnel from making certain recommendations to a parent or guardian that a child take or continue to take psychotropic medication as a condition for attending school, and it also bars school personnel from engaging in mental health, behavioral health or psychiatric treatment of a child.
Similarly, the bills pending in New Jersey and New York, AB 4348 and AB 3795, will also restrict school districts in recommending psychotropic drugs for children. AB 4348 will require schools to inform parents of the side effects and consequences of these medications on children, while AB 3795 will prohibit school personnel from recommending these drugs for any child.
Georgia SB 277, Tennessee’s identical bills HB 1419 and SB 1959, South Carolina HV 3240 and SB 237 also prevent schools from prohibiting children from attending class or school-related activities if their parents refuse to place them on psychotropic medication or submit them for testing. Schools will also not be allowed to use these refusals as a basis for charging the parent with child, educational, or medical neglect. South Carolina’s bills also state that school personnel, while permitted to share school-based observation of a child’s academic and behavior performance and offer program and assistance options, may not compel a parent to act or require a student be put on medication.
The two bills that died last session, Florida SB 2850 and New Hampshire HB 164, if passed would have followed the trend of restricting schools by prohibiting them from recommending the use of psychotropic medications for any child.
CMS Proposed Rules Regarding Transport and Administrative Activities
On August 31, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would limit Medicaid reimbursement for certain school-based administrative activities and would end federal funding available for transportation from home to school and back for children with disabilities.
Title XIX of the Social Security Act currently authorizes Federal grants to States for Medicaid programs, operated by the State under an approved State plan, that provide medical assistance to needy individuals, including those with disabilities. Under the Individuals with Disabilities Education Act (IDEA), schools can deliver a broad range of educational and related services (e.g. educational, social and medical) to students with disabilities that address their diverse needs.
States can receive Federal payment for medical assistance services that are medically necessary on the basis that the services provided by the school or a community health provider are included in the child’s Individualized Education Program (IEP) or Individualized Family Services Plan (IFSP) and the services are included in the State’s approved Medicaid plan.
States can also claim Federal Medicaid matching funds at a rate of 50 % for the costs of qualified school-based administrative activities that directly relate and support the Medicaid State plan or waiver services (e.g. Medicaid outreach, eligibility intake, information and referral, coordination and monitoring of health services). In addition to covering costs of administrative activities, the Federal regulations require that State plans specify that the Medicaid agency will ensure necessary transportation for recipients to and from health providers.
Current CMS regulations make it possible for school administrators to ensure that children with disabilities receive essential medical treatment, including mental health treatment. With Medicaid funding, school employees and administrators can carry out the necessary activities that will help support and contribute to the proper and efficient administration of the State plan. Further, by providing transportation services, schools can ensure that all children will receive the care they need.
The new rule proposes that federal financial participation (FPP) would not be available for the costs of school-based administrative activities under Medicaid that are not included in the scope of a covered service. The following activities are only deemed necessary when conducted by employees of the State or local Medicaid agency, not school employees or anyone under the control of a private or public educational institution:
- Medicaid Outreach
- Facilitating Medicaid Eligibility Determinations
- Transportation Related Activities in Support of Medicaid Covered Services
- Translation Related to Medicaid Services
- Program Planning, Policy Development, and Interagency Coordination Related to Medical Services
- Medical/Medicaid Related Training
- Referral, Coordination, and Monitoring of Medicaid Services
Federal funding will still be available for administrative overhead costs that are integral to, or an extension of, a direct medical service, and as such, are claimed as medical assistance.
Under the proposed rules, FFP would not be available for the costs of transportation from home to school and back for children with an IEP or an IFSP established pursuant to IDEA. However, CMS will reimburse for transportation of children from community health providers to school or home. States will be reimbursed for transportation of school-aged children from school or home to a non-school-based direct medical service provider that bills under the Medicaid program, or from the non-school-based health provider to school or home. CMS will reimburse for transportation costs related to children who are not yet school-age and are being transported from home to a community health provider or school, and back to receive direct medical service, as long as the visit does not include any activity unrelated to the covered direct medical service. CMS will continue to reimburse states for school-based direct Medicaid services in their approved State plans. This means that the proposed rule would not affect expenditures for direct medical services that are in the approved State Medicaid plan and provided in schools.
Recently, the House approved legislation to reauthorize and expand the State Children's Health Insurance Program (SCHIP) by a vote of 265-159. The final agreement reached by the House and Senate includes a six-month moratorium on the issuance of new rules from CMS on Medicaid reimbursement of school-based services. For more information on SCHIP, please see our Public Policy Update newsletter at http://www.thenationalcouncil.org/cs/september_27_2007.
The proposed rule on school-based services can be accessed on the CMS website: http://www.cms.hhs.gov/MedicaidGenInfo/Downloads/CMS2287P.pdf
Current and pending state legislation
For a detailed description of all the state legislation that become law or is currently pending, please see below.
School-Based Health Centers
Thirteen states filed 28 bills relating to mental health programs in school-based health centers in 2007. These bills all provide funding and/or establish school-based substance abuse and mental health programs.
The District of Columbia, Illinois, Louisiana, Massachusetts and Pennsylvania enacted eight bills in 2007. Seven bills appropriate funds for school-based mental health and substance abuse services while one bill outlines program eligibility requirements.
The District of Columbia Council enacted three bills which will provide funding for mental health related school-based health center programs. B17-002 appropriates $4.1 million for fiscal year 2007. B17-148 and B17-276 appropriate $4.35 million for fiscal year 2008 for school-based mental health services and two additional full-time equivalent positions within the Mental Health Authority for the purposes of expanding the School Mental Health Program.
Illinois HR 113 was adopted on June 7. This resolution asked that $6 million be allocated for fiscal year 2008 under the Children’s Mental Health Partnership line item to the Illinois State Board of Education. Portions of the monies will be used to increase school based mental health support services.
Identical bill SR 90 is still pending in the Senate Rules committee.
Louisiana Democratic Gov. Kathleen Blanco signed HB 1 on July 12. This bill appropriates $9,936,073 to school-based health centers for fiscal year 2008. The bill also appropriates $30,814,831 to the Capitol Area Human Services District, a portion of which will be used for a clinic or school-based outpatient mental health treatment facility located in each of the seven parishes served by the district.
Massachusetts HB 4141 was signed Democratic Gov. Deval Patrick on July 12. This bill appropriates $16,748,474 to the Department of Public Health Office of Health Services for school health services and school-based health centers in public and non-public schools for fiscal year 2008. Out of those funds, not less than $300,000 will be expended for mental health and substance abuse services.
Pennsylvania HB 1286 was signed by Democratic Gov. Edward Rendell on July 17. This bill appropriates $348,000 in Federal funds to the Department of Education for school-based mental health services for fiscal year 2007-2008
Illinois SB 715, the “School Health Center Act,” is included with this group of bills because “improving mental health” is listed as one of the legislative priorities that prompted the bill. The bill, which was signed by Democratic Gov. Rod Blagojevich on August 28, provides that all students younger than 18 are eligible for school health center services, if they have obtained written parental consent, or if they are permitted to consent on their own behalf under state law. The school health center must provide a form listing all services it provides, and must state a right of refusal. Subject to appropriations, the Department of Human Services is authorized to initiate 20 new school health centers over a five-year period.
California, Illinois and Massachusetts are still in session and have six bills that are pending.
California SB 564 would expand the definition of “school health center” to allow a center to conduct routine physical health, mental health, and oral health assessments, and provide for any services not offered onsite or through a referral process. The bill would also require a school health center receiving grant funds under the Public School Health Center Support Program to have a plan regarding how the center will strive to provide comprehensive services, including medical, oral health, mental health, health education, and related services in response to community needs.
This bill would become effective only if funds are appropriated to the department in the annual budget act or other statutes for implementation of this article.
Illinois SR 90, identical to HR 113, is pending in the Senate Rules committee. This resolution asks that $6 million be allocated for fiscal year 2008 under the Children’s Mental Health Partnership line item to the Illinois State Board of Education. Some of these funds would be used to increase school based mental health support services.
Massachusetts HB 4000, HB 4001, SB 3 and SB 2250 were written as amendments to the 2008 budget bill and have been rolled into HB 4141, written above. All four bills appropriate funds to the Department of Public Health Office of Health Services for school health services and school-based health centers in public and non-public schools for fiscal year 2008. Each bill also states that out of the funds appropriated, not less than $300,000 will be expended for mental health and substance abuse services.
Minnesota will carry-over two bills (HF 1575 and SF 1399) to 2008. These bills would create a grant program to support new school-based health clinics which would provide mental health assessments and therapy, or referrals for those services.
Connecticut, Florida, Montana, New Mexico, Texas and West Virginia considered 12 bills which died pursuant to the legislatures’ adjournment. Connecticut HB 6336 and SB 175 would have appropriated a combined $1.1 million dollars for the provision of mental health services in school-based health centers for fiscal year 2008. SB 1349 and SB 1371 would have required the Department of Public Health to expand the state’s network of school-based health clinics so that all public school children in the state have ready access to such clinics. The school-based health clinics would have provided physical and behavioral health care services which include mental health and family services.
Identical Florida bills HB 1463 and SB 2256 would have defined school-based health centers by requiring that each organization provide basic mental health services including assessment, individual, group and family counseling, consultation with school administrators, parents, teachers and students, and crisis intervention.
Montana HB 365 and HB 417 would have created a voluntary mental health screening program and created the position of coordinator of volunteer school-based mental health screening and referral in the Office of the Superintendent of Public Instruction.
New Mexico HB 27 would have appropriated $500,000 to the Department of Health to provide increased hours of service by mental health care providers in school-based health centers at schools with at least 15 percent Native American students. The bill also stipulated that 98 percent of the funds needed to go directly to student mental health care services or mental health care provider training.
Texas HB 2893 would have required the Office of Children’s Mental Health to assess the availability and adequacy of school-based mental health services and the assistance provided to schools and children who exhibit a clear indication of risk for referral to disciplinary classrooms or other behavioral referrals, juvenile justice involvement, or other actions by community-based mental health services.
Identical West Virginia concurrent resolutions HCR 53 and SCR 48 asked the Legislative Oversight Commission on Education Accountability and the Oversight Commission on Health and Human Resources to study the means to create a school health system. The school health system would have included coordination between school health nurses, school-based health centers, local medical, dental and mental health services and public health resources.
Psychotropic Medications in Schools
Eight states filed 10 pieces of legislation relating to recommendations for and refusals of the use of psychotropic medications by children in 2007. Only one bill has been enacted to date.
Utah HB 202, which was signed by Republican Gov. Jon Huntsman Jr., prohibits school personnel from making certain medical recommendations to a parent or guardian that a child take or continue to take a psychotropic medication as a condition for attending school. The school personal will also not be able to recommend that a parent or guardian seek or use a type of psychiatric or psychological treatment for a child and will not be able to conduct a psychiatric or behavioral health evaluation or mental health screening, test, evaluation, or assessment of a child.
New Jersey and New York each have one bill pending (AB 4348 and AB 3795 respectively) and are currently still in session. AB 4348 would stipulate that school districts that recommend that a student younger than 18 use psychotropic medications must inform the parent or guardian of the possible physical and psychological side effects and potential negative consequences that may result from using those medications. AB 3795 would require the commissioner of Education to establish rules and regulations prohibiting school personnel from recommending psychotropic drugs for any child.
Georgia, South Carolina and Tennessee will carry-over five bills regarding recommendations for and refusals of the use of psychotropic drugs by children to 2008.
Georgia SB 277 and Tennessee identical bills HB 1419 and SB 1959 state that a local school system could not use a parent’s, guardian’s or custodian’s refusal to consent to the administration of a psychotropic medication to a child or to the administration of a psychiatric screening, evaluation, testing, or examination of a child as grounds for prohibiting the child from attending class or participating in a school-related activity or as the basis for reporting or charging child abuse, child neglect, educational neglect, or medical neglect.
A local school system could not use or threaten use of administering school sanctions to a child or student to coerce the consent of the child’s parent, guardian or custodian to a psychiatric screening, evaluation, testing, or examination. A person employed by a local school system could not require that a child or student be evaluated or treated with any psychotropic medication or for a particular mental health diagnosis.
Identical South Carolina bills, HB 3240 and SB 237, state that a school may not deny any student access to programs or services because the parent of the student has refused to place the student on psychotropic medication. The bill defines psychotropic medication as a prescription medication that is used for the treatment of a mental disorder, including, but not limited to, antihypnotics, antipsychotics, antidepressants, anxiety agents, sedatives, psychomotor stimulants and mood stabilizers.
Both bills state that both a teacher and school district personnel may share school-based observations of a student’s academic, functional and behavioral performance with the student’s parent, and offer program options and other assistance that are available to the parent and the student based on these observations. The school personnel may not compel or attempt to compel any specific action by the parent or require a student to take medication. SB 237 also states that a parent can refuse psychological screening of the student. Any medical decision made to address a student’s needs is a matter between the student, the student’s parent, and a competent health care professional chosen by the parent.
Florida SB 2850 died pursuant to legislative adjournment on May 4, and New Hampshire HB 164 was killed in the Senate Education committee on May 24. Both bills would have required schools to adopt and implement policies prohibiting school personnel from recommending the use of psychotropic medications for any child.
