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As of this week, payments for certain mental health services at public schools across the state will be handled using a new multi-step, multi-agency process prescribed by the 2021 Montana Legislature. The change has generated confusion among school leaders and elected officials for months, and as it finally goes into effect, questions and concerns continue to linger over precisely what is expected of participating school districts.

The Comprehensive School and Community Treatment program, or CSCT, is a school-based service that places mental health professionals from third-party providers directly in school facilities, ensuring all-day support for students diagnosed with a serious emotional disturbance. Prior to this month, schools received federal Medicaid funds through the Montana Department of Health and Human Services to pay providers for the service. Schools were allowed to count in-kind expenses for CSCT, such as office space and equipment, toward the matching funds they were required to put up.

Now, providers will submit their claims to DPHHS at the beginning of each month, and the agency will use those claims to calculate each district’s share. The Office of Public Instruction will then pass that information to districts, collect the match payments and submit them to DPHHS before the state releases the Medicaid reimbursement dollars districts need to pay their providers directly. Under the new system, match payments must be made in cash from a non-federal source. Districts must also sign a memorandum of understanding outlining the new process by Feb. 11. According to an emailed response from OPI, if a district doesn’t sign the MOU, they can’t be reimbursed.

“The whole thing has about seven or eight steps to it before the money comes back to the school district and the school district then cuts a check to the provider,” Ginny Haines, special education director at Missoula County Public Schools, said in an interview. “It’s a little bit hard really at this point to see exactly what that picture is going to look like, having not actually been through even a month or two of that.”

Data from DPHHS shows that 53 districts statewide were offering CSCT services at the beginning of 2022. OPI spokesperson Brian O’Leary wrote via email that 16 districts had signed and returned the MOU as of Jan. 31, adding that the agency is maintaining a list of those districts on its website and will update it weekly. 

A NEW FINANCIAL BURDEN

The complexity of the changes, and lingering uncertainty about what’s expected of districts in the process, have fueled questions, finger-pointing and outright criticism at public meetings and in agency webinars held in December and January. OPI responded by revising the MOU language and turning its documentation requirements into “recommendations” — working with DPHHS and statewide associations such as the Montana Association of School Business Officials to clear up the confusion. Meanwhile, the state exhausted a $2.2-million chunk of bridge funding set aside by the Legislature to keep the program afloat through the transition on Dec. 28. 

As recently as last week, some districts continued to appeal to state leaders for guidance in dealing with backlogged paperwork and late invoices for CSCT services going back to October. Others asked OPI and DPHHS for more clarity regarding what specific funding sources can and cannot be used for their match. After receiving mixed reports from school officials and state agency staff at an interim legislative meeting last month, Sen. Mary McNally, D-Billings, characterized the entire situation as a “trainwreck” and pressed OPI to provide some assurance that the new process wouldn’t drive schools away from the CSCT program.

Rep. Moffie Funk, D-Helena, echoed that concern at a Jan. 25 meeting of the Legislature’s Education Interim Committee. Funk asked OPI Chief Financial Officer Jay Phillips whether the agency had a plan to ensure the match requirement didn’t detert districts from participating in the program. Phillips said that was the primary concern he’d heard from districts. He told Funk that OPI compiled a list of funding sources districts could utilize. Phillips added that the financial burden is the result of the Legislature’s changes, and finding a way to cover the match is “something that OPI cannot solve for the schools on their behalf.”

In multiple meetings last month, Phillips also suggested congressional COVID-19 relief funds as an alternative source of CSCT money for districts. However, he stipulated that, since those funds are federal, they could not be used as a match to qualify for Medicaid reimbursement but would instead have to be used to cover the entirety of a district’s payment to its provider.

The switch to a hard match isn’t the only point of concern that districts raised. 

Bozeman Public Schools Director of Business Services Mike Waterman said his primary concern is that the accounting guidance OPI provided says providers can only bill districts for actual costs. If the district’s Medicaid reimbursement exceeds those costs, the district must return the excess funds to DPHHS according to OPI. This creates a potential financial risk for his district, Waterman said. 

Waterman added that the documentation his office would be required to maintain, should any agencies question its CSCT expenses, has made the district’s continued participation in the program a daily subject of conversation among district administrators.

“I don’t want to create a financial risk or an audit risk for our district,” Waterman said. “That’s just not what we do.”

Waterman added that the Bozeman School Board has not yet signed the MOU, but he does not anticipate an interruption of CSCT services if the board opts to do so at a later date. So far, he said, the district intends to continue offering those services.

’THIS SHOULD HAVE BEEN A SIMPLE FIX’

Mary Windecker, executive director of the Behavioral Health Alliance of Montana, said the bumpy transition to a new CSCT funding process couldn’t have come at a worse time for the program. CSCT services were already suffering the effects of a workforce shortage in the mental health field and two years of the COVID-19 pandemic, she said. 

At its pre-pandemic peak, the program served more than 5,000 students in 100 different districts throughout Montana. Now, according to data from DPHHS, the number of school districts participating in CSCT has dropped to 53 as of January 3, 2022, and the number of students served in those districts has declined to 2,253.

Windecker said she wonders why lawmakers decided to place OPI in the middle of a complex Medicaid funding stream, and she worries that the resulting confusion generated in the development of that process will only prompt more districts to reconsider their involvement.

“This should have been a simple fix,” Windecker said. “This program should have been put in place in the two months after the Legislature said, ‘Get this fixed.’ But here we are a year later and it’s still in complete disarray.”

Missoula County Public Schools is prepared to continue offering CSCT services under the new process through the end of the spring semester. After that, Haines said, the district will assess how the new process is working and determine what partnerships with CSCT providers might look like moving forward.

“Not only is it going to impact us with having to provide that hard match, but it’s also going to have an impact on the providers in just what their reimbursement for services potentially looks like,” Haines said.

Haines said that Missoula’s CSCT program has changed considerably in recent years, due to the challenges Windecker cited. The district used to have multiple two-person CSCT teams in each of its schools, but is now down to one in the majority of its buildings. One middle school and two elementary schools don’t have any CSCT personnel, Haines added. The state also changed the reimbursement rate applied to providers last year, requiring them to bill per day instead of in 15-minute units. Haines is concerned that change might force providers to see a minimum number of students in a day and limit a CSCT team’s ability to respond to an emerging mental health crisis.

“Our mental health and our social-emotional stability is at the forefront of a lot of the district’s concerns,” Haines said. “There’s a lot going on out there that’s impacting people, a lot of really heavy stuff. And I know that just on a day-to-day basis, we see staff struggling, we see families struggling.”

The Eastern Montana Community Mental Health Center staffs five CSCT teams in Miles City, two in Huntley Project, two in Glendive and one in Broadus, and each of those teams works with between 15 and 25 students. COO Jeff Regan said the organization has been in close contact with each of its district partners about the changes to the program, and they’ve all expressed a desire to continue with CSCT. However, Regan said, it’s been “stressful” in recent months trying to help those districts gain a clear understanding of the administrative requirements and financial demands they’ll face.

“Seems like it’s ever changing,” he said. “If we just knew exactly what we needed to do, I don’t think we would be having a problem, but it just seems like you can’t get a definitive answer on what the path we need to go down.”

In the approximately eight years his center has provided CSCT services, Regan said the program has played a critical role in supporting some of the region’s most vulnerable students throughout the school day and into the summer. And, he noted, the consistency of the mental and behavioral therapy offered to those students would be difficult to replicate given the relative scarcity of other resources in rural communities. Regan added that the recent confusion reflected in public meetings and media reports has led staff at his organization to wonder if their jobs will be impacted as well.

Denise Williams, executive director of the Montana Association of School Business Officials, is hopeful that the process implemented this week will start to run smoothly, and that OPI and DPHHS will address the outstanding questions generating the lingering confusion. Back in August, Williams said, she would have agreed with McNally’s “trainwreck” assessment, and while she still has specific concerns of her own, she’s optimistic that districts will adapt. It’s a change, she added, but not the first one schools have had to contend with.

“We just need to make it part of the routine,” Williams said. “It’s going to be a little bit of extra work because yeah, they have to cut a check and they have to get it approved by their trustees and send it in. But they will get used to the flow, now that the flow is clearer.”

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Alex Sakariassen is a 2008 graduate of the University of Montana's School of Journalism, where he worked for four years at the Montana Kaimin student newspaper and cut his journalistic teeth as a paid news intern for the Choteau Acantha for two summers. After obtaining his bachelor's degree in journalism and history, Sakariassen spent nearly 10 years covering environmental issues and state and federal politics for the alternative newsweekly Missoula Independent. He transitioned into freelance journalism following the Indy's abrupt shuttering in September 2018, writing in-depth features, breaking...