Joint Informational Bulletin 
 
DATE:   July 1, 2019   
 
FROM:   Elinore McCance-Katz, M.D., Ph.D., Assistant  
Secretary for Mental Health and Substance Use 
 
Calder Lynch, Acting Deputy Administrator and Director  
Center for Medicaid and CHIP Services 
 
SUBJECT:   GUIDANCE TO STATES AND SCHOOL SYSTEMS ON ADDRESSING 
MENTAL HEALTH AND SUBSTANCE USE ISSUES IN SCHOOLS 
 
 
Together, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the 
Centers for Medicare & Medicaid Services (CMS) are issuing this Joint Informational Bulletin 
(Bulletin) to provide the public, including states, schools, and school systems, with information 
about addressing mental health and substance use issues in schools.  Specifically, this guidance 
includes examples of approaches for mental health and SUD1 related treatment services in 
schools and describes some of the Medicaid state plan benefits and other Medicaid authorities 
that states may use to cover mental health and SUD related treatment services.  Additionally, the 
guidance summarizes best practice models to facilitate implementation of quality, evidence-
based comprehensive mental health and SUD related services for students. 
 
Background   
 
There is an urgent need to identify children and adolescents who have or are at risk for mental 
disorders, including SUDs, and connect these children and adolescents with other services they 
need.  Schools can fill a critical role in both identifying such children and adolescents and 
connecting them with treatment and other services they need.2,3  An estimated ten percent of 
children and adolescents in the United States have a serious emotional disturbance (SED),4 yet 
approximately 80 percent of those children and adolescents with an SED do not receive needed 
services.5,6,7  Approximately 80 percent of children and adolescents with mental health diagnoses 
have unmet mental health needs.8 
  
Substance use rates among adolescents remain concerning, with over 16 percent of adolescents 
ages 12 to 17 reporting illicit drug use during 2017,9 and more than 31 percent of adolescents 
endorsing use of tobacco or alcohol during the same timeframe.10  Further, during 2017, four 
percent of 12 to 17 year olds met criteria for a substance use disorder,11 with 82.5 percent of 
those adolescents not receiving needed care.12 
 
 
  Intervening early is critical, given that half of all lifetime cases of mental illness begin by age 14 
and three-fourths by age 24.13  Research has shown that early identification and treatment 
improves outcomes.  For example, early interventions conducted by comprehensive school-based 
mental health and substance treatment systems have been associated with enhanced academic 
performance,14,15 decreased need for special education,16 fewer disciplinary encounters,17 
increased engagement with school,18 and elevated rates of graduation.19 
  
However, most communities and schools lack high quality, comprehensive treatment for children 
and adolescents.  Many areas of the nation entirely lack or have insufficient numbers of 
psychiatrists, psychologists, social workers, and other professionals, especially those with 
experience in treating children and adolescents, to meet the growing needs.20  Navigating 
complex systems to seek care often presents challenges for families and caregivers, such as long 
wait times, insufficient available services, and poor insurance coverage. 
 
Based on the aforementioned access challenges, schools are particularly critical in identifying 
and supporting students with mental health issues.  Unfortunately, schools often lack the capacity 
to both identify and adequately treat mental disorders including SUD needs of their students.  
School principals report that student mental health needs are one of their biggest challenges.21  
Despite these challenges, integrating evidence-based mental health and SUD services into 
schools can provide many benefits, including increased access to care and decreased stigma 
when seeking treatment.  Schools also can use multidisciplinary approaches to help provide early 
identification, intervention, and a full continuum of services.  Schools often collaborate with 
community providers as a strategy to expand needed services.  Typically, schools access funds 
for school-based mental health and SUD services through a number of statutory authorities.  
These include Medicaid benefits available under state plan authority, including benefits required 
under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit; Medicaid 
demonstrations and waivers, such as Section 1115 demonstration projects and Section 1915(c) 
home and community-based services (HCBS) waiver programs; Section 1915(i) HCBS available 
under the state plan; and non-Medicaid authorities, such as the Individuals with Disabilities 
Education Act (IDEA) and Title I of the Elementary and Secondary Education Act, as amended 
by the Every Student Succeeds Act (ESSA).  It is important to also note that the Americans with 
Disabilities Act (ADA) compels states to provide certain services for people with disabilities 
including mental disorders within integrated settings,22 and Medicaids EPSDT benefit mandates 
that states provide and arrange for services necessary to meet childrens medical needs, including 
mental health needs.23,24,25  
 
Best Practice Models 
 
There are a number of best practice models, which are potentially funded by non-Medicaid 
funding sources that can assist with supporting students with mental health and SUD related 
needs in schools.  As detailed below, states also have several options within Medicaid to support 
school-based services. 
2 
  Multi-tiered System of Supports 
Mental health and substance-related services in schools may be organized into a multi-tiered 
system of supports (MTSS) that ranges from offering services universally to all students to 
providing more intensive services for select students based on medical necessity.26  MTSS is an 
umbrella term for an approach designed to respond to the needs of all students within a system 
that integrates, but is not limited to, tiered behavioral and academic supports, and is part of the 
structure of a comprehensive school-based mental health system.  MTSS is a whole school, data-
driven, prevention-based framework for improving learning outcomes for all students through a 
layered continuum of evidence-based practices and systems.27  Universally offered Tier 1 
services (i.e., services offered to all students within a school system) typically include 
widespread screening, social-emotional based learning curricula, and prevention-based activities 
that foster healthy functioning in a generative school climate.  Tier 2 services allow for early 
intervention and targeted support (e.g., for students exhibiting risk factors often associated with 
potential issues but for whom the issues have not fully manifested), and may include more 
directed student screening and interventions to reduce the likelihood of  issues developing or 
resolve early manifestations of difficulty.  Tier 3 services are generally for students identified as 
experiencing mental health or substance-related difficulties, and may include individual or 
family/caregiver treatment or other individualized interventions to address the identified illness 
or condition. 
  
Positive Behavioral Interventions and Supports (PBIS),28 the Interconnected Systems 
Framework,29 and the Response to Intervention,30 are examples of approaches using an MTSS 
framework.  These MTSS programs involve modeling and practicing social skills with students, 
then prompting and supporting their application in different contexts.  Training students on 
prosocial behaviors and supporting their use has been associated with improved school climates, 
an enhanced sense of safety, and the perception of greater trust and respect in student-teacher 
relationships.31  Additional evidence-based approaches using the MTSS framework to improve 
pro-social skills and emotional awareness that can be incorporated into curriculum are referred to 
as Social Emotional Learning (SEL), and their implementation has been associated with 
improved academic achievement, reduced behavioral problems, and a positive economic return 
on investment.32  Evidence-based programs and practices are those that have been carefully 
evaluated and are supported by empirical data demonstrating improved outcomes.  There are 
multiple evidence-based programs and practices from which schools can choose to respond to 
the needs of their students.  Many evidence-based programs and practices, such as trauma 
responsive school programs, positive disciplinary practices and bullying prevention programs, 
cut across the three tiers to meet the comprehensive needs of students. 
 
Comprehensive School Mental Health Systems 
Comprehensive school mental health systems (CSMHSs) are an effective and broad multi-tiered 
approach to caring for students.  CSMHSs are school-community collaborations that provide a 
continuum of mental health services across all three tiers of care (i.e., promotion and prevention 
for all students, early identification and interventions for those students at risk, and indicated 
treatment for those students with more intensive needs).  There are innovative opportunities for 
these collaborations to enhance the mental health of students, improve the school climate, and 
decrease student social isolation and marginalization.33,34  Key aspects of the CSMHS approach  
3 
  include evidence-based universal prevention efforts, training for school and community members 
to identify and respond to early warning signs of mental health difficulties, and targeted 
prevention and intervention programs and services supporting the mental health of students.  The 
CSMHS framework includes integrating mental health care delivery within school settings. 
  
In addition to collaborations with community mental health providers and families, CSMHSs 
with their host schools, can develop collaborations with the faith community, law enforcement, 
physical health care providers, community mental health and substance treatment providers, 
local businesses, and government agencies.  These collaborations can be utilized to help prevent 
mental health or substance use issues among children and adolescents in schools, better identify 
and support children and adolescents with mental disorders including SUDs, and make referrals 
to needed treatment for mental health and substance use issues.  Although the school system 
plays an integral role in ensuring the sound mental health of its students, a comprehensive 
community approach has been essential to the successful  expansion of school-based mental 
health systems. 
  
Schools and their community partners that have implemented CSMHSs often utilize the School 
Health Assessment and Performance Evaluation system (SHAPE), a free, web-based portal that 
provides a virtual workspace for self-assessment of their CSMHSs level of quality 
implementation based upon the National Indicators for School Mental Health.35  SHAPE also 
provides schools and community partners with a blue print to inform ongoing planning and 
implementation in building their CSMHS based best practices and quality indicators.  The 
SHAPE system can also help CSMHSs identify needed  services, such as global screening, 
wellness education, psychotherapy and counseling, access to medication when indicated, and 
case management.  The SHAPE system also addresses factors that can facilitate the expansion of 
the mental health and substance treatment workforce within and outside of schools in order to 
support the provision of school-based mental health and substance related services.  The National 
Center for School Mental Health (NCSMH) at the University of Maryland School of Medicine,36 
a sub-recipient of a Health Resources and Services (HRSA) grant to support the Collaborative 
Improvement and Innovation Network on School-Based Health Services (CoIIN-SBHS) 
project,37 also supports the SHAPE system, which it offers at no cost to all schools and school 
districts nationally that are interested in improving and strengthening their school mental health 
and substance related services. 
 
States have also received SAMHSA funding to implement Safe Schools/Healthy Students 
(SS/HS) or Project Advancing Wellness and Resilience in Education (AWARE) grants.  The 
SS/HS framework provides schools and communities with a template for implementing best 
practices to prevent violence among children and adolescents, and has been found to reduce 
suspensions and expulsions by half, reduce risks associated with depression by 51 percent, and 
decrease the number of students staying home from school due to feeling unsafe by 37 
percent.38,39  SAMHSA has provided SS/HS funding to seven states, and profiles of the 
initiatives in these states are available online.40  While SAMHSA no longer funds SS/HS grants, 
SAMHSAs Project AWARE grants support states in developing quality comprehensive school 
mental health systems that seek to meet the needs of all students.  The first Project AWARE 
grants funded 20 States in 2014.  A second Project AWARE cohort of 24 states and tribes began 
in 2018, and a third cohort is planned for implementation in the spring of 2019 when 
4 
  approximately six additional states and two tribes are expected to receive Project AWARE grant 
funds.41  Project AWARE has demonstrated improved ability to identify and refer children and 
adolescents with mental health problems to appropriate treatment, with nearly a 10-fold increase 
in referrals achieved from fiscal year 2015 to fiscal year 2016.42,43  Further, Project AWARE 
participants who were non-clinician mental health helpers, received Youth Mental Health First 
Aid training, after which they reported significantly improved mental health literacy, and 
significantly enhanced confidence in being able to provide appropriate help to students when 
indicated.44  Additionally, Project AWARE performance outcomes reported by grantees included 
improved school climate, improved school safety, and improved student coping and resiliency 
skills.45  
 
It should be noted that the cost of implementing a comprehensive system varies due to the range 
of student needs, evidence-based practices used, and reimbursement for services by public and 
private insurance.  Financing of CSMHSs may require multiple streams of funding.  Federal 
grants, such as SS/HS and Project AWARE, have assisted or are currently assisting over 50 
states, territories, and tribal entities in the development of school mental health systems. 
 
Building Mental Health Literacy 
Building mental health literacy is a universal prevention strategy that schools can implement 
with all staff and students within a specific school, school district, and/or more broadly within 
the community.  Raising awareness and literacy around mental health issues is a critical 
component of improving school-based mental health.  Mental Health First Aid and Youth Mental 
Health First Aid are examples of mental health literacy training programs designed to provide a 
basic understanding of common mental health issues and how to refer people in mental health 
crises appropriately.  These training programs are widely available to school personnel, parents/ 
families/caregivers, first responders, law enforcement, and others in communities, with more 
than one million people across the nation already trained.  
 
Research has indicated that gains in mental health knowledge over the course of the mental 
health literacy trainings were associated with increased help-seeking intentions, suggesting that 
mental health literacy may facilitate treatment utilization.  Generally, as of 2018, instructor 
training costs between $1,500 and $2,000, while individual course training varies, with an 
average cost of $119.  This training can empower school staff with skills to recognize and assist 
students experiencing mental health needs and better prepare them to make appropriate referrals.  
Various non-Medicaid funding sources for mental health literacy training may be explored, such 
as those listed in the section below entitled, Funding for School-Based Mental Health and 
Substance Use Related Prevention and Treatment Services. 
 
Counseling, Psychological, and Social Services Coordinators 
Establishing counseling, psychological, and social services (CPSS) coordinators can have a 
positive impact on the quality and delivery of mental health and other related services.46  CPSS 
coordinators can coordinate various providers within and outside of schools to meet students 
needs.47  Coordination of services can also result in a clear mission, goals, and objectives that 
promote the integration of procedures and programs.48  Integration of services within the larger 
school environment helps secure resources, such as provision of confidential space for providing 
5 
  services, and helps minimize lost class time for students seeking services.  A recent survey of 
school districts nationwide revealed that 79.5 percent had staff to oversee or coordinate CPSS.49 
 
School Resource Officers 
The National Association of School Resource Officers (NASRO) underscores three primary 
roles of the school resources officer (SRO)namely, that of educator and guest lecturer, that of 
informal counselor or mentor, and that of law enforcement officer.50  The SRO is a non-
Medicaid covered mechanism utilized by many schools.  When implemented with a highly 
trained officer, SROs can be an invaluable component of creating a safe and supportive school 
climate.  SROs can be an integral member of multi-disciplinary teams within schools, 
collaborating with teachers, administrators, mental health providers and guidance counselors in 
the best interest of the students.  SROs can directly help identify students with mental disorders 
including SUDs to connect them with appropriate mental health or substance use services in the 
school.  By fostering positive relationships with students, SROs can also help address situations 
that students bring to their attention for other children or adolescents who may need support.  
Further, SROs can have an online presence to help identify potential student needs and 
encourage indicated help seeking through school-based mental health and substance related 
resources.51 
  
Crisis Intervention Teams (CITs)  
Law enforcement officers well trained in mental health issues can be a tremendous asset to the 
local school systems.  CITs are a community partnership of law enforcement, mental health and 
substance use practitioners, individuals living with mental disorders including SUDs, their 
families/caregivers and other advocates that provide specific training to law enforcement and 
other first responders in safely responding to people with mental disorders or experiencing a 
mental health emergency who are in crisis.  While CITs are not limited to a school environment, 
they can help address crises within school settings as they may in other parts of a community.  
This innovative first responder model helps people with mental disorders including SUDs access 
medical treatment rather than the criminal justice system and promotes officer safety and the 
safety of the individual.  The CIT model reduces both stigma and the need for further 
involvement with the criminal justice system and provides a forum for effective problem solving.  
Research also suggests that communities that subscribe to the CIT model have higher success 
rates in resolving crises.52 
 
Behavioral Health Aides and Peer Supporters 
Support from behavioral health aides and peers can be critical to help children and adolescents 
and their families and caregivers navigate challenges associated with mental and substance use 
issues, and can enhance efforts of practitioners and others in the school and health system.  
Trained peers can develop trust and effective relationships through similar lived experiences with 
others facing mental and substance use difficulties,53 and have been found to improve quality of 
life, engagement, and satisfaction with services and supports, improve overall health, and reduce 
overall cost of services.54  While not specific to school-based settings, research has demonstrated 
the clinical and social/emotional benefits for individuals with mental illness receiving peer 
support, including reductions in hospitalizations, increased feelings of respect, humanity, and 
6 
  trust, and increased empowerment to engage in care and pursue personal goals.55,56  Peer 
supporters are included in various settings across the nation including child-serving systems, and 
include student peer counseling programs and statewide peer and family support 
organizations.57,58  In 2015, 37 states used various funding sources to provide peer and consumer 
run services.59 
 
Workforce and Rural Setting Considerations 
Some settings, including rural locations, have unique challenges regarding building an adequate 
mental health and SUD treatment workforce.  While important, these factors are beyond the 
focus of this document, so will not be addressed in detail.  However, Appendix A highlights 
information addressing workforce shortages, training the mental health and SUD treatment 
workforce, and using telemental health to expand access to mental health and substance related 
services in rural schools or other settings in which particular difficulty may be experienced 
recruiting or retaining qualified mental health and SUD treatment practitioners. 
 
Funding for School-Based Mental Health and Substance Use Related Prevention and 
Treatment Services 
 
Various funding sources can be utilized to pay for the costs of school-based mental health 
services, including to:60  
 
1) leverage diverse funding streams and resources to support a full continuum of services;  
2) increase reliance on more permanent funding;  
3) apply best practices strategies to retain staff;  
4) use economies of scale to maximize efficiencies;  
5) utilize third party reimbursement mechanisms (i.e., Medicaid, Childrens Health 
Insurance Program (CHIP), private insurance) for these services;  
6) implement evidence-based practices and programs to maximize return on investment;  
7) evaluate and document outcomes, including impact on academic and classroom 
functioning, using outcome data to inform states, school districts, and community 
partners; and  
8) apply for public grants, formula grants (e.g., via ESSA, or the Office of Juvenile 
Justice and Delinquency Prevention), block grants such as the Community Mental Health 
Services Block Grant or discretionary/program grants (e.g., Garrett Lee Smith Suicide 
Prevention, Project AWARE, SAMHSA Systems of Care, HRSA Workforce 
Development), as a time-limited bridge to more sustainable funding streams. 
 
Many states have used multiple financing strategies for school mental health and SUD related 
prevention and treatment services, including the use of Medicaid.  Medicaid is a state-federal 
program in which states have the flexibility to design their programs and the services offered, 
subject to federal requirements.  Each state develops and operates its Medicaid program under 
a state plan outlining the nature and scope of services.  Subject to federal requirements, states 
choose which eligibility groups and services to include (some eligibility groups and services 
are mandatory, while others are optional), which providers may participate and the payment 
methods that will be used to pay for services.  The Medicaid state plan and any amendments 
to the state plan must be approved by CMS.  States may also pursue other Medicaid statutory 
7 
  authorities to support the populations and services they wish to cover, subject to CMS 
approval.  The FY 2016 CMS Medicaid Financial Management Report indicates that forty-
five states and the District of Columbia offer reimbursement for a range of school-based 
services, which would include all Medicaid reimbursable school-based services. 61 
   
8 
   
 
Some specific examples of state-level strategies for Medicaid and other financing of school-
based mental health services can be found in the table below. 
 
STATE  DESCRIPTION 
Alabama  Alabama Departments of Education and Mental Health developed cross system 
funding to support school-based mental health programming.62 
Arkansas  Developed administrative procedures to finance a school-based mental health 
program.  Arkansas also formed a state-level collaboration between their 
Departments of Education, Mental Health/Behavioral Health, and Juvenile Justice 
for shared funding of school-based services,63 and a comprehensive manual of 
Arkansass approach to school-based mental health within their State is available 
online.64 
California  Passed the Mental Health Services Act, which levies a 1% income tax on 
personal income in excess of $1 million65 to support mental health initiatives, 
including comprehensive school-based mental health systems. 
Florida  Utilized a SAMHSA Project AWARE66 grant to produce a Universal Screening 
Planning Packet, designed to guide schools in implementation of broad-based 
mental health screening so that students may receive further support and mental 
health services when indicated. 
Louisiana  Used Medicaid state plan authority in LA 15-0019 to cover the services of a 
licensed nurse in the school setting for Medicaid-eligible students with an 
individualized health plan thereby not limiting the nursing services to services in 
an Individualized Education Plan (IEP.) 
Massachusetts  Amended their Medicaid state plan to cover services within Individual Health Care 
Plans, Individualized Family Service Plans, Section 504 plans, or services 
otherwise deemed medically necessary.  The state plan amendment MA 16-012 was 
approved on July 17, 2017 and was effective on July 1, 2016.  
Michigan  IDEA revisions expanded counseling sessions for students at elevated risk for 
mental health concerns (i.e., Tier 2) and for those with existing mental health 
needs (i.e., Tier 3). 
Nevada  The governors state-funded block grant called Social Workers in Schools began 
in the 2015-2016 school year, and provides full-time social workers to address 
mental health/behavioral health issues identified on school climate surveys.  
Through Social Workers in Schools, the Department of Educations Office for a 
Safe and Respectful Learning Environment has placed over 225 social workers in 
170 schools over the past two years.67 
 
South  Department of Education created a Psychosocial Behavioral Health Rehabilitative 
Carolina  Medicaid Standard for students in Tiers 2 and 3 to enhance coverage for school-
based services.68  South Carolina also developed a recurring line item in the state 
budget to ensure funding for rural communities to develop school mental health 
programs.69 
Tennessee  Johnson City designated school mental health funding for case managers in schools 
to provide Tier 2 and Tier 3 level services.70 
9 
  Medicaid Coverage of Mental Health and Substance Treatment Services 
 
The following section describes general Medicaid requirements, state plan benefits that may 
be used to cover services to treat mental disorders including SUDs, and other Medicaid 
authorities that may be used to cover these services. 
 
Section 1905(a) State Plan Services 
 
The Medicaid state plan is a comprehensive written statement that describes the nature and 
scope of a states Medicaid program and contains assurances that the program will be operated 
per the requirements of Title XIX of the Social Security Act (Act) and other official guidance.  
While there is no distinct Medicaid state plan benefit called school health services or school-
based services, states may submit a state plan amendment (SPA) to provide such services and 
ensure that services are covered by Medicaid and eligible for federal financial participation 
(FFP).  The states Medicaid state plan must provide for coverage of mandatory services and 
include any optional services that the state elects to cover and must include a comprehensive 
description of the states method of payment for those services. 
  
A coverage SPA must meet three basic tenets of comparability, freedom of choice of provider, 
and statewideness, except in the limited circumstances where a particular benefit included in 
that SPA allows for any of these requirements to be disregarded.  
 
Comparability: A Medicaid-covered benefit generally must be provided in the same 
amount, duration, and scope to all enrollees within a group; 
  
Freedom of choice: Medicaid beneficiaries must be permitted to choose a health care 
provider from any qualified provider who undertakes to provide the services, and any 
willing and qualified provider must be able to participate in the Medicaid program;  
Statewideness: The plan will be in operation statewide under equitable standards for 
assistance and administration that are mandatory throughout the state. 
  
In addition, a coverage SPA must meet the requirements for coverage under the particular 
benefit, and include any limitations on amount, duration, and scope of services.  
 
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Benefit 
The EPSDT benefit provides a comprehensive array of prevention, diagnostic, and treatment 
services for Medicaid-enrolled children under age 21 as specified in section 1905(r) of the Act.  
The EPSDT benefit requires states to have a schedule for screening services both at established 
times and on an as-needed basis.  Covered screenings for children include medical, mental 
health, vision, hearing, and dental.  Incorporating an age appropriate, evidence-based screening 
tool designed to identify behavioral health conditions into well-child examinations is an 
important step to identify mental health and SUD conditions early.  In addition, the EPSDT 
benefit requires that states provide all medically necessary services covered under the benefits in 
section 1905(a) of the Act to correct or ameliorate physical and mental illnesses or conditions. 
10 
  Behavioral health counseling, for example, could be covered under the rehabilitative services 
benefit at section 1905(a)(13) of the Act, but states would not need to amend their state plans to 
add EPSDT coverage for screening and behavioral health services.  However, some states choose 
to do so in order to clarify the services covered in school settings.  
 
Examples of Medicaid Benefits for Coverage of Mental Health and SUD Treatment Related 
Services 
 
Mandatory Section 1905(a) Benefits 
 
Physicians Services Benefit 
The physicians services mandatory benefit is defined in section 1905(a)(5) of the Act and in 
regulations at 42 C.F.R. 440.50.  Physicians services are furnished within the scope of practice 
of medicine or osteopathy as defined by state law whether furnished by or under the personal 
supervision of an individual licensed under state law to practice medicine or osteopathy.  
Physicians services can be furnished in the school, office, the recipients home, a hospital, a 
skilled nursing facility, or elsewhere.  Since psychiatrists are physicians, their services could be 
covered under this benefit.   
Federally Qualified Health Center (FQHC) Benefit  
FQHC services are defined in section 1905(a)(2)(C), section 1905(l)(2), and section 1861(aa)(3) 
of the Act.  This mandatory benefit includes services provided by certain core providers 
including physicians, nurse practitioners and physician assistants (subject to any state law 
prohibition on furnishing primary health care), nurse midwives, clinical psychologists, clinical 
social workers and visiting nurses in areas with a shortage of home health agencies.  FQHC 
services also include other ambulatory care services otherwise included in the Medicaid state 
plan, such as mental health and substance use related treatment services.  Although FQHC 
services are a mandatory benefit and a state must cover services furnished by the core providers, 
the state has flexibility in determining the other ambulatory care services covered under this 
benefit to the extent that the services are already covered in another benefit of the state plan. An 
FQHC could provide covered school-based services, and be located at or near a school as a 
school-based health center.  
 
Rural Health Clinic (RHC) Benefit 
RHC services are defined in section 1905(a)(2)(B), section 1905(l)(1) and section 1861(aa) of 
the Act and federal regulations at 42 C.F.R. 440.20(b) and (c).  RHC mandatory services are 
provided by a rural health clinic certified in accordance with 42 C.F.R. Part 491 and include 
services provided by certain core providers including physicians, nurse practitioners and 
physician assistants (subject to any state law prohibition on furnishing primary health care), 
nurse midwives, clinical psychologists, clinical social workers and visiting nurses in areas with a 
shortage of home health agencies.  The state has flexibility in determining the other ambulatory 
care services covered under this benefit to the extent that the services are already covered in 
11 
  another benefit of the state plan.  Like FQHCs, RHCs could provide covered school-based 
services, and be located at or near a school as a school-based health center.  
 
Optional Section 1905(a) Benefits 
Rehabilitative Services Benefit 
Rehabilitative services are an optional benefit as specified in section 1905(a)(13) of the Act. 
Medicaid regulations at 42 CFR  440.130(d) broadly define rehabilitative services as any 
medical or remedial services recommended by a physician or other licensed practitioner of the 
healing arts, within the scope of his practice under State law, for maximum reduction of physical 
or mental disability and restoration of a beneficiary to his best possible functional level.  The 
state will need to describe the services it seeks to cover and list the practitioners who will furnish 
the services, along with their qualifications.  For example, a state may seek to cover individual 
and group counseling, or peer support services for children in schools with mental illness or 
substance use disorders.  On August 15, 2007, CMS issued State Medicaid Director Letter, #07-
011, to provide guidance to states seeking to cover peer support services under the Medicaid 
program.71 
 
Other Licensed Practitioner Services Benefit 
Section 1905(a)(6) of the Act provides states flexibility in covering services provide by licensed 
practitioners as defined by state law.  As set forth in 42 C.F.R.  440.60(a), other licensed 
practitioner services are, any medical or remedial care or services, other than physicians 
services, provided by licensed practitioners within the scope of practice as defined under State 
law.  Under the state plan, states may elect to cover services furnished by state licensed 
practitioners.  For example, this benefit could be used to cover the services of a licensed clinical 
social worker to furnish counseling, a licensed psychologist to administer psychological tests, or 
a licensed nurse to administer medications for the treatment of depression or other mental 
illnesses, to children in schools.   
 
Clinic Benefit  
Under the optional clinic benefit at 42 C.F.R.  440.90, a state could cover a school-based health 
clinic that furnishes physical health, as well as mental health and substance related services.  
Clinic services means preventive, diagnostic, therapeutic, rehabilitative, or palliative services 
that are furnished by a facility that is not part of a hospital but is organized and operated to 
provide medical care to outpatients by or under the direction of a physician or dentist.  Services 
must be furnished at the clinic.  Services furnished outside the clinic, by clinic personnel, are 
only available to eligible individuals who do not reside in a permanent dwelling or have a fixed 
home or mailing address.  A clinic could be located at or near a school and provide Medicaid 
covered school-based services. 
   
12 
  Prescription Drug Benefit 
While coverage of outpatient prescription drugs is an optional service under section 1902(a)(54) 
of the Act, all states currently provide prescription drug coverage to all state plan eligible 
individuals.  When providing the optional prescription drug benefit, states are required under 
section 1927 of the Act to cover all outpatient drugs of manufacturers that participate in the 
Medicaid drug rebate program.  However, states may subject drug coverage to utilization 
management mechanisms, such as step therapy, quantity limits, and prior authorization.  Many 
states use preferred drug lists that attempt to encourage prescribers to use more cost effective 
drugs for their patients.  However, Medicaid beneficiaries typically have very generous drug 
coverage.  This benefit can assist with providing access to needed SUD treatment as children 
and adolescents may need prescribed medications, such as antidepressants, during the school 
day.   
 
Case Management Benefit 
Case management, an optional benefit defined at 42 C.F.R.  440.169 and 42 C.F.R.  441.18, 
includes services that assist eligible individuals to gain access to needed medical, social, 
educational, and other services.  Case management services must include all of the following: 
comprehensive assessment of an eligible individual, development of a specific care plan, 
referral to needed services, and monitoring activities.  Under this benefit, states may target case 
management services for a specific group of individuals, or to individuals who reside in 
specified areas of the state (or both).  Direct services for a beneficiary are not covered under the 
case management benefit.  However, the state may cover otherwise coverable direct services 
under a different benefit.  The state has flexibility to define qualifications for practitioners to 
deliver these services, which can include specialized qualifications for case management 
services for individuals with intellectual disabilities or with chronic mental illness (or other 
conditions as appropriate) and does not have to meet comparability or statewideness 
requirements.  States may wish to target children with SED or SUDs in order to ensure that 
they have access to all needed medical, social, educational, and other services.  This would 
include all Medicaid children in schools who meet the states medical necessity criteria for the 
case management services.  
 
Other Relevant Medicaid Authorities 
 
Depending on how a state determines the design and scope of their school services, Medicaid 
authorities described in this section may be used in concert with state plan benefits to achieve 
desired goals.  These authorities can be used in a variety of ways such as changing the 
delivery system and incorporating services beyond those coverable in the traditional coverage 
authorities.  These authorities are available at state option. 
 
Section 1945 of the Act - Health Home Benefit 
 
This authority allows states to implement health homes for Medicaid beneficiaries (both 
children and adults) with chronic conditions.  A Medicaid beneficiarys eligibility for 
participation in a health home is based on whether the beneficiary has the chronic conditions 
13 
  identified in the approved health home provisions of the state plan, and could also be based on 
whether the beneficiary is in an approved targeted geographic area for health home services, 
but does not depend on what general Medicaid eligibility category the beneficiary is in.  Health 
home services are intended to promote integration of all primary care, acute care, mental 
health care, substance use related care, and long-term services and supports to treat the whole 
person.  Health home services include comprehensive care management, care coordination, 
health promotion, comprehensive transitional care/follow-up, individual and family support, 
and referral to community and social support services.  The health home benefit allows states 
to provide a multi-disciplinary team approach to coordinating care.  States are also able to 
target the provision of health home services geographically.  Additionally, states receive a 
time-limited enhanced federal match for their expenditures on the health home services listed 
in the state plan. 
 
Managed Care 
States may use a managed care delivery system, involving contracts with managed care plans 
and/or to provide some or all Medicaid-covered services to eligible Medicaid beneficiaries.  
There are several authorities, from which states have the option to elect, to set up and design a 
managed care delivery system, including a 1932 state plan amendment, section 1915(a) and (b) 
waivers, or section 1115 demonstration projects.  In most instances, states must meet the 
requirements of sections 1903(m) of the Act, which incorporates many of the requirements in 
section 1932 of the Act.  While states can choose what services will be covered under the 
managed care plan, they must continue to assure access to the full set of state plan services, 
including the EPSDT benefit.  When using a managed care delivery system, a state generally 
must provide beneficiaries with a choice of at least two managed care plans.  Payments to 
managed care plans are generally made on a risk basis, meaning that the managed care plan is 
paid a set amount per enrollee for the scope of services covered under the contract called a 
capitation payment.  Contracts, which must include the capitation rates payable to managed 
care plans, are subject to CMS approval and capitation rates must be actuarially sound. 
 
States may contract with a managed care plan to cover the full range of EPSDT screening, 
diagnostic, and treatment services, including services to children in schools, or states may 
carve out some EPSDT services, or services beyond contracted limits, and retain responsibility 
for them in fee-for-service coverage, or contract with another managed care plan to provide 
those services. 
 
Section 1915(b) of the Act - Freedom of Choice Waiver 
In addition to the use of section 1915(b) of the Act to authorize a managed care delivery 
system, CMS may grant a waiver to permit states to restrict a beneficiary within a more limited 
fee-for-service provider network.  When using this authority, states may be able to use the 
savings accrued through the use of more efficient care delivery to authorize additional services 
beyond what is included in the state plan. 
 
   
14 
  Section 1115 - Demonstration Projects  
Section 1115 of the Act gives the Secretary of HHS authority to approve experimental, pilot, or 
demonstration projects that further the objectives of the Medicaid and Childrens Health 
Insurance Program (CHIP).  These demonstrations give states additional flexibility to design 
and improve their programs and to demonstrate and evaluate policy approaches subject to CMS 
approval. 
  
Medicaid Payment for School-Based Services 
 
Medicaid payments can play a vital role in the provision of comprehensive school-based mental 
health care services.  The availability of payment for these services has been noted to be a 
central issue in the ability to provide services in school settings for Medicaid-eligible 
beneficiaries. 
  
Mental health and substance use services provided in the school setting are subject to the same 
federal and state laws and regulations that apply to Medicaid services provided in other 
settings.  Since the EPSDT benefit requires states to make available all medically necessary 
services for children under age 21 that are coverable under the benefits listed in section 1905(a) 
of the Act, states are not required to submit state plan coverage pages that include school-based 
services for children.  However, a comprehensive description of the payment methodology 
must be included in the reimbursement section.  The provider must meet the states licensing, 
certification or other applicable qualifying criteria and must document the provision of the 
service by creating and maintaining clinical and billing records that would be required of any 
other provider.  Also, CMS relies on states to implement policies and procedures to help ensure 
freedom of choice of providers while also ensuring that services are not duplicative of any 
services provided elsewhere. 
 
The most common approaches that states use for provider billing and payment for Medicaid-
covered services provided in schools to Medicaid-enrolled students are: 
 
1.  Fee-for-service/claim-based payment: Under this approach, the state establishes a fee 
schedule and any coverage limitations for each service.  The provider then submits a 
request for payment to the Medicaid program in essentially the same way that any 
medical provider would bill a health insurance company by submitting a claim that 
details the name and Medicaid identification number of the Medicaid-enrolled student, 
the date and billing code of the service provided, the supporting diagnosis code and any 
other information required by the Medicaid program.  However, this process is not 
commonly used for school-based services not only because most schools do not have 
medical claim billing systems that provide a means to bill in this way but also, perhaps 
even more importantly, because most state Medicaid programs pay for these services on 
a reconciled cost basis. 
 
2.  Recognized cost reimbursement: The overwhelming majority of school-based services 
are reimbursed by state Medicaid programs using a reconciled cost methodology. Under 
this method, each Local Education Agency uses a cost reporting system to compile and 
aggregate the costs of providing the services, usually on a quarterly or annual basis.  
15 
  These costs are then allocated between services that were provided to Medicaid-enrolled 
students and those that were provided to non-Medicaid students.  This effort not only 
requires direct service providers working in schools to maintain appropriately 
comprehensive clinical records to support the reported expenditures, but also requires 
that school districts maintain sufficient cost data and service utilization documentation 
to facilitate an accurate allocation of cost to Medicaid consistent with federal cost 
principles.  Schools are strongly encouraged to work with their states Medicaid 
program staff and CMS staff to develop an appropriate cost identification and allocation 
methodology that meets federal requirements.  It must also be noted that even though 
individual claims for services are not submitted to the Medicaid agency in order to 
request payment, CMS requires that the Medicaid program use its Medicaid 
Management Information System to record all school-based services in order to 
document services at the individual level and to provide information necessary to assess 
the economy and efficiency of the payments. 
 
Medicaid Payment for Services without Charge (Free Care) 
Historically, CMS guidance on free care was that Medicaid payment was generally not 
allowable for services that were available without charge to the beneficiary.  CMS issued a State 
Medicaid Director Letter (SMDL), #14-006,72 on December 15, 2014, stating that, Medicaid 
reimbursement is available for covered services under the approved state plan that are provided 
to Medicaid beneficiaries, regardless of whether there is any charge for the service to the 
beneficiary or the community at large.  As a result, Federal Financial Participation (FFP) is 
available for Medicaid payments for care provided through providers that do not charge 
individuals for the service, as long as all other Medicaid requirements are met.  Accordingly, 
CMS no longer limits FFP to Medicaid covered services included in a childs Individual 
Education Plan (IEP) or Individualized Family Service Plan (IFSP).  Medicaid coverage may 
include covered services in a childs individual service plan pursuant to section 504 of the 
Rehabilitation Act of 1973, covered services in some other written health care plan, or services 
covered under the benefits in section 1905(a) of the Act that are determined to be medically 
necessary.   FFP is available only when all of the following elements are satisfied: 
 
 The individual is a Medicaid beneficiary. 
 The service is a covered Medicaid service, provided in accordance with approved state 
plan methodologies, including coverage under the EPSDT benefit provided to children. 
 
 The provider is a Medicaid-participating provider and meets all federal and/or state 
provider qualification requirements. 
 
 The state plan contains a payment methodology for determining rates that are consistent 
with efficiency, economy and quality of care or provides for payment at cost using a 
CMS approved methodology. 
 
 Third party liability (TPL) requirements are met. 
16 
   Medicaid payment does not duplicate other specific payments for the same service. 
 The state and provider maintain auditable documentation to support claims for FFP.  
 The state conducts appropriate financial oversight of provider billing practices.  
 All other program requirements (statutory, regulatory, policy) for the service, payment, 
and associated claiming are met. 
 
Other Considerations and Regulatory Requirements 
 
Medicaid Qualified Providers  
In order for schools and practitioners to participate in the Medicaid program and receive 
Medicaid reimbursement, they must meet the applicable Medicaid provider qualifications and the 
requirements in 42 C.F.R.  431.107, including having a provider agreement and a Medicaid 
provider identification number.  Practitioners in schools are also subject to the screening and 
national provider identification (NPI) requirements in section 1866(j)(2) of the Act and 42 C.F.R. 
 455.400  455.470.  Rendering providers must meet the screening requirements and claims 
must include the NPI of the physician or other professional who ordered or referred such items or 
services.  Finally, practitioners who furnish services in school settings must meet applicable 
qualifications established by the state and those qualifications must minimally be the same as 
those providers who furnish services in other settings in the community. 
 
Collaborations with Community Providers Within or Near Schools 
Within federal requirements affecting coverage, payment and financing of Medicaid services, 
schools may establish collaborations with community providers.  CMS encourages states to seek 
technical guidance for compliance with these requirements prior to committing to a collaboration 
arrangement.  Commonly, these collaborations between schools and community providers result 
in what are referred to as, school-based health centers (SBHCs).   To be covered as a facility 
service, an SBHC would need to operate under a recognized Medicaid facility benefit, such as 
the clinic benefit or under the FQHC benefit, provided the requirements for these benefits are 
met.  Both benefits have certain requirements that may influence the way a school chooses to 
organize as a Medicaid recognized facility benefit.  For example, to the extent that services 
would be furnished outside of the clinic, the clinic benefit may not be used, as there is a general 
prohibition at 42 C.F.R.  440.90 on the furnishing of clinic services outside of the clinic for 
individuals except for those without a fixed dwelling or mailing address.  Accordingly, the 
FQHC benefit may be a better option for a school and community provider collaboration.  A 
state may elect to offer services of FQHC-affiliated practitioners in schools that trigger payment 
of the FQHC prospective payment system (PPS) rate. 
 
In general, SBHCs provide health care services that help students succeed in school and in life 
and operate during school hours.  They are staffed by qualified health care professionals and are 
focused on the prevention, early identification, and treatment of medical and mental health or 
substance related concerns that can interfere with a students learning.  They are located in or 
17 
  near a school facility and are organized through school, community, and health provider 
relationships.  According to the 2013-14 Census Report from the School-Based Health 
Alliance,73 there are three main models of  SBHCs : 1) those that are staffed by primary care 
providers such as a licensed nurse or nurse practitioner;  2) those that are staffed by a primary 
care provider and also a mental health provider such as a licensed clinical social worker, a 
psychologist, or substance abuse counselor;  and 3) those that are staffed by a primary care 
provider, a mental health provider, and also other practitioners such as a case manager, an oral 
health provider, a health educator, and a nutritionist. 
  
Medicaid Reimbursement for Telehealth/Telemedicine 
Telehealth/telemedicine74,75 is an alternative approach to providing face-to-face services, but the 
Medicaid statute does not recognize telehealth/telemedicine as a distinct service.  Services 
furnished via telehealth/telemedicine are subject to the same Medicaid requirements that apply to 
the underlying service.  Telehealth/telemedicine offers two-way, real time, interactive 
communication that links a Medicaid beneficiary and a practitioner at a distant site and can be 
helpful to ensure that Medicaid services are provided to Medicaid beneficiaries who are in rural 
areas or in areas where qualified practitioners are scarce.  States have flexibility in designing 
their telehealth/telemedicine program parameters, including when and how services may be 
provided using telehealth/telemedicine.  A state may allow the school to serve as an originating 
site, where the beneficiary is located, and/or as a destination site, where the direct service 
provider is located.  Whether developing a rate to pay for services under a fee schedule or using 
a cost recognition reimbursement method, the state Medicaid program may recognize costs 
incurred by schools to provide covered services via telehealth/telemedicine but may not include 
the start-up costs incurred to set up their telehealth/telemedicine technology.   
The Telehealth Network Grant Program (TNGP),76 operated by HRSAs Office of Rural Health 
Policy/Office for the Advancement of Telehealth, demonstrates the use of telehealth networks to 
improve healthcare services for medically underserved populations in urban, rural, and frontier 
communities.  The current TNGP encourages telehealth services delivered through school-based 
health centers, particularly those serving high-poverty populations.  Services include behavioral 
health services. 
 
Conclusion 
 
Mental health and substance use challenges negatively affect how well children and adolescents 
can learn, and there is an urgent need to identify students at risk or experiencing these challenges 
to connect them with appropriate prevention and treatment services.  Early intervention improves 
outcomes, and comprehensive school mental health systems have been associated with multiple 
positive educational and performance outcomes.  No single funding source can adequately 
support all mental health and substance-related prevention and treatment needs of students and 
their families and caregivers; however, federal, state, and community-level resources can be 
leveraged with philanthropic and other funding streams to ensure appropriate levels of support.  
Providing these services within schools increases the likelihood of children and adolescents 
receiving needed services, thus better ensuring academic and life success. 
 
18 
  States interested in learning more on this topic and/or requesting technical assistance may 
contact Dr. Nainan Thomas, Chief, Mental Health Promotion Branch 
(nainan.thomas@samhsa.hhs.gov, 240-276-1744) or Kirsten Jensen, Director, Division of 
Benefits and Coverage, (kirsten.jensen@cms.hhs.gov, 410-786-8146.)  State Medicaid Agencies 
should contact their Medicaid Regional Offices for technical assistance.  Schools systems and 
providers should engage with their state Medicaid agencies to discuss how Medicaid covers and 
reimburses for mental health and SUD treatment services in schools in their states. 
 
   
19 
  Appendix A 
 
 
This appendix provides information specific to expanding access to mental health providers 
within and outside of schools, for the provision of school-based mental health services.  See 
below for considerations regarding workforce shortages, training the mental health workforce, 
the use of telemental health to expand access to mental health services across settings in which 
particular difficulty may be experienced recruiting or retaining qualified mental health providers, 
and systems of care frameworks. 
 
1.  Mental Health and Substance Treatment Workforce Shortages: A lack of mental health 
professionals in schools or in centers that students and schools could easily access has 
been highlighted by school employees, governmental leaders, advocacy groups, and by 
families across the nation.  The National Association of School Psychologists (NASP) 
recommends school districts have one school psychologist for every 500-700 students77 
to ensure comprehensive services, although the ratio across the U.S. was estimated to be 
one psychologist for every 1,383 students.78  Further, research suggests that as the 
provider to student ratio increases, the availability and provision of mental health services 
provided within school settings decreases.79  Other mental health professionals can also 
assist in addressing school-based mental health and substance-related student needs, in 
addition to support roles played by non-professionals.  Peer and family support is critical 
to help children, adolescents and their families with serious emotional disturbance engage 
in and navigate complex systems of care.  High turnover rates, aging workforce, and low 
compensation all contribute to workforce shortage across the mental health arena.  
Unfortunately, this shortage is all too apparent in the school system.  Peer and family 
support providers may be used to enhance the workforce efforts by developing trust and 
effective relationships through similar lived experiences.80, 81   They help to address 
critical caregiver supports and have been shown to improve quality of life, engagement, 
and satisfaction with services and supports, improve overall health, and reduce overall 
cost of services.82  Research has shown the clinical and social/emotional benefits for 
individuals with mental illness receiving peer support, including reductions in 
hospitalizations, increased feelings of respect, humanity, and trust versus traditional 
providers, and increased empowerment to engage in care and pursue personal goals.83, 84 
Peer supporters are included in various settings across the nation including child-serving 
systems and include student peer counseling programs and statewide peer and family 
support organizations.85, 86   In 2007, CMS issued a letter to state Medicaid Directors 
providing guidance on using Medicaid to reimburse peer support services.87  In 2015, 37 
states also used various funding sources to provide peer and consumer run services.88 
 
2.  Training the Workforce: It is important to support clinicians and others in providing high 
quality care to ensure broad use and appropriate implementation of best practices.  
Several new efforts have recently been initiated to accomplish this, including 1) the 
Clinical Support System  Serious Mental Illness, to support the implementation of 
evidence-based practices in the treatment and recovery of individuals with SMI; 2) 
twelve Mental Health Technology Transfer Centers, which provide regionally-focused 
assistance to clinicians and others; 3) a 90 minute Specialized Educational Tool on 
20 
  Assessing and Addressing Risk of Youth Violence, developed in collaboration with the 
Department of Education, for teachers, first responders, parents, and students at no cost; 
and 4) mental health literacy training, such as Mental Health First Aid and Crisis 
Intervention Training.  In addition, the Health Resources and Services Administration 
(HRSA) supports several training programs that include the training of future child and 
adolescent mental health and substance related treatment professionals.  Within HRSAs 
Maternal and Child Health Bureau, the Developmental and Behavioral Pediatrics training 
program supports the advanced postdoctoral fellowship training of pediatricians to 
enhance the behavioral, psychosocial, and developmental components of pediatric care. 
 
3.  Using Technology to Address Workforce Issues: Technology can play a significant role 
in enhancing the workforce.  Telemental health is the use of video-conferencing to 
conduct real-time mental health treatment between a clinician and patient.  This can 
provide needed treatment to people who otherwise may not have access to mental health 
care, including those in underserved or rural areas.  The use of telemental health services 
in both rural and urban environments, including schools, has been found to be effective, 
cost efficient, and met with high ratings of satisfaction by students.  The cost of 
implementing telemental health services can vary; however, generally, the purchase of 
equipment can be between $500 and $10,000.  Telehealth care extension strategies 
include ECHO-type models.  ECHO (Extension for Community Healthcare Outcomes) is 
a SAMHSA distance education model that connects specialists with general practitioners 
via simultaneous video link for the purpose of facilitating care-based learning.  These 
models have been very effective in supporting and educating practitioners in hard to 
reach areas.  HRSA has a variety of telehealth-related grants and resources, including a 
Telehealth Network Grant Program, a Substance Abuse Treatment Telehealth Network 
Grant Program, an Evidence-Based Tele-Behavioral Health Network Program, among 
other resources.89  Information on HRSAs telehealth grant programs can be found at 
https://www.hrsa.gov/rural-health/telehealth/index.html, and telehealth resources and 
technical assistance can be obtained through the HRSA-supported National Consortium 
of Telehealth Resource Centers at https://www.telehealthresourcecenter.org/.  Telehealth 
provides a means to treatment access for those who might not otherwise be able to access 
it.  Reimbursement for services delivered via telehealth will vary across payers.  The 
Center for Connected Health Policy developed a document that outlines each state law 
around telemedicine and reimbursement for mental health services, which can serve as a 
resource to school systems desiring to incorporate telemental health into their schools.90  
 
4.  Systems of Care (SOC) framework:  The SOC framework is an effective model that has 
been supported by SAMHSA grants.  The systems of care (SOC) framework is an 
approach that explicitly includes all systems that are involved with providing services for 
children and is a proven best practice in providing comprehensive, community-based 
mental health treatment and support services for children and adolescents with SED or 
serious mental illness and their parents and families.  Examples of the types of systems 
that are included in an SOC approach include departments of health, education 
departments, social services, juvenile justice and others.  Recipients of services provided 
have demonstrated significant improvements in behavioral and emotional functioning; 
significant reductions in thoughts of suicide and suicide attempts; significant reductions 
21 
  in unlawful activities; and significant cost reductions due to decreases in hospitalizations 
and arrest.91  States such as Wisconsin include SOC in their MTSS framework that 
guides local districts in development of their school mental health systems. 
 
   
22 
  ENDNOTES 
                                                           
1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental 
disorders (5th ed.). Arlington, VA. 
2 Interdepartmental Serious Mental Illness Coordinating Committee, The Way Forward: Federal 
Action for a System That Works for All People Living with SMI and SED and Their Families 
and Caregivers. December 13, 2017. 
3 Keeping Youth Drug Free. HHS Publication No. (SMA) 17-3772. Rockville, MD: Center for 
Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 
2017. 
4 The Federal Register defines the term "children with a serious emotional disturbance" 
(SAMHSA, 1993, p. 29422). Pub. L.102-321 defines children with an SED to be people "from 
birth up to age 18 who currently or at any time during the past year have had a diagnosable 
mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria 
specified within the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, 
Revised (DSM-III-R; American Psychiatric Association, 1987) that resulted in functional 
impairment, which substantially interferes with or limits the child's role or functioning in family, 
school, or community activities" (SAMHSA, 1993, p. 29425). 
5 Williams, N.J., Scott, L., & Aarons, G.A. (2018). Prevalence of serious emotional disturbance 
among U.S. children: A meta-analysis. Psychiatric Services, 69(1):32-40. 
6 David-Ferdon, C., Vivolo-Kantor, A.M., Dahlberg, L.L., Marshall, K.J., Rainford, N., & Hall, 
J.E. (2016). A comprehensive technical package for the prevention of youth violence and 
associated risk behaviors. Atlanta, GA: National Center for Injury Prevention and Control, 
Centers for Disease Control and Prevention. Georgetown University, Center for Child and 
Human Development. Retrieved from 
https://gucchdtacenter.georgetown.edu/publications/ECMHCStudy_Report.pdf. 
7 Centers for Disease Control and Prevention. Improving access to childrens mental health care. 
https://www.cdc.gov/childrensmentalhealth/access.html. 
8 Kataoka, S.H., Zhang, L., & Wells, K.B. (2002). Unmet need for mental health care among 
U.S. children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159, 
1548  1555. 
9 Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on 
Drug Use and Health: Detailed Tables. Rockville, MD: SAMHSA; 2018. Retrieved January 10, 
2019 from https://www.samhsa.gov/data/sites/default/files/cbhsq-
reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.htm#tab1-2B 
10 Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on 
Drug Use and Health: Detailed Tables. Rockville, MD: SAMHSA; 2018. Retrieved January 10, 
2019 from https://www.samhsa.gov/data/sites/default/files/cbhsq-
reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.htm#tab2-2B 
11 Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on 
Drug Use and Health: Detailed Tables. Rockville, MD: SAMHSA; 2018. Retrieved January 10, 
2019 from https://www.samhsa.gov/data/sites/default/files/cbhsq-
reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.htm#tab5-1B 
12 Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on 
Drug Use and Health: Detailed Tables. Rockville, MD: SAMHSA; 2018. Retrieved January 10, 
 
23 
                                                                                                                                                                                             
2019 from https://www.samhsa.gov/data/sites/default/files/cbhsq-
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13 Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005). 
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National 
Comorbidity Survey Replication. Arch Gen Psychiatry, 62(6), 593-602. 
14 Greenberg, M., Weissberg, R., OBrien, M., Zins, J., Fredericks, L., Resnik, H., & Elias, M. 
(2003). Enhancing school-based prevention and youth development through coordinated social, 
emotional, and academic learning. American Psychologist, 58, 466. 
15 Zins, J. E., Bloodworth, M. R., Weissberg, R. P., & Walberg, H. J. (2004). The scientific based 
linking social and emotional learning to school success. In J. Zins, R. Weissberg, M. Wang, and 
Walberg, H. J. (Eds.), Building academic success on social and emotional learning: What does 
the research say? (pp. 3-22). NY: Teachers College Press. 
16 Bruns, E. J., Walwrath, C., Glass-Siegel, M., & Weist, M. D. (2004). School-based mental 
health services in Baltimore: Association with school climate and special education referrals. 
Behavior Modification, 28, 491-512. 
17 Jennings, J., Pearson, G., & Harris, M. (2000). Implementing and maintaining school-based 
mental health services in a large, urban school district. Journal of School Health, 70, 201-206. 
18 Greenberg, M. T., Domitrovich, C. E., Graczyk, P. A., & Zins, J. E. (2005). The study of 
implementation in school-based prevention interventions: Theory, research, and practice (Vol. 
3). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health 
Services Administration. 
19 Lehr, C. A., Johnson, D. R., Bremer, C. D., Cosio, A., & Thompson, M. (2004). Essential 
tools: Increasing rates of school completion: Moving from policy and research to practice. 
Minneapolis, MN: University of Minnesota, Institute on Community Integration, National Center 
on Secondary Education and Transition. 
20 Health Resources and Services Administration/National Center for Health Workforce 
Analysis; Substance Abuse and Mental Health Services Administration/Office of Policy, 
Planning, and Innovation. 2015. National Projections of Supply and Demand for Behavioral 
Health Practitioners: 2013-2025. Rockville, Maryland. 
21 Iachini AL, Brown, EL, Ball, AB, Gibson, JE, and Lize, SE. (2015). School Mental Health 
Early Interventions and Academic Outcomes for at-risk High School Students: A meta-analysis.  
Advances in School Mental Health Promotion, 8 (3), 156-175. 
https://doi.org/10.1080/1754730X.2015.1044252.  
22 Americans with Disabilities Act, 42 U.S.C. 12101-12213; 28 C.F.R. 35. 130(d); Olmstead v. 
L.C. ex rel. Zimring, 527 U.S. 581 (1999); U.S. Dept of Justice, Statement of the Dept of 
Justice on Enforcement of the Integration Mandate of Title II of the Americans with Disabilities 
Act and Olmstead v. L.C. (June 22, 2011), https://www.ada.gov/olmstead/q&a_olmstead.htm. 
23 42 U.S.C. 1396a(a)(43); see also 42 U.S.C. 1396a(a)(10)(A); 1396d(a)(4)(B); 1396d(r). 
24 CMS, EPSDT  A Guide for States: Coverage in the Medicaid Benefit for Children and 
Adolescents 24 (2014). 
25 Lav, J., and Lew, K. (2018). Childrens mental health services: The right to community-based 
care. National Health Law Program. www.healthlaw.org  
26 Sulkowski, M. L., & Michael, K. (2014). Meeting the mental health needs of homeless 
students in schools: A Multi-Tiered System of Support framework. Children and Youth Services 
Review, 44, 145-151. 
 
24 
                                                                                                                                                                                             
27 U.S. Department of Educations Office of Special Education Programs (OSEP) and the Office 
of Elementary and Secondary Education (OESE) Technical Assistance Center on Positive 
Behavioral Interventions and Supports (PBIS). Retrieved January 15, 2019 from 
https://www.pbis.org/. 
28 U.S. Department of Educations Office of Special Education Programs (OSEP) and the Office 
of Elementary and Secondary Education (OESE) Technical Assistance Center on Positive 
Behavioral Interventions and Supports (PBIS). Retrieved January 15, 2019 from 
https://www.pbis.org/. 
29 https://www.pbis.org/school/school-mental-health/interconnected-systems 
30 http://www.rtinetwork.org/learn/what/whatisrti 
31 U.S. Department of Educations Office of Special Education Programs (OSEP) Technical 
Assistance Center on Positive Behavioral Interventions and Supports (PBIS). Retrieved January 
15, 2019 from https://www.pbis.org/school/swpbis-for-beginners/pbis-faqs.   
32 Collaborative for Academic, Social, and Emotional Learning (CASEL): What is Social and 
Emotional Learning (SEL)? Retrieved January 15, 2019 from https://casel.org/what-is-sel/. 
33 Center for School Mental Health, 2015. 
34 Comprehensive School Mental Health Services: Why and What? 
https://healthysafechildren.org/sites/default/files/Comprehensive_SMH_Webinar_PowerPoint.pdf   
35 School Health Assessment and Performance Evaluation (SHAPE). Retrieved January 15, 2019 
from https://theshapesystem.com/. 
36 National Center for School Mental Health (2018). Retrieved April 11, 2019 from 
http://csmh.umaryland.edu/. 
37 https://mchb.hrsa.gov/fundingopportunities/?id=eee6758f-c4a4-412b-b511-b07b3c152ffa 
38 Final Report of the Federal Commission on School Safety (2018). Retrieved January 8, 2019 
from https://www2.ed.gov/documents/school-safety/school-safety-report.pdf.  
39 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services 
Administration. Rockville, MD. Retrieved on January 10, 2019 from 
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