Whats at stake in Washington

1
Whats at stake in Washington?

• Presentation by Elaine M. Ryan
• June 1, 2005

2
Hot Issues

• Budget Reconciliation
• FY 2006 Administration Proposals
• Welfare Reform
• IV-E Administrative Actions
• APHSA Proposals

3
Budget Reconciliation

• 500 billion deficit and growing.
• Senate and House passed Budget Resolution with
  Reconciliation Instructions on April 29th.
• 10 billion cut to Medicaid from FY 2007-2010
• It instructs committees to reduce spending on
  mandatory programs by 34.7 billion from fiscal
  year 2006-2010.
• It sets a cap on discretionary spending of 843
  billion. 23 b in FY 2006 and 59 b in 2010.

4
Budget Reconciliation

• The House Energy and Commerce Committee with
  jurisdiction over a broad range of programs
  including Medicaid is instructed to identify 2
  billion in reduced spending for FY 2006 and 14.7
  billion between FY 2006-2010.
• The agreement also reserves funds for the Family
  Opportunity Act that would allow for the purchase
  of Medicaid coverage for children with special
  needs and for the restoration of funds for the
  State Childrens Health Insurance Program.

5
Budget Reconciliation

• The House Ways and Means Committee is instructed
  to reduce spending by 250 million in FY 2006 and
  by 1 billion for FY2006-2010.
• Ways and Means along with the Senate Finance
  committee are also instructed to reduce taxes by
  11 billion in FY 2006 and by 70 billion for FY
  2006-2010.
• The House Education and the Workforce Committee
  is requested to identify 12.7 billion in savings
  and the Senate Health, Education, Labor, and
  Pensions Committee 13.7 billion. 

6
FY 2006 Administration Proposals

• Medicaid Targeted Case Management
• Limit IV-E Administrative Costs
• Reverse the Rosales Decision
• Foster Care Flexible Funding Option

7
Targeted Case Management

• What is TCM?
• Common TCM activities include assessment of
  service needs, development of a care plan,
  referral to needed services, and monitoring of
  care plans and service delivery.
• Case management ensures that beneficiaries with
  complex health and social service needs receive
  all required care in a timely and efficient
  manner.
• Who receives TCM services?
• Many states provide TCM services to children in
  foster care, persons with HIV or AIDS, children
  with disabilities, infants and toddlers with
  developmental delays, pregnant women, or persons
  with mental illness.

8
Medicaid TCM

• Administration proposes to reduce federal match
  rate and restrict TCM for rehabilitation and for
  children in the child welfare system.
• 11 billion in federal savings would be achieved
  over 5 years.
• Such a change would have a significant impact for
  child welfare.

9
IV-E Administration

• The budget eliminates IV-E administrative claims
  for children in unlicensed relative homes and in
  certain facilities (detention centers, medical
  and psychiatric hospitals, etc.).
• Savings estimated to be 82 million for FY
  2006 and 457 million over five years.

10
NPRM on Title IV-E Administrative Costs

• Three major provision areas
• IV-E admin costs for children in unlicensed
  foster family homes
• Exception for placement in unlicensed relative
  caregiver homes while the relative is in the
  process of becoming licensed.
• IV-E admin costs for children in ineligible
  facilities
• One month exception to retroactively claim admin
  when IV-E eligible child placed in or returned to
  an eligible facility.
• IV-E eligibility determination and
  re-determinations for foster care and candidacy

11
Rosales

• Clarification of IV-E Eligibility based on
  Rosales
• Based on a CA case, the Rosales decision in the
  9th Circuit Court of Appeals allowed states to
  consider the IV-E eligibility home as that of a
  specified relative in whose home the child may
  have resided within 6 months of removal.
• HHS has limited the application of this decision
  to states within the jurisdiction of the 9th
  Circuit (AK, AZ, CA, HI, ID, MT, NV, OR, WA)
• The savings from this statutory amendment are
  projected to be 84 million in FY 2006 and 399
  million over five years.

12
Flexible Funding Option

• States opting-in would receive IV-E foster care
  funds in the form of a flexible grant over 5
  years
• Funds for foster care payments, prevention,
  permanency efforts, case management, admin
  activities, training, post-adoption services.
• Child protections outlined in the Adoption and
  Safe Families Act apply, MOE and continued
  participation in CFSR process required.
• Access to the TANF Contingency Fund in case of a
  severe foster care crisis.
• Cost is projected to be 36 million in FY 2006
  and budget-neutral over five years.

13
Welfare Reform

• House Ways and Means Committee approved a welfare
  reform reauthorization bill that includes the
  expansion and reform of the child welfare waiver
  authority.
• The Senate Finance Committee version includes a
  simple reauthorization of current law.
• Welfare reform law expires 6/30/05.

14
Child and Family Services Reviews (CFSRs)

• What are the results from the first round of
  CFSRs?
• Number of States in Substantial Conformity
• Safety Measures
• Children are protected from abuse and neglect 6
• Children are safely maintain in home when
  possible 6
• Permanency Measures
• Children have permanency and stability in living
  situations 0
• Continuity of family relationships/connections is
  preserved 7
• Well-Being Measures
• Families have enhanced capacity to provide for
  childrens needs 0
• Children receive services to meet their
  educational needs 16
• Children receive services to meet their physical
  and mental health needs 1

15
Child and Family Services Reviews (CFSRs)

• More Information on Results
• http//www.acf.hhs.gov/programs/cb/cwrp/results.ht
  m
• Second Round of CFSRs
• ACF held three workgroup meetings in 2004 to
  identify changes or additions to the next round
  of CFSRs.
• ACF has not yet finalized what changes will be
  made to the second round of CFSRs.
• In January 2005, ACF issued a Technical Bulletin
  indicating they are currently planning a process
  for scheduling the second round of CFSRs.

16
Child and Family Services Reviews (CFSRs)

• What are the penalties associated with CFSRs?
• The formula for calculating penalties is based in
  part on each states allocation of federal child
  welfare funds form Titles IV-B and IV-E and the
  number of outcomes and systemic factors for which
  substantial conformity has not been achieved.
• No financial penalties have been applied to date.
• According to an April 2004 GAO report
  (GAO-04-333), potential penalties could range
  from 90,000 to 18 million.

17
Title IV-E Eligibility Reviews

• What are the Title IV-E Eligibility Reviews?
• This is the second review component implemented
  by ACF in addition to the CFSRs.
• Sample of 80 cases reviewed.
• The error tolerance level is 10.
• The disallowance can be for the entire
  out-of-care episode and not limited to the
  6-month review period and applies to both
  maintenance and admin claims.
• If state has 9 or more error cases, a program
  improvement plan is developed
• A secondary review is conducted after one year
  with sample of 150 cases.

18
Title IV-E Eligibility Reviews

• States that have been reviewed through 2000-2004
• Initial Primary Review 52 (includes DC and
  Puerto Rico)
• Primary Review 15
• Secondary Review 4
• 2005 review schedule
• Primary Review 7
• Secondary Review 5
• Reasons for Disallowances in Initial Primary
  Reviews
• 53 Judicial determination documentation
• 37 Licensing documentation
• 23 IV-E eligibility determinations based on
  AFDC income, resources and deprivations
  requirements not met

19
Title IV-E Eligibility Reviews

• What are the penalties?
• Disallowance estimates
• Initial Primary Review over 6 million
• Any disallowance amounts from the secondary
  reviews (150 case sample) would be used to
  extrapolate a one-time disallowance penalty
  against the full state IV-E claim for maintenance
  and admin costs for that year which would likely
  amount to several million dollars.

20
Office of Inspector General Audits

• From 2003-2004, OIG has conducted audits and
  issued disallowances on
• Title IV-E training costs
• Title XIX Rehabilitative Treatment Services for
  foster children
• Title IV-E Adoption Assistance claims
• Estimated disallowances
• 14.5 million

21
APHSA Proposals

• Increase IV-B mandatory funding by 1 billion
• Support guardianship
• Support enhanced child welfare waiver
  flexibility
• Oppose Rosales reversal
• Oppose TCM Medicaid changes
• Oppose NPRM mandates re unlicensed caregivers
  and candidacy

22
APHSA Proposals

• Support delinking eligibility
• At minimum, update standard and create s options
  to relink to TANF or Medicaid
• Oppose administration and training block grant
• Bifurcate administrative costs into overhead and
  services
• Provide CFSR bonuses at 80/20 match