Funding SBIRT in Public Schools

Schools are uniquely positioned to reach a broad population of young people, including those who are at risk of drug or alcohol misuse. Schools are also a vehicle for reaching students who may be disconnected from other services or supports, including students from communities of color who face significant barriers to accessing adequate health care services.1 It’s particularly important for advocates to push for universal screening (e.g., screening all students in a certain grade) in school settings. Selective screening allows for bias and could lead to the disproportionate targeting of students of color.

This section includes strategies for leveraging Medicaid reimbursement, state and local budget resources, and federal funding to support prevention initiatives, including SBIRT, in K-12 school settings.

MEDICAID REIMBURSEMENT

Medicaid is currently a source of revenue for many school districts across the United States. There are generally three types of opportunities for schools: reimbursement for services provided (fee-for-service), funds for coordination of services (administrative claiming), and funds gained by partnering with a provider or community organization (leveraged funds). 2

Medicaid funds are most commonly used by schools to deliver services to students with an Individualized Education Program (IEP). However, a policy change by the Centers for Medicare and Medicaid Services (CMS) now allows states to provide any service covered by the state’s Medicaid plan to any student enrolled in Medicaid, creating an opportunity for Medicaid to support school-based SBIRT. However, this is only possible in states where the Medicaid plan:

ADVOCACY STRATEGIES

Determine if screening and brief intervention are reimbursable by Medicaid in your state.

Investigate the status of your state’s Medicaid SBI codes by referencing your state’s Medicaid provider billing manual and fee schedule, which should be available online on your state’s Medicaid website. These manuals outline the services that are reimbursable through Medicaid in your state.

To assess if the SBI Medicaid codes can be used in schools, look for the following information:

Meet with Medicaid officials to explore reimbursement opportunities.

Armed with the preliminary information referenced above, advocates can meet with Medicaid officials – such as the state Medicaid director or staff at local/regional Medicaid offices – to explain the importance of school-based drug and alcohol prevention and uncover additional reimbursement information that may be useful for school administrators. Below are a few issues advocates may want to address in these conversations:

Inform school boards, school administrators and other community members of opportunities to support drug and alcohol misuse prevention through Medicaid.

Advocates can work with school administrators to identify avenues for fee-for-service, administrative claiming or leveraged funding to support SBIRT.

School boards will be a key player in these conversations. School boards are usually responsible for approving any health screenings provided district-wide, and they make financial decisions regarding the school budget. It is also important to consult with other key stakeholders, such as school administrators (principals and superintendents), parents (through the PTA or other parent groups) and students.

Help school districts identify partnerships to leverage Medicaid funds.

Advocates can facilitate partnerships between a school district and a Medicaid-certified provider, such as a community health center or drug and alcohol treatment provider – ideally a program that specializes in treating youth. These providers can offer services on site at a school or school-based health center. Schools can also refer students to these providers when problematic substance use is detected. This partnership can leverage funding that neither entity could generate on their own.

Example from New York: New York City Public Schools partners with a community group, the Children's Aid Society, to provide a wide range of health and social services to children throughout the city. Medicaid fee-for-service funds support about half of the budget of the program, while other resources from the Children’s Aid Society cover the remaining costs.2

Work with Medicaid officials in your state to leverage the “free care” rule change.

Until recently, public schools could not bill Medicaid for care provided to Medicaid-eligible students if the care was available for free to other students. A rule change issued by the Centers for Medicare and Medicaid Services (CMS) in December 2014 lifted the “free care” restriction.

Decision makers at your state Medicaid office (i.e. the state Medicaid director or staff at local/regional offices) or school administrators may not know this barrier was removed. Advocates can pave the way for additional school-based Medicaid billing by informing these key decisions makers about the rule change.

Advocates can push for administrative changes or revisions to the state Medicaid plan that would be needed to allow for schools to bill Medicaid. It can be particularly effective to cite the crisis of drug overdose deaths in our country and underscore the importance of stopping substance use among young people before it becomes a problem. Other useful messaging may include the interconnectedness between educational achievement and child health and well-being.

For specific information on changing state policies and developing state plan amendments, see our Advocates’ Guide to the Change in the Medicaid Free Care Rule.

Example from Massachusetts: CMS recently approved a state plan amendment (SPA) submitted by MassHealth (Massachusetts’ Medicaid agency), allowing school districts to bill Medicaid for any Medicaid-enrolled student. This SPA was needed to remove language in the state plan that specifically limited reimbursement to Medicaid students with an Individualized Education Program (IEP).

RESOURCES

STATE AND LOCAL BUDGETS AND RESOURCES

There are several opportunities for advocates to secure funding for SBIRT by engaging in the school budgeting process. Funding is needed for the delivery of SBIRT and/or the backfilling of the regular duties of the school personnel who are conducting the screening or brief intervention. Training and ongoing technical assistance to support school personnel is also needed. Below are suggested strategies for navigating the school budgeting process to secure support for school-based SBIRT.

ADVOCACY STRATEGIES

Work with your state’s school nursing association to advocate for increased funding to support school nurses’ involvement in SBIRT.

School nurses are an ideal provider for SBIRT in school settings. However, as school budgets continue to be squeezed, allocations for school nurses are often cut back. Current funding levels may not enable nurses to take on these additional roles. It’s important to remember this and ensure that adequate fiscal resources accompany any additional workload demands placed on school nurses.

School nurse positions are typically funded as a line item in local school district budgets and included in special education budgets. Additional support often comes from departments of health or public health. Advocates can work with their state nursing association and identify possible avenues for securing additional funding from these sources for drug and alcohol prevention.

Example from Massachusetts: Advocates secured funding for three consecutive years to support training and implementation of SBIRT by school nurses in all middle and high schools across the state.

Engage with state agencies to support SBIRT training for school personnel.

Learn which agencies or organizations fund and deliver training to school personnel on substance use disorders, mental health or other related topics. The lead education agency (i.e. Department of Education or Office of Public Instruction) is typically responsible for coordinating the training of school personnel. Additionally, school nurses will have specific training requirements related to their licensure. Advocates can pitch including SBIRT in these trainings.

If your state currently or previously participated in the SAMHSA-funded SBIRT project, the lead entity on that grant may still be active and providing SBIRT training to other providers and may have the capacity to train school personnel.

Example from Wisconsin: Advocates worked with a state legislative champion to pass a bill that added $400,000 ($200,000 per year for two years) in new funding to the Department of Public Instruction’s Safe & Healthy Schools Training & Technical Assistance Center to train school personnel in SBIRT.

Advocate for including SBIRT in the school budget.

Advocates can elevate screening and early intervention as a priority for the school budget. In most states, school boards are ultimately responsible for approving the school budget. School administrators (principals and superintendents), parents (through the PTA or other parent groups), and students are also important players in the budgeting process.

School boards are generally required to hold public hearings on the budget, and some districts allow the public to comment or add to the hearing agenda. Advocates should find out when and how key funding decisions are made, which budget items are controlled by the school board, and where there might be opportunities to engage in the budget process.4

Specific budget asks may include increased support for school counselors or other school personnel to conduct screenings and/or brief interventions or funding for a universal drug and alcohol screening initiative.

Keep in mind that school boards are consistently struggling with limited resources and judging various priorities from teachers, administrators, parents and other community members. It’s important to recognize those challenges and make the case that screening and brief intervention is an efficient and effective spending decision that can improve the academic and social development of the students.5

RESOURCES

FEDERAL FUNDING SOURCES

There are several federal grants currently available to support drug and alcohol prevention initiatives in school settings. One way federal funds are distributed to state and local government agencies is through block grants (also called formula grants). This type of funding is unique in that all states receive funds based on a set of criteria, usually based on characteristics of the state’s population and/or the resources already available in the state to support the services that would be provided through the grant.

Legislation or regulations set the parameters for the block grants but the lead state agency – which differs depending on the grant – has discretion in how the funds are allocated. Most block grants require states to conduct a needs assessment and submit an application annually to lay out the intended use of the funds.

It is important to note that block grant funding is typically fiercely protected by the programs that currently rely on these funds. However, with respectful and careful coordination, there may be room to collaborate or improve the use of these funds. The following list includes grants that are particularly suited to support school-based SBIRT and strategies for leveraging the funds.

ADVOCACY STRATEGIES

Leverage the Substance Abuse Prevention and Treatment Block Grant for SBIRT.

The Substance Abuse Prevention and Treatment Block Grant (SABG) provides funds to states through the single state authority for substance abuse services to plan, implement and evaluate activities that prevent and treat substance misuse and promote public health.

States can use SABG block grant funds for SBIRT services. However, that funding may not come from the 20 percent of the state’s SABG funds allocated to primary prevention strategies.

States are required to have a stakeholder input process in place to inform the annual application to the federal government for the block grant. Each state’s SABG applications should be posted on the state government website. The applications outline the process through which stakeholder feedback was collected.

Most states have a Behavioral Health Planning/Advisory Council that provides feedback to the state administration, state legislature and/or governor on how the state should use their SABG. The councils are comprised of advocates, consumers, family members of consumers and other stakeholders.

Advocates can leverage SABG funds for SBIRT or other school-based prevention by engaging in the block grant planning process by joining the advisory council and ensuring that school boards, parents, students and/or other key school officials are part of this planning process as well.

Example from New Hampshire: Advocates worked with the governor’s planning council to leverage SABG funds to support a wide range of prevention activities. Following the state’s expansion of Medicaid, block grant funds previously supporting treatment were shifted to prevention, including one large school-based prevention program. Currently, $1.35 M in SABG funds are allocated to the Student Assistance Program, which includes prevention education, early identification and referral to services for youth.

Identify avenues for schools to use Maternal and Child Services Block Grant (Title V) for school-based screening.

The Maternal and Child Services Block Grant (Title V) is distributed by the Health Resources and Services Administration (HRSA) and is governed by the state’s department of health/public health. The purpose of this funding is to improve the health of women, children and families.

Thirty percent of these funds are earmarked for preventive and primary care services for children. The grant underwent a transformation in 2015 which included the creation of an Adolescent and Young Adult Health National Resource Center (AYAH-NRC) and an additional focus on adolescents/young adults up to age 24.

Title V funds are commonly used for school health services, including health screenings (e.g., vision, hearing, obesity), general health promotion and to support the day-to-day operations of school-based health centers. Substance misuse prevention is an allowable activity under this grant, but it is not typically an area of focus for Title V. When states do use Title V funds for these activities, it’s usually targeted to prevention for pregnant women.

While school-based drug and alcohol screening and brief intervention is not commonly supported by Title V funds, it is permissible. Advocates can develop partnerships within the state public health agency to identify opportunities to use Title V to support school-based prevention. For example, states may be interested in expanding existing school health screenings to include drug and alcohol assessments and/or brief interventions.

There is an opportunity for advocates to weigh in about block grant spending during a public comment period required as part of the state’s application process. Unlike the SAMHSA block grants, there is no requirement for a planning council with consumer representation. However, advocates can encourage and help parents, students and other stakeholders to voice their support of drug and alcohol screening during the comment period.

✔ Leverage the Every Student Succeeds Act for school-based SBIRT.

The Every Student Succeeds Act (ESSA) is the main federal education law governing K-12 public schools. ESSA replaced No Child Left Behind and gave states greater flexibility to measure and improve school performance. ESSA directs states to use federal funds to improve academic achievement as well as student health and safety. Titles I, II, and IV of the ESSA law can fund SBIRT training and implementation.

Title I: The purpose of Title I is to enhance the educational attainment of young people living in low-income communities. This program mandates that the school districts with the highest percentage of children from low-income families receive the most funding. Title I funds can be used for health-related services in school-wide programs, such as screening and brief interventions.6

Example from Wisconsin: Wisconsin’s department of education currently uses the Title IV School Climate Transformation Grant to support school-SBIRT activities.

Title II: This title supports teacher quality. State departments of education receive these funds from the U.S. Department of Education (ED) and distribute them to school districts based on Title II formulas. Title II can be used to equip teachers to address drug and alcohol misuse and link students to appropriate treatment and intervention services in the school and in community. Title II is an appropriate funding source for training school personnel – including school nurses and counselors – to implement prevention interventions like SBIRT.

Title IV: Title IV is a formula grant program that consolidates 49 grant programs from the previous education law. The state department of education receives funding from ED, and school districts apply to the state for funding to carry out Title IV activities. Title IV funding can pay for activities beyond traditional academic supports, including initiatives that improve school climate and support safe and healthy students. Substance use prevention activities, such as SBIRT, are allowable uses for Title IV funding.

In general, the allocation of ED funds can be contentious, especially given increasingly tight education budgets. Districts may rely on these grants for existing programs – perhaps other drug and alcohol prevention programs – and may be reluctant to engage in conversations about diverting funds elsewhere.

However, advocates can inform key stakeholders about the range of activities that could be supported through ESSA. Advocates can also educate state officials and key decision makers in school districts about the importance of promoting universal evidence-based prevention services. Advocates can emphasize the importance of protecting ED grants and ensuring those funds are used in the most efficient way possible to address the states’ needs for substance use prevention in elementary and secondary schools.

For more information on ESSA financing opportunities, see Leveraging the Every Student Succeeds Act for Substance Use Prevention to Improve Young People’s Lives and Integrating Substance Use Prevention into the Every Student Succeeds Act: A Step-by-Step Guide for Advocates.

RESOURCES