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Fiscal Essentials for Children’s Services Forum What’s at Stake in Washington, D. C. June Fiscal Essentials for Children’s Services Forum What’s at Stake in Washington, D. C. June 11, 2007

Overview l TANF l Child Care l Food Stamps l Medicaid & SCHIP l Overview l TANF l Child Care l Food Stamps l Medicaid & SCHIP l Child Welfare l National Children’s Policy Forum

TANF Deficit Reduction Act (DRA) l Included new $$ for child care funding l TANF Deficit Reduction Act (DRA) l Included new $$ for child care funding l Imposes new rigor around work requirements l Interim Final Rules limit state flexibility l Limits vocational education training to 12 months

TANF State Work Verification Plans l States to submit second round of WVP’s to TANF State Work Verification Plans l States to submit second round of WVP’s to HHS by June 29 th l First round of WVP’s resulted in no state plans being approved by HHS l Following round one, HHS released Further Work Plan Verification Guidance l Still operating under Interim Final Rules l Final Rules expected late in the year

TANF Regulations on Work Definitions l Excludes “barrier removal” activities l Narrows work experience TANF Regulations on Work Definitions l Excludes “barrier removal” activities l Narrows work experience and community service l Time limits job search and job readiness to 4 weeks (6 wks in “needy states”) l Baccalaureate education no longer counts l ABE and ESL only count when included in employment or vocational education

TANF Some State Concerns: l Final Rules release date won’t give states time to TANF Some State Concerns: l Final Rules release date won’t give states time to implement changes resulting in compliance with regulations l Attendance verification and documentation for each hour of participation is extraordinary and creates a paperwork burden l Supervised homework time imposes family stress and increased cost for child care and supervision

TANF Some State Concerns: l Excused absences must be counted in days and not TANF Some State Concerns: l Excused absences must be counted in days and not hours, unlike the real world of work l Narrow definitions of job readiness exclude activities like arranging child care and work transportation – known to be necessary for job success. l Serving individuals with multi-barriers will be difficult due to time limits and narrow interpretation of countable activities

TANF Current APHSA & NASTA Efforts: l Meeting with HHS Department of Data Collection TANF Current APHSA & NASTA Efforts: l Meeting with HHS Department of Data Collection and Analysis to develop TANF Data Reporting Work Group l Visiting Senate Finance Committee and House Ways and Means staff to inform of state concerns and request state flexibility in Final Rules l Drafting 2 nd letter to HHS clarifying state concerns and call for increased flexibility that reflects unique needs states have in administering programs

TANF Rockefeller Bill Introduced in May – S. 1461 l Senator Rockefeller (D-W. Va. TANF Rockefeller Bill Introduced in May – S. 1461 l Senator Rockefeller (D-W. Va. ) introduced a TANF penalty relief bill l Prohibits HHS from imposing state penalties for: – Failure to satisfy minimum work participation rates – Failure to comply with work participation verification procedures l Penalty relief is for a 12 month period beginning on the date of HHS approval of the State’s work verification plan

TANF Smith Bill Being Introduced This Week or Next: l Senator Smith plans to TANF Smith Bill Being Introduced This Week or Next: l Senator Smith plans to introduce Pathways to Independence TANF bill l Brings TANF in line with ADA obligations l Adjusts federal work participation requirements so that state could get credit when individuals with disabilities participate in work-related activities – Even if activities or the number of hours do not match current TANF requirements

Child Care l Child Care Development Fund Reauthorization l Head Start Reauthorization l Notice Child Care l Child Care Development Fund Reauthorization l Head Start Reauthorization l Notice of Proposed Rulemaking on Improper Payments in the Child Care Program

Food Stamps Food Stamp Program will be reauthorized in the farm bill – on Food Stamps Food Stamp Program will be reauthorized in the farm bill – on time (by 9 -30 -07) as far as we know l Good news: program is doing well and enjoys wide support l Bad news: funding is a serious problem; new Ag spending of $20 B (House) and $15 B (Senate) is on the table, but uncertain how it will be allocated among Ag programs l New Congress, new Agriculture Committee chairs, new members – challenge AND opportunity for education and reminders l

Food Stamps l APHSA has again joined with FRAC and ASH – our common Food Stamps l APHSA has again joined with FRAC and ASH – our common agenda: – Expand access – Continue to simplify and streamline the program – Improve adequacy of benefits l Major proposals so far: Administration – – – Exclude combat pay and certain savings accounts New name: Food and Nutrition Program Restrict categorical eligibility; terminate CSFP New penalty for high negative errors New reinvestment restrictions Automated system overissuances: restrictions and penalties

Food Stamps Nutrition community stakeholders support H. R. 2129 and several other bills that Food Stamps Nutrition community stakeholders support H. R. 2129 and several other bills that have similar benefit increases l House and Senate Ag committees seem focused largely on farm issues so far l l HOUSE SUBCOMMITTEE MARKUP EXPECTED WEEK OF JUNE 11

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 1. As measured Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 1. As measured by expenditures, Medicaid is America’s largest single health and longterm care program. – Medicaid accounted for 16. 5% of all U. S. health care spending in 2005. – Total federal Medicaid spending in FY 2005 was $313. 1 billion.

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 2. Medicaid is Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 2. Medicaid is efficient compared to private health coverage – Between 2000 -2004, Medicaid per capita growth in spending was 6. 4% for acute care and 4. 2% for long term care. – For private health insurance the per capita spending growth rate was 9. 5% for acute care during this period. – Medicaid administrative costs are in the range of 4 to 6% while commercial insurers admin costs are often well above 10%.

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 3. The rate Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 3. The rate of growth in Medicaid spending has slowed since 2000. – The rate of Medicaid spending increased 7. 2 percent in 2005—the fourth consecutive year of decelerating growth. – Federal Medicaid spending declined in FY 2006 for the first time in history. – Preliminary data for the first three months of FY 2007 indicate that the leveling off of spending is continuing into FY 2007.

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 l l l Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 l l l Greater use of home and community based care programs and services Stronger economy driving enrollment declines Increased fraud and abuse control activities Focus on disease and case management programs especially for disabled and elderly populations. Dramatic decreases in Medicaid prescription drug spending, including increased use of generic drug and pharmacy cost and usage controls

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 4. As measured Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 4. As measured by enrollment, Medicaid provides health and long-term care coverage for more individuals than any other program — 57 million Americans -27 million children -14 million low-income uninsured adults -16. 5 million individuals with disabilities and elderly

Medicaid & SCHIP Medicaid Spending on Categories of Enrollees Elderly 9% Blind & Disabled Medicaid & SCHIP Medicaid Spending on Categories of Enrollees Elderly 9% Blind & Disabled 17% Adults 26% Children 48% 2006 U. S. Total = 59. 7 million Elderly 23% Blind & Disabled 46% Adults 13% Children 19% U. S. Total = $299 billion in 2006 Note: Expenditure distribution based on spending only on services. Excludes DSH, supplemental provider payments, vaccines for children, and administration. SOURCE: Health Management Associates estimates based on CBO Medicaid Baseline, March 2006.

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 5. Medicaid is Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 5. Medicaid is the single largest source of funding for long-term care in the U. S. – Long-term care services can include nursing facility care, assisted living, hospice care, and home and community based services such as home health care, case management, personal care, and private duty nursing services.

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 6. Medicaid fills Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 6. Medicaid fills the gaps in Medicare – 7 million “dual eligibles” -- Low-income seniors and disabled, who quality for Medicaid in addition to Medicare – 42% of all Medicaid expenditures are for individuals who are also on Medicare. – Part D is operating below budget estimates at the same time that state “clawback” payments are increasing

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 7. Changes in Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 7. Changes in the economy and employer sponsored market are impacting Medicaid – Increases in Medicaid and SCHIP enrollment since 2001 have helped offset declines in employer-based coverage. – The downturn in the economy forced some states to implement cost containment measures between 2002 and 2005 that contributed to the deceleration in the rate of spending.

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 8. Medicaid is Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 8. Medicaid is a cornerstone of states’ initiatives to expand health care coverage and control costs – Between 2001 and 2005 the number of uninsured increased from 41 million to nearly 47 million. – Between 2004 and 2005, the number of uninsured children increased by 1. 5 million. – Since early 2006, 14 states have or plan to pursue health coverage expansions.

Medicaid & SCHIP Broad State Coverage Initiatives—including kids l l l l Alaska California Medicaid & SCHIP Broad State Coverage Initiatives—including kids l l l l Alaska California Connecticut Illinois Massachusetts Minnesota New York l l l New Mexico Oregon Pennsylvania Rhode Island Vermont Washington

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 9. Deficit Reduction Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 9. Deficit Reduction Act of 2005 (DRA) provides new opportunities to strengthen Medicaid – Increases transparency in prescription drug pricing – Creates incentives for purchase of long-term care insurance and eliminates abuse of asset policies – Invests resources to strengthen Medicaid integrity – Grants new state flexibility to develop more appropriate cost sharing rules and benefit packages – Imposes new limits on state financing, including on MCO provider taxes and targeted case management

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 l The President’s Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 l The President’s budget includes significant cost savings proposals: – $13 billion in legislative proposals over 5 years – $12. 7 billion in regulatory proposals over 5 years l The Administration’s FY 2008 proposed regulatory proposals include: – Prohibit Medicaid reimbursement for school-based administration and transportation expenses – Prohibit Medicaid reimbursement for graduate medical education (GME) for providers – Clarify reimbursement policies for rehabilitation services – Reform payment to government providers

Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 10. Medicaid serves Medicaid & SCHIP 10 Things to Know about Medicaid in 2007 10. Medicaid serves as the foundation upon which states design and implement their SCHIP programs. – States design their SCHIP programs to provide coverage to low-income individuals at the point where state Medicaid eligibility rules end.

Medicaid & SCHIP Quick Facts about SCHIP 1. The State Children's Health Insurance Program Medicaid & SCHIP Quick Facts about SCHIP 1. The State Children's Health Insurance Program (SCHIP) is jointly financed by the federal and state governments and is administered by the states. – Within broad federal guidelines, each state determines the design of its program, eligibility groups, benefit packages, payment levels for coverage, and administrative and operating procedures.

Medicaid & SCHIP Quick Facts about SCHIP 2. States can design their SCHIP program Medicaid & SCHIP Quick Facts about SCHIP 2. States can design their SCHIP program in three ways. l Stand-Alone Program l Medicaid Expansion Program l Combination Program

Medicaid & SCHIP Quick Facts about SCHIP 3. States must consider a range of Medicaid & SCHIP Quick Facts about SCHIP 3. States must consider a range of factors when choosing their program type – State budget constraints – Insurance market – Health care provider system – Appropriate agency to administer – Eligibility criteria that meets the needs of the state and its demographics

Medicaid & SCHIP Quick Facts about SCHIP 5. SCHIP and Medicaid covered populations are Medicaid & SCHIP Quick Facts about SCHIP 5. SCHIP and Medicaid covered populations are somewhat different. l l l l Medicaid § SSI Recipients Children under age 6 and pregnant women whose family § income is ≤ 133% FPL § Children under age 19 and born after 9/30/83 in families with incomes ≤ FPL § Infants born to Medicaid-eligible women Recipients of adoption assistance and foster care Certain people with Medicare Others SCHIP Targeted towards uninsured lowincome children Limited to children under 19, unless state has a waiver Generally targeted to children from families earning up to 200% FPL, unless state has a waiver Applicants must be uninsured at the time of application, not eligible for Medicaid or state employee coverage through a parent, and must not be a resident of a state institution

Medicaid & SCHIP Quick Facts about SCHIP 6. The benefits for Medicaid and SCHIP Medicaid & SCHIP Quick Facts about SCHIP 6. The benefits for Medicaid and SCHIP differ. Medicaid l Mandatory services must be offered by all states l Under DRA may offer new benefit flexibility l SCHIP l Medicaid expansion services provided under SCHIP mirror Medicaid services l Stand alone: 3 coverage options

Medicaid & SCHIP Quick Facts about SCHIP 7. There are different match rates for Medicaid & SCHIP Quick Facts about SCHIP 7. There are different match rates for Medicaid and SCHIP. Medicaid l Federal match rates range from 50 -76 percent l SCHIP l Programs receive an enhanced match rate ranging from 65 -85 percent

Medicaid & SCHIP Quick Facts about SCHIP 8. There are different rules for administrative Medicaid & SCHIP Quick Facts about SCHIP 8. There are different rules for administrative expenditures in Medicaid and SCHIP. Medicaid l No cap on administrative expenditures l SCHIP l 10 percent limit on certain expenditures related to administration, outreach, and other child health assistance and initiatives

Medicaid & SCHIP Quick Facts about SCHIP 9. Public employees are treated differently in Medicaid & SCHIP Quick Facts about SCHIP 9. Public employees are treated differently in Medicaid and SCHIP Medicaid l Statute explicitly l Allows for qualifying excludes dependents of state employees from employees to be eligible enrolling in the SCHIP for and receive program, regardless of Medicaid coverage their income eligibility l

Medicaid & SCHIP Quick Facts about SCHIP l SCHIP spending was initially low, but Medicaid & SCHIP Quick Facts about SCHIP l SCHIP spending was initially low, but now a growing number of states are experiencing shortfalls in funding for their program. – “Redistribution” of funds has helped to alleviate shortfalls, but the pool of available funds continues to shrink as programs mature. – 14 states are expected to face shortfalls in FY 2007.

Medicaid & SCHIP Quick Facts about SCHIP l Annual Funding Uncertainty l New Proposed Medicaid & SCHIP Quick Facts about SCHIP l Annual Funding Uncertainty l New Proposed Rules l Transitional Medical Assistance l Coverage of Targeted Populations l Fund Redistribution l Support of Employer Sponsored Insurance

Medicaid & SCHIP Federal Regulatory Issues l l l l PERM Capping payments to Medicaid & SCHIP Federal Regulatory Issues l l l l PERM Capping payments to government providers DSH payments Targeted Case Management Provider Taxes Citizenship documentation Rehabilitation Option GME

Medicaid & SCHIP Congressional Actions l SCHIP shortfall l SCHIP reauthorization l Part D Medicaid & SCHIP Congressional Actions l SCHIP shortfall l SCHIP reauthorization l Part D sharing of information l Medicare Part D data sharing l Health care expansion l Electronic health records/HIT l DSH redistribution legislation

Child Welfare FEB 2006 Deficit Reduction Act JUL 2006 Safe & Timely Interstate Placement Child Welfare FEB 2006 Deficit Reduction Act JUL 2006 Safe & Timely Interstate Placement Act Adam Walsh Act SEPT 2006 DEC 2006 Child & Family Svcs Imp Act Tax Relief & Health Care Act 109 th Congress – 2 nd Session

Child Welfare LEGISLATION INTRODUCED IN THE 110 th Congress: l Foster Children Self-Support Act Child Welfare LEGISLATION INTRODUCED IN THE 110 th Congress: l Foster Children Self-Support Act (HR 1104) l Kinship Caregiver Support Act (S 661) l Keeping Families Together Act (HR 687/S 382)

Child Welfare l Regulations in Proposed Rule Stage – AFCARS: new data reporting on Child Welfare l Regulations in Proposed Rule Stage – AFCARS: new data reporting on children in foster care, subsidized adoption and subsidized guardianship arrangements; penalty requirements l NPRM expected in December 2007 – Privatizing Functions: Addresses states’ ability to delegate some decision making authority to private agencies performing admin functions and the availability of foster care training funds l NPRM expected in December 2007

Child Welfare l Regulations in Proposed Rule Stage – Rehabilitation Option: amends the definition Child Welfare l Regulations in Proposed Rule Stage – Rehabilitation Option: amends the definition to exclude services furnished by other non-Medicaid services from federal, state or local programs including foster care, child welfare, and juvenile justice l NPRM expected in the summer – Chafee National Youth in Transition Database: requires states to collect data on youth receiving IL services and outcomes of youth who have aged out of foster care l Final action expected in March 2008

Child Welfare Upcoming Congressional Action l Mc. Kinney-Vento Reauthorization – Recommendations by advocates: l Child Welfare Upcoming Congressional Action l Mc. Kinney-Vento Reauthorization – Recommendations by advocates: l Include all children and youth in out of home care for eligibility for the full range of education protections, rights and supports l Clarify who can make education decisions for children and youth in out of home care l For children and youth in the custody of the child welfare agency in out of home care, notice of school of origin decisions, appeals, and transportation that are provided to the decision-maker, should additionally be given to the child welfare agency and the court of jurisdiction l Increase funding levels to $210 M

Child Welfare: Joint Financing Recommendations l Partners: NATIONAL CHILD ABUSE COALITION Child Welfare: Joint Financing Recommendations l Partners: NATIONAL CHILD ABUSE COALITION

Child Welfare: Joint Financing Recommendations 1. 2. 3. Guarantee services, supports and safe homes Child Welfare: Joint Financing Recommendations 1. 2. 3. Guarantee services, supports and safe homes for every child who is at-risk of being or has been abused or neglected by strengthening the federal-state child welfare partnership by amending the federal Title IVE statute to do the following without converting any of Title IV-E to a block grant Promote program effectiveness Enhance accountability

National Children’s Policy Forum Purpose: designed to address the informational needs of key decision-makers National Children’s Policy Forum Purpose: designed to address the informational needs of key decision-makers and provide a safe harbor for open and frank conversations l Advisory Committee: representatives of the policy staff from key Congressional committees, U. S. Department of Health and Human Services, select Congressional support agencies, NGA, NCSL and key child welfare leaders l Site Visits for Congressional Staff l

CONTACT INFORMATION TANF: Linda Lawson, Senior Policy Associate – llawson@aphsa. org Food Stamps: Larry CONTACT INFORMATION TANF: Linda Lawson, Senior Policy Associate – [email protected] org Food Stamps: Larry Goolsby, Senior Policy Associate – [email protected] org Child Care: Rachel Demma, Policy Associate – [email protected] org Medicaid: Martha Roherty, Director, NASMD – [email protected] org Andrea Maresca, Senior Health Policy Associate, NASMD – [email protected] org Child Welfare: Sonali Patel, Senior Policy Associate & Director of the National Children’s Policy Forum – [email protected] org APHSA: (202) 682 -0100