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HOUSE BILL 966 REPORTSubmitted by HEALTH AND HUMAN SERVICES COMMISSION Don A. Gilbert October 25, 2002 TABLE OF CONTENTS I. Quantification of Money Appropriated for Institutional Care
II. Implications Related to Redirection of Funds By
Agency IIA. Common Agency Implications
IIIA. Other Related Statutes IV. Stakeholder Input and Recommendations VI. Appendix B, TDPRS Specifics HB 966 Report, Recommendations, and
Discussions of Feasibility During the 77th Legislative Session House Bill 966 was passed, which required the Health and Human Services Commission (HHSC) to undertake the development of a study related to the redirection of all or part of the funds appropriated to care for a person who is receiving institutional care to community services. In order to meet the requirements of the legislative mandate, the HHSC formed a workgroup of staff from those affected agencies to collect the initial necessary information and examine implications from a fiscal standpoint. The workgroup undertook tasks required by HB 966, which were to "study ways in which the health and human services agencies may:
Additionally, the Commission and the workgroup were required to " consider ways in which the money may be redirected under existing law, whether the money could be redirected in advisable ways if changes were made in the General Appropriations Act, and advisable ways in which the money could be redirected that would require changes in general law." Agencies who participated in the workgroup as approved by the legislative liaison to the House Human Services Committee were: The Texas Department of Mental Health and Mental Retardation (TDMHMR), The Texas Department of Protective and Regulatory Services (TDPRS), and the Texas Department of Human Services (TDHS). These agencies are in some part responsible for the institutions named
in the legislation.
Although TDHS currently is required through Rider 37, of the 77th Legislature, to allow funds to follow an individual to community-based services from nursing home care, the Commission has included in this report data, knowledge and information TDHS has received from initial implementation of Rider 37. The current status of services within the state relevant to institutions and community care may be best described through the numbers of individuals served in these programs and the state's commitment to services as it relates to Medicaid. Throughout the report the term "institution" is used as defined in Government Code 531.151 to include all Intermediate Care Facilities for Persons with Mental Retardation (ICFs/MR), as defined by Section 531.002 Health and Safety Code, all Nursing Facilities (NFs), and all facilities for individuals with mental retardation licensed by TDPRS. Currently, TDMHMR serves 5,071 individuals within the State Mental Retardation Facilities (SMRFs), 7,519 individuals within community ICF/MR programs, 4,130 individuals within the Home and Community Based (HCS) waiver, 2,297 individuals within the Mental Retardation Local Authority (MRLA) waiver, and 72 individuals within the Home and Community Based- Omnibus Budget Reconciliation Act (HCS-OBRA) waiver. TDHS serves 61, 363 individuals on average each month in NFs; 30,040 individuals within the Community Based Alternative (CBA) waiver; 1,492 individuals within the Community Living Assistance and Support Services (CLASS) waiver; 925 individuals within the Medically Dependent Children's Program (MDCP) waiver; 118 individuals within the Deaf-Blind- Multiple Disabilities (DB-MD) waiver; and 116 individuals within the Consolidated Waiver (CWP) Pilot. TDPRS provides protective services, including out of home care, to children who have been abused and neglected. Of the children who are in foster care placement in a child care institution, a monthly average of 113 children in the conservatorship of TDPRS are placed in two Institutions for the Mentally Retarded licensed by TDPRS. Medicaid clients who have a medical necessity, which would require a State Plan service, are entitled under federal law to receive these services. State Plan services include ICF/MR and Nursing Facility (NF) care. The total size of the ICF/MR program in Texas is set by the HHSC Long-term Care Plan for People with Mental Retardation and Related Conditions. There are no specific federal requirements regarding the number of ICF/MR beds to be included in the Long-term Care Plan. However, federal regulations speak to timely availability of services. As beds are removed from the program the state's ability to meet that requirement may be compromised. Waiver programs have limited capacity and people are not entitled to receive these services. The capacity of waivers and the additional services offered by waivers are approved by the federal Medicaid agency (Centers for Medicare and Medicaid Service -CMS). They are different in each waiver. Waiver services may target specific populations and geographic areas of the state. The TDMHMR has received questions related to cost data specific to children within its programs. This data is currently unavailable because level of need (LON) and size of setting (number of beds) drive the rate paid for services in the various programs, rather than age. In the ICF/MR program, individuals do not have ability to move within the system of providers as they do in the waiver programs because they do not own the "bed" they occupy. Their ability to move to different providers is also limited by the high occupancy rates in the program and the fact that the Long-term Care Plan sets the number of ICF/MR beds and the capacity of waiver programs. Within the waiver services, the individual owns the "slot" and can move freely within the system of providers in the state. As indicated by the numbers reported below, the wait for community services is long and frustrating for many individuals and their families. Therefore, it is imperative that funding alternatives are examined thoroughly in this report, as required by HB966. The current waiting list for each of the state's community service waivers is as follows:
The HB 966 report begins with the quantification of appropriated funds spent to care for individuals in institutions operated by the state, as well as current agency performance measures that indicate the average cost per person in an institution. The second table, related to performance measures, also includes notes, which indicate the costs that are not included in the average. The report continues with issues of implications, by agency, related to the re-direction of funds to community-based programs. The issues cover fiscal implications, programmatic implications, and common implications to all agencies. The report contains information related to the requirements in the General Appropriations Act (GAA) and the current general laws that would be affected by redirection of these appropriated funds. The report concludes with recommendations from agency staff and stakeholders in order for the legislature to see the various opinions, recommendations, and input from those affected by decisions related to money being re-directed to community services. These comments were received in individual stakeholder meetings and a final public comment meeting. These meetings occurred throughout the spring and summer. Two appendices are also included which provide information specific to the methods of finance and the information regarding the quantification of appropriated monies. <<back to top>>
<<back to top>> II: IMPLICATIONS RELATED TO REDIRECTION OF FUNDS BY AGENCY TDMHMR:MR:
Vacancy Issues Regarding the ICF/MR Program Issue: Community-based ICFs/MR are operating at a 98% occupancy level. TDMHMR reports that large facilities have 0.67% vacancy rate, medium facilities have a 1.64% vacancy rate, and small facilities have the lowest vacancy rate. Thus, when a consumer moves from an ICF/MR setting to the community, the ICF/MR bed vacancy is usually quickly filled. This results in an increase in the number of people served without any increase in financing. If the bed vacancy is not open to being refilled, some facilities may close producing a shortage in the availability of ICF/MR beds. If the state closes beds as they become vacant and continues to limit the number of beds through the Long-term Care Plan, the effect is a downward trend in ICF/MR beds. A plan to close vacant beds must consider the stability of the ICF/MR provider community and the need for a planned and financially supported transition if this option is chosen. Infrastructure and Overhead of SMRFs Issue: When individuals moving to community settings statewide or through attrition decrease the SMRF census, each individual facility will not see immediate cost savings. This is true for community-based ICF/MR providers of any size, where the reimbursement rates vary based on the size of the facility. All costs to operate a facility are factored into the rates, including physical plant operations. A small number of people leaving an institution will not reduce certain fixed cost such as:
It is likely that the cost per individual will actually increase, and will be reflected in a higher rate of reimbursement. Budgets for the SMRFs must be maintained in a manner to provide services to existing clients and meet certification requirements in order to maintain federal match dollars. However, TDMHMR may need to submit a plan for balancing costs if a large-scale decrease in census occurs. Potential cost savings to the state may exist via the reduction of state jobs and state benefits, as the largest ICF/MR institutions are operated by the state. If the state chooses to consolidate or shift existing institutional care to community care, state jobs could be maintained if the state were to become a provider of services in the community. Unit Cost Increase Issue: As bed reductions occur in the ICF/MR program the unit cost for these facilities will increase. Many facilities, as previously noted, will not see fiscal efficiencies with a gradual decrease in clients. Additionally, the State would need to revise the Long-term Care Plan, and amend the waivers to include increase and/or decrease in numbers of individuals served as required by law. Viability of Private ICF/MR Providers Issue: Incremental reductions in census to a facility reduces the revenue for that provider. Providers will need to refill bed vacancies, be reimbursed at a higher unit cost to maintain their revenue, or need other interim supports. TDMHMR would need to manage this process and additional dollars may be needed to assist facilities to transition to a decreased bed size or closure. State Cost Outside of TDMHMR's Budget Issue: If money were to follow the consumer in the TDMHMR budget, the amount would be based on the cost of the services on the individual's plan of care. But other state costs exist to maintain the SMRFs that are not reflected in the TDMHMR budget and would not be considered as available to follow the consumer. Items such as retirement, health insurance and workers compensation amount to over $30 million GR and $90 million in all funds annually. Dollars to retain staff at facilities would need to be maintained in the state's budget, until decreases in these costs are realized. Breakeven Point Issue: The economics of reducing SMRFs census and increasing community care capacity will have higher cost implications initially. However, at some time a breakeven point will be realized in which costs should start to decrease. Therefore, a long-term management plan by TDMHMR to facilitate facility transitions and reductions in staffing would be needed. The more quickly services/jobs can be shifted to the community the sooner the state can scale down SMRF expenses and achieve cost neutrality. TDMHMR indicates that initial upfront expenditures may be necessary in order to shift services to the community. The experiences of Fort Worth State School and Travis State School could provide data related to these upfront costs. TDMHMR should study the long-range savings that may be accrued over time, after the initial upfront costs are paid during a facility's transition from institutional to community services. TDMHMR reports that the cost to place all consumers from a large ICF/MR facility into waiver services is roughly 30% more because the reimbursement rate for large community ICFs/MR is their lowest rate paid for ICF/MR services. Additionally, the costs associated with closing such facilities depend upon the circumstances that cause the closure. The TDMHMR has assisted in closing several large ICF/MR facilities when owners have voluntarily closed, when owners were having regulatory difficulties and no longer wanted to provide services in the large facility, and when the facility has been decertified and TDHS has placed a Trustee in charge of the facility. In each of these situations, the TDMHMR has attempted to offer a choice of service alternatives to families, guardians, and consumers. The service choice has been generally either waiver services or other ICF/MR services. In some instances, admission to nursing facilities has also provided a resource to the consumer, family, and/or guardian. Generally, closures use resources (vacancies) that are available in the ICF/MR program. Such closures have resulted in large ICF/MR providers filling otherwise vacant beds. Waiver providers have developed new resources in local areas in order to offer options for consumers or in some cases have been able to fill unused capacity in existing waiver programs. Each closure has been different. However, the recent trend has been to utilize waiver services to provide many consumers an alternative to ICFs/MR and use the ICF/MR allocation to pay for a bed converted to waiver services. There are frequently issues with family involvement such as not being able to locate families and consent issues when there is no guardian or family. Regarding SMRF closures, the TDMHMR learned several things from the experiences of Travis State School and Fort Worth State School. It takes additional time and effort to work with family members and consumers in providing an appropriate alternative setting. Extraordinary planning is required for people who have extensive behavioral and medical needs. Maintaining appropriate staffing requires additional costs as the facility is consolidated. TDPRS:
Method of Finance Issue: As children move from an institutional setting to a community setting within the current TDPRS system, the method of finance used to fund a child's foster care placement will change. Unlike an agency using one federal funding source such as Medicaid to fund services, TDPRS funds foster care placements with TANF (Temporary Assistance for Needy Families/Emergency Assistance), Title IV-E Foster Care, and General Revenue. Each federal funding source has a unique set of matching requirements and potential allowable expenses. If the plan for the child is to move from an institution within the TDPRS system to a community- based Medicaid waiver program there can be no assumption that the amount of GR used in the Method of Finance (MOF) for the institutional setting will be the same as in the community setting. Issue: Services vary across the state. As children change placements or as foster care families move, waiver services may not be available or accessible even though the child's eligibility for services continues. The money following the clients will affect the total method of financing for the agency; therefore the state may see an increase in GR funding as the money follows the client in this system. TDPRS already monitors its complex method of financing as it pertains to Foster Care and Adoption Subsidies. Small incremental movement of clients will not have an effect on the overall financing. However, TDPRS would need to project the long-term financing changes for the agency. There are two important points - one is that the child remains eligible for federal funding under TANF or IV-E without regard to the placement type; however, each federal program identifies the type and amount of expenses for which Federal Financial Participation is offered. The MOF for each type of placement will differ. Also, if the child is not eligible for either TANF or Title IV-E, then the agency uses GR to pay for foster care placement. This GR would then be available in the new waiver setting to meet the required Medicaid match. If the child were eligible under TANF and IV-E, then only the IV-E GR - Match would be available for match in the new waiver setting. The TANF funds are 100% federal and could not be used as Medicaid match. It is also important to note that TDPRS remains responsible for a child's care regardless of the child's placement type. The agency will continue to incur expenses related to the child's overall care even when the child is placed within a community based Medicaid waiver program. Another implication related to redirection of TDPRS funds concerns when children age out of TDPRS services. If funds follow the child to purchase a waiver service from another agency, upon the child reaching the age of 18, they would no longer be eligible for TDPRS services. Therefore, TDPRS funds, which were purchasing other agency waiver services, would no longer be available, causing a cost shift to that existing agency requiring them to use their own general revenue, in order to continue to provide waiver services to the child. TDHS:
Viability of Nursing Home Industry Issue: Incremental reductions to nursing homes reduce the revenue for that provider. The occupancy level in nursing homes is already at 76% and reducing this further will produce higher unit cost and closures. TDHS is currently managing the viability of the nursing home industry to the extent possible. Current Experiences: Rider 37 has been in effect only since September 1, 2002. TDHS Rider 37 is entitled Promoting Independence. The Rider states, "It is the intent of the legislature that as clients relocate from nursing facilities to community care services, funds will be transferred from Nursing Facilities to Community Care Services to cover the cost of the shift in services." TDHS is collecting data regarding this Rider as to the disability specific information, costs, and other demographics such as what community services the consumer is accessing, how long was the individual in the nursing facility before they accessed the community services, etc. As of July 31, 2002, 815 consumers accessed the CBA waiver by using Rider 37. All of these consumers were under the TILE (Texas Index Level of Effort) when they were approved for CBA and since Rider 7 provisions apply only to approved waiver recipients, TDHS denies applicants that exceed the cost ceiling. In order to accomplish the Rider 37 relocations, TDHS caseworkers, who have other Community Care for the Aged and Disabled (CCAD) responsibilities, provided this service. This was necessary since no new funding was allocated for additional staff to perform Rider 37 relocations. Approximately 40% of the individuals who qualified under Rider 37 moved into assisted living facilities (AL), probably because they no longer had a home in the community or had no family to assist them. If there is no family or other natural supports to provide some care, the expense to the waiver can be so great that the client is denied eligibility. Also, many NF residents with no informal supports will choose to move to an AL facility if CBA services in a private home are denied due to cost. AL is often more cost effective than paying an attendant to provide care in the individual's own home. Early estimates show the average annual CBA waiver costs of Rider 37 clients are less than the average costs of other CBA clients. The cost may be less because the 40% who move to an Assisted Living (AL) pay a co-payment (applied income), thereby lowering the Medicaid costs. TDHS Rider 7 was also passed during the 77th Session of the legislature. This rider included several elements as follows:
TDHS has included the following data related to consumers who have utilized Rider 7, which provides information related to costs of services and costs to TDHS due to the implementation of Rider 7. As of 8/24/02 the data is as follows: CBA WAIVER: 194 individuals accessed Rider 7, with an overall average of $12,205.00 over the cost ceiling. This is based on an estimated annual plan of care. The breakdown of these 194 consumers is as follows:
CLASS WAIVER: There were 45 individuals who accessed Rider 7, with an overall average of $3,769.31 over the annual cost ceiling of $63,360.00 (All CLASS participants have the same cost ceiling.)
DEAF/BLIND WAIVER: There were 3 individuals who accessed Rider 7, with an overall average of $22,000 over the annual cost ceiling of $59,750.00
Future Implications TDHS is in the process of adding Transition Services as a service in all waivers. This service will pay for a new provider base to help transition people out of the NF. Under Transition Services, TDHS will pay a fixed monthly amount for up to 6 months while arrangements are being made to move the NF resident into the community and will also pay up to $2,500 for one-time relocation expenses, such as utility deposits. If Transition Services are added, many providers, such as independent living centers, will contract with TDHS to provide this service. If TDHS contracts with providers to help move people out of NFs, it is expected that more clients will qualify for waiver services. Contracted transition services will require funding not only for those services, but also for additional contract managers to manage the transition services contracts and additional case managers for the new community care clients moving out of NFs. TDHS reports that providers have noted that the waiver population is changing, as more frail clients with higher levels of acuity move out of institutions to the community. Assuring the clients' health and safety in the community is a concern expressed by providers. 1915(C) waivers require that the state guarantee the health and safety of individuals within these waivers. Health Care Support Service Agency (HCSSA) licensing regulations state that agencies cannot accept a client if his or her medical, social, and nursing needs cannot be met in the community. Locating care providers is an ongoing problem. <<back to top>> IIA. COMMON AGENCY IMPLICATIONS Redirection of funds from institutions to community - based care, following the choice of the consumer:
<<back to top>> No statutory barriers to the concept of dollars following the consumer were found and thus there are no recommendations regarding statutory changes. There are legislative intent riders that would need review to determine if they inhibit dollars following the consumer. Related Riders in the Current General Appropriations Act:
Analysis of the General Appropriations Act and the "Money Following the Client"The General Appropriations Act (GAA) does not include any language that directly prohibits institutional money from following the client to community care. However, a TDPRS rider does restrict Foster Care/ Adoption Payments from being transferred to other strategies. This could have an affect on the money following the client, depending on what type of community care services the client moves into and the financing attached. The GAA contains one new rider (Rider 37, TDHS, Article II, SB1, 77th Session) that explicitly allows the money to follow the client from nursing facilities to community care. Additionally, a rider does exist that explicitly prohibits money from following a client from community care services to an institution (Rider 22, Special Provision, Article II, SB1, 77th Session). TDHS Rider 37: Promoting Independence. It is the intent of the legislature that as clients relocate from nursing facilities to community care services, funds will be transferred from Nursing Facilities to Community Care Services to cover the cost of the shift in services. Special Provisions Sec. 22. Limitation on Appropriations for Long-term Care Waiver Slots. None of the funds appropriated above to the Department of Human Services and the Department of Mental Health and Mental Retardation for long-term care waiver slots may be utilized for purposes other than: a. the establishment and maintenance of long-term care waiver slots; b. the provision of wraparound services, as identified in the Health and Human Services Commission Consolidated Budget for 2002-03 that are specifically associated with such slots and that relate to transitional services, access to immediate housing, and transportation services; or * c. contingent upon the enactment of House Bill 1213 or similar legislation, the development of family-based alternatives for children leaving institutions. This provision applies to funds appropriated for the Home and Community-based Services (HCS) waiver program at the Department of Mental Health and Mental Retardation and the following waiver programs at the Department of Human Services: Community-based Alternatives (CBA), Community Living Assistance and Support Services (CLASS), Medically Dependent Children's Program (MDCP) and Deaf-Blind with Multiple Disabilities Waiver. TDPRS Rider 7. Foster Care Rates. It is the intent of the Legislature that the Department of Protective and Regulatory Services not reduce foster care rates during the 2002-03 biennium. The department may transfer funds into Strategy A.1.5, Foster Care/Adoption Payments, for the purpose of maintaining foster care rates. The department may not transfer funds out of Strategy A.1.5, Foster Care/Adoption Payments. The department may also use funds in Strategy A.1.5, Foster Care/Adoption Payments, to recommend alternate service provision intake and investigation that will consider expansion of contract services, regional planning, service outcomes, and appropriate funding mechanisms to be tested in pilot projects. Such pilot approaches to innovative service delivery shall be designed in conjunction with providers, approved by the Health and Human Services Commission, and funded at no increased cost to the State. The department may include a modification of rates for existing and new pilot approaches implemented in this manner. The majority of GAA riders allow for oversight of the process by requiring prior approval for various funding transfers. In addition to providing oversight, many of the riders will allow oversight and leadership offices to restrict and/or limit the process of the money following the client. The riders listed below enable leadership offices to monitor and /or restrict the money following the client. SB1, Art II, HHSC RidersHHSC Rider 13. Medicaid and Other Reporting Requirements. None of the funds appropriated by this Act to the Health and Human Services Commission may be expended or distributed by the Commission unless:
HHSC Rider 29. Medicaid and Other Reporting Requirements.
SB1, Art II, TDMHMR RidersTDMHMR Rider 2. Limitation of Specific Strategy Transfers. The transfer of appropriations from Strategy B.1.1, Mental Health State Hospital Services, to any other strategy is limited to 10 percent and the transfer of appropriations from Strategy D.1.1, State School Services, to any other strategy is limited to 5 percent without the prior approval of the Legislative Budget Board and the Governor. TDMHMR Rider 13. Home and Community-Based Services (HCS) Waiver Program. The department shall ensure the cost-effectiveness of the HCS program by limiting the average annual HCS expenditure per client to 80 percent of the average annual per client ICF-MR expenditure. Expenditures for individual clients may exceed this cap as long as the overall average expenditure for HCS clients remains below 80 percent of the annual average. Furthermore, it is the intent of the Legislature that, in order to increase the number of clients served, the overall average monthly expenditure per client shall not exceed $3,511 per month in fiscal years 2002 and 2003. The Department of Mental Health and Mental Retardation and the Health and Human Services Commission shall report to the Legislative Budget Board and Governor by October 1of each year of the biennium, on the measures taken to decrease the average cost per person and to increase the number of clients served in the HCS program. TDMHMR Rider 16. Enhanced Equity. It is the intent of the Legislature that the Department of Mental Health and Mental Retardation shall distribute any funds appropriated for the purpose of expanding or improving services in Strategies A.1.2, Adult MH Community Services, and C.1.2, MR Community Services for community mental health and community mental retardation and for addressing the waiting list in Strategy C.1.4, MR Home and Community-based Services, by applying the allocation methodology recommended in the department's Equity Task Force Report until all local authorities are brought up to the state average in per capita funding. The Equity Task Force Report was adopted by the board and submitted to the Legislature in December of 2000. Allocations to local mental health and mental retardation authorities shall not be reduced for the purpose of redistribution to other authorities to enhance equity. The department shall evaluate its progress at enhancing equity in funding and provide an impact analysis of any change to the previous year's funding, by local authority, to the Legislative Budget Board and the Governor. This report shall be submitted by January 15 of each year of the biennium. TDMHMR Rider 17. State School Funding. It is the intent of the Legislature that the department implement a single funding methodology for state schools which funds all state schools equitably and at a level which is adequate to maintain compliance with applicable federal standards. The methodology should be based on the number of residents in each school and the needs of those residents. TDMHMR Rider 26. State School Funding and Staffing Levels. It is the intent of the legislature that funding for state schools shall be based on the number of residents in each state school at the beginning of the fiscal year and the needs of those residents. Staffing patterns at state schools shall not reflect a census decline until a campus has realized a decline in census. TDMHMR Rider 54. Residential Providers. It is the intent of the Legislature that individuals seeking residential services for a person with mental retardation have a choice of available providers. To ensure choice, the agency shall inform individuals seeking residential services of all the service options available, including large and small congregate living arrangements and waiver services. TDMHMR Rider 55. Placement Options. An individual with mental retardation or an individual's legally authorized representative seeking residential services shall receive a clear explanation of programs and services for which the individual is determined to be eligible, including state schools, community ICFs-MR, 1915(c) waiver services or other services. The programs and services that are explained shall be documented in the individual's record and acknowledged in writing by the individual or the individual's legally authorized representative. If the chosen programs or services are not available, the individual or the individual's legally authorized representative shall be given assistance in gaining access to alternative services and the selected waiting lists. The department shall keep a central list of the number of openings available for each type of residential service. The department shall honor the program and services preferences of the person or the person's legally authorized representative to the maximum extent openings are available in a residential program or service for which the individual meets program criteria. TDMHMR Rider 62. Provision of Information about All Care Alternatives. The Department of Mental Health and Mental Retardation shall comply with the requirements of § 533.038 of the Health and Safety Code by specifically providing to a person with mental retardation who is seeking residential services, or that person's legally authorized representative, information regarding the full continuum of care alternatives that are available, as well as information regarding spaces available in all the care alternatives. SB1, Art II, Special Provision RidersHHSA Rider Sec. 8. Approval of Transfers of Medicaid - Title XIX Funds. As an exception to other provisions of this Act, a transfer that exceeds $1 million in all funds, state and federal, appropriated for Medicaid - Title XIX purposes between strategies of an agency receiving appropriations in this article cannot be made without the prior approval of the Commissioner of Health and Human Services established in Chapter 531 of the Government Code. The Commissioner shall establish procedures that expedite the approval process. Within 14 days of the transfer, agencies are to submit a report to the Legislative Budget Board, Governor's Office of Budget and Planning, and the Comptroller of Public Accounts. The report shall include information regarding affected strategies; method of finance; performance measure changes; and full-time equivalent positions due to the transfer of Medicaid funding. HHSA Rider Sec. 19. Transfer Authority. The Commissioner of Health and Human Services is authorized to make the following transfers, subject to prior approval by the Legislative Budget Board and the Governor, between health and human services agencies listed in Chapter 531, Government Code, including the Health and Human Services Commission, and between the strategies of each such agency. Any such transfers shall be made solely for purpose of creating an efficient, integrated system of business operations across health and human service agencies, for achieving the efficient and effective operation of the Medicaid program, to maximize federal funds, or for other purposes specifically described in Chapter 531, Government Code.
HHSA Rider Sec. 31. Limitation on Appropriations for Rates. None of the funds appropriated to the Department of Health, the Department of Human Services, the Department of Mental Health and Mental Retardation, and the Department of Protective and Regulatory Services for rates may be utilized for purposes other than rates for service providers. SB1, Art II, TDPRS RidersTDPRS Rider 2. Substitute Care Permanency Goal. In order to comply with P.L. 105-89, it is the intent of the Legislature that the Department of Protective and Regulatory Services actively seek permanent homes for the children who are in the department's substitute care program for long periods. To this end, the department shall seek to limit the number of children under the department's responsibility who are in substitute care for a period longer than 24 months. The department shall strive to assure that no more than 45 percent of the children in paid placements are in substitute care for more than 24 months for fiscal years 2002 and 2003. Further, it is the intent of the Legislature that whenever possible, the department shall utilize state and/or federal funds currently being expended for substitute care to cover the cost of assuring permanent homes where appropriate for foster children. TDPRS Rider 14. Medicaid and Other Reporting Requirements.
<<back to top>> TDMHMR
<<back to top>> IV. STAKEHOLDER INPUT AND RECOMMENDATIONS I. AGENCY STAFF RECOMMENDATIONS:
II. ADVOCATE STAKEHOLDERS:ADVOCATES IN SUPPORT OF INSTITUTIONAL SERVICES PROVIDED THE FOLLOWING COMMENTS AND SUGGESTIONS:
ADVOCATES IN SUPPORT OF COMMUNITY SERVICES PROVIDED THE FOLLOWING COMMENTS AND SUGGESTIONS:
PROVIDER REPRESENTATIVES SERVICES PROVIDED THE FOLLOWING COMMENTS AND SUGGESTIONS:
<<back to top>> Texas Department of Mental Health and Mental Retardation (TDMHMR) Description: TDMHMR operates facilities for the mentally retarded (eleven state schools and two state centers) and for mental illness (nine state hospitals). The budget amounts for SMRFs and SMHFs are detailed below. SMHFs are included for informational purposes, since for the most part; consumers do not stay long-term in a SMHF. Also included is a budget for the infrastructure of facilities, which includes SMRFs and SMHFs. TDMHMR SMRFs FY02
* Employee Benefits are budgeted in the Employee Retirement System. Method of Finance for SMRFs
Note: GR shown available does not include the reduction for HHSC Transfer of 1,099,401 TDMHMR SMHFs FY02
* Employee Benefits are budgeted in the Employee Retirement System. Method of Finance for SMHFs
* Note: GR shown available does not include the reduction for HHSC Transfer of 1,099,400
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Program |
GR | All Funds |
|
Foster Care/Adoption Payments |
$ 25,500,374 | $ 64,380,663 |
|
Total Foster Care/Adoption Payments |
$ 25,500,374 | $ 64,380,663 |
1. Method of Finance for 13+ Beds
|
Method of Finance Code |
FY02 |
|---|---|
|
0001 General Revenue |
$ 12,435,110 |
|
8008 Gen Rev. for IV-E Match |
$ 13,065,264 |
|
TOTAL GEN REV |
$ 25,500,374 |
|
93.658 IV-E Foster care |
$ 19,680,629 |
|
93.558 TANF |
$ 19,199,660 |
|
TOTAL FEDERAL |
$ 38,880,289 |
|
TOTAL ALL FUNDS |
$ 64,380,663 |
Average Daily Rate per client in this Group $108.08
Converted to Monthly Rate
$3,287.41
Assumptions in data:
Financial Issues:
The major portion of case management for this client population is included in the daily rate.
Program Issues:
TDPRS Child Protective Services (CPS) is required to place children in the least restrictive, most family like setting, given their needs, by federal legislation [Social Security Act, Title IV-E, a 475 (5)]. When making placements, if the placement is not a family setting, CPS staff must document the reason a less restrictive placement such as a foster home was not selected for the child. In-house administrative reviews, called Permanency Planning Team (PPT) staffings are held regularly and review these types of placements along with the other service planning issues that are specific to each individual child.
While the figures shown above represent the totals appropriated for TDPRS, there is a variation in the amount expended on each child in the designated settings based on their Level of Care. As children are able to be moved to less restrictive settings, their LOC payments are lowered as it is related to the child's individual service or therapeutic needs.
2. TDPRS and Child Placing Agency Group Homes of 7-12 Beds FY02
|
Program |
GR | All Funds |
|---|---|---|
|
Foster Care/Adoption Payments |
$ 15,655,520 | $ 39,267,570 |
|
Total Foster Care/Adoption Payments |
$ 15,655,520 | $ 39,267,570 |
2. Method of Finance for 7-12 Beds
|
Method of Finance Code |
FY02 |
|---|---|
|
0001 General Revenue |
$ 5,968,279 |
|
8008 Gen Rev. for IV-E Match |
$ 9,687,241 |
|
TOTAL GEN REV |
$ 15,655,520 |
| 93.658 IV-E Foster care | $ 13,176,576 |
| 93.558 TANF | $ 10,435,474 |
| TOTAL FEDERAL | $ 23,612,050 |
| TOTAL ALL FUNDS | $ 39,267,570 |
Average Daily Rate per client in this Group $ 64.46
Converted to Monthly Rate $ 1,960.63
Assumptions in data:
Financial Issues:
The major portion of case management for the clients placed in Contracted Group Homes is included in the daily rate. TDPRS Group Homes may have some additional Case Management allocation; however the TDPRS group homes represent only 12% of the total expense for this scenario. The agency time study for substitute care caseload allocation is not specific to facility types and is not reliable as a cost per case indicator for the entire population in this scenario.
3. Two TDPRS Financed Facilities Designated for MR FY02
|
Program |
GR | All Funds |
|---|---|---|
|
Foster Care/Adoption Payments |
$ 1,662,250 | $ 2,901,988 |
|
Total Foster Care/Adoption Payments |
$ 1,662,250 | $ 2,901,988 |
3. Method of Finance for TDPRS MR Facilities
|
Method of Finance Code |
FY02 |
|---|---|
|
0001 General Revenue |
$ 1,280,969 |
|
8008 Gen Rev. for IV-E Match |
$ 381,281 |
|
TOTAL GEN REV |
$ 1,662,250 |
|
93.658 IV-E Foster care |
$ 580,828 |
|
93.558 TANF |
$ 658,910 |
|
TOTAL FEDERAL |
$ 1,239,738 |
|
TOTAL ALL FUNDS |
$ 2,901,988 |
Average Daily Rate per client in this Group $ 99.38
Converted to Monthly Rate $ 3,022.90
Assumptions in data:
Financial Issues:
The major portion of case management for this client population is included in the daily rate.
The relationship of GR to Total Dollars is greater in this scenario
because most of the children do not meet the eligibility criteria for
Emergency Assistance (TANF funds).
Program Issues:
These two facilities provide residential care for children with developmental disabilities and/or complex medical needs.
Description: TDHS makes Medicaid payments to nursing facilities, determines eligibility, and conducts quality assurance for the facilities. The budget amounts for these activities are detailed below.
Nursing Facilities FY02
|
Program |
GR | All Funds |
|---|---|---|
|
Salaries |
18,947,592 | 37,895,183 |
|
Operating Expenses |
29,487,435 | 58,974,871 |
|
Client Services |
935,630,798 | 2,343,177,556 |
|
Total Nursing Facilities |
984,065,825 | 2,440,047,610 |
Method of Finance for Nursing Facilities
|
Method of Finance Code |
FY02 |
|---|---|
|
General Revenue Match for Medicaid |
984,065,825 |
|
Federal Medicaid |
1,455,981,785 |
|
Total MOF Nursing Facilities |
2,440,047,610 |
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For the purposes of this report PRS will use the definition of institution found in the Government Code 531.151 to organize the reporting of financial data.
Note that the reader should not assume all children served in such institutions meet the definition of child found in this same chapter, which references the child's developmental disability.
PRS provides protective services to children, regardless of the child's disability status.
Government Code § 531.151
In this subchapter:
(3) "Institution" means:
(A) An ICF-MR, as defined by Section 531.002, Health and Safety Code;
(B) A group home operated under the authority of the Texas Department of Mental Health and Mental Retardation, including a residential service provider under a Medicaid waiver program authorized under Section 1915(c) of the federal Social Security Act (42 U.S.C. Section 1396n), as amended, that provides services at a residence other than the child's home or foster home;
(C) A foster group home or an agency foster group home as defined by Section 42.002, Human Resources Code;
(D) A nursing facility;
(E) An institution for the mentally retarded licensed by the Department of Protective and Regulatory Services; or
(F) Another residential arrangement other than a foster home as defined by Section 42.002, Human Resources Code that provides care to four or more children who are unrelated to each other.
Definitions of placement types referred to in this report and in the Government Code can be found in Human Resources Code Section 42.002
(4) "Child-care institution" means a child-care facility that provides care for more than 12 children for 24 hours a day, including facilities known as children's homes, halfway houses, residential treatment centers, emergency shelters, and therapeutic camps.
(5) "Foster group home" means a child-care facility that provides care for 7 to 12 children for 24 hours a day.
(6) "Foster home," means a child-care facility that provides care for not more than six children for 24 hours a day.
(10) "Agency foster group home" means a facility that provides care for seven to 12 children for 24 hours a day, is used only by a licensed child-placing agency, and meets department standards.
(11) "Agency foster home" means a facility that provides care for not more than six children for 24 hours a day, is used only by a licensed child-placing agency, and meets department standards.
(12) "Child-placing agency" means a person, including an organization, other than the natural parents or guardian of a child who plans for the placement of or places a child in a child-care facility, agency foster home, agency foster group home, or adoptive home.
*PRS provides out of home care to children as part of the broad array of protective services. Residential care for elderly or disabled adults is provided by other Texas state agencies
Department of Protective and Regulatory Services; Responsibility
(a) The Department of Protective and Regulatory Services is composed of the board, the executive director, an administrative staff, and other officers and employees necessary to efficiently carry out the purposes of this chapter.
(b) The department is the state agency with primary responsibility for:
(1) Providing protective services for children and elderly and disabled
persons, including investigations of alleged abuse, neglect, or exploitation
in facilities of the Texas Department of Mental Health and Mental
Retardation
Children enter the managing conservatorship of the Texas Department of Protective and Regulatory Services (TDPRS) as a result of a court order following a validated abuse or neglect investigation. If it is determined that a child is not safe in their home of origin, TDPRS staff search for appropriate family members as a first placement resource. If appropriate family resources are not available, TDPRS staff seek a foster care placement.
In most cases, the goal of the Department and the court is to return the child to their family of origin. This goal can be met after the home has been established as a safe environment through the Department's casework services to the family. In some cases return to the family is not a safe option. Adoption becomes the goal or, in the case of older children, preparation for independent living upon their emancipation from TDPRS, usually at age 18.
During the time the child is in TDPRS conservatorship, the Department makes placement decisions on two parallel but interrelated set of choices. The type of care that best suits the child, and the type of facility best able to deliver the type of services required.
Children come into custody of TDPRS with a wide range of medical, social, and therapeutic needs. As part of determining the best range of services for an individual child, the TDPRS caseworker submits family, behavioral, medical, social, psychological, and educational history to Youth for Tomorrow (YFT), an independent contractor.
All children who enter foster care are assigned a Level of Care One. Upon request by a TDPRS caseworker, professionals at YFT evaluate the child's information to determine a therapeutic Level of Care for the child, ranging from two to six. The Level of Care is an indicator of the child's current level of functioning and helps the caseworker to select the best type of placement. A child whose behaviors are such that they cannot function in a foster home may be appropriate for some types of more structured residential care. Though there are occasional exceptions, the Levels of Care generally correspond to the type of care a child will need.
A child assigned a Level of Care One is a child in need of basic care. Typically, this would be a child appropriate for placement in the routine environment of a basic care foster home.
A Level of Care One is typically assigned to a child with no notable medical or behavior problems. Level One is the baseline level for all children entering PRS foster care; they will remain at Level One until a TDPRS caseworker requests that the child's information be reviewed by Youth for Tomorrow.
Therapeutic care is for children with an assigned Level of Care Two through Six. These are children whose needs usually demand a therapeutic foster home or other more structured setting, with additional counseling from professional staff.
A child assigned a Level of Care Two is typically one with occasional and brief behavioral difficulties. A foster home can provide a routine home environment with some supplemental guidance and discipline to meet the needs of the child.
A Level of Care Three designates a child who has more frequent or repetitive minor problems or who may engage in some non-violent but anti-social acts.
A Level of Care Four child is typically a child at moderate risk of causing harm to themselves or others, and has poor social skills, and frequent episodes of aggressive or antisocial behavior.
A Level of Care Five is assigned to children, who may exhibit unpredictable aggression, or are withdrawn and isolated due to either mood or thought disturbance. They have made suicidal attempts or gestures.
A Level of Care Six designates a child in the most urgent need of immediate professional assistance and who exhibits severely aggressive or self-destructive behavior. They may be actively suicidal. A child assigned this level would be in need constant supervision.
Note: THE LEVEL OF CARE SYSTEM SERVES NOT ONLY AS A BEHAVIORRAL MARKER FOR TREATMENT PURPOSES, BUT ALSO AS THE BASIS OF A RATE STRUCTURE FOR REIMBURSEMENT TO FOSTER CARE PROVIDERS. THE DEPARTMENT CONTRACTS WITH PROVIDERS FOR FOSTER CARE SERVICES. THE RATE OF REIMBURSEMENT RISES WITH THE CHILD'S ASSIGNED LEVEL OF CARE.
An array of different types of foster care placements is available to meet the individual needs of children at all Levels of Care. Children in foster care may be placed into homes directly licensed and monitored by TDPRS, placed into foster homes licensed and monitored by child placing agencies, or placed into facilities regulated by the TDMHMR or the TDHS.
TDPRS staff strive to place children in settings that are as "home-like" as possible, but many children require a higher degree of supervision or therapeutic services.
Foster Homes
The most commonly used placements are foster homes. Foster homes are basically families that agree to take children into their homes and act as substitute parents. Children in foster homes most often attend school in the community in which they live. Foster homes may be approved to operate either directly by TDPRS, or by a private Child Placing Agency (CPA). A CPA must have a license to operate issued by the TDPRS Licensing division.
There are several different types of foster homes that accept children with various types of needs - from basic homes, which deal primarily with children who have no special needs to primary medical homes that serve children with serious health problems to therapeutic homes where children receive professional therapy services for behavioral or emotional issues.
Facilities
Children with severe behavioral or psychological problems not appropriate for a foster home may be placed in Residential Treatment Centers (RTC), which are staffed with professional staff and may have a higher level of constant supervision. Basic Care Facilities are most often campus-like settings serving primarily basic care children.
Emergency Shelters
When children first come into the care of TDPRS or are otherwise in need of an immediate placement, Emergency Shelters may be a short-term option until a more appropriate setting can be arranged.
All of these placement types are subject to TDPRS contract monitoring and the minimum licensing standards of the TDPRS Child Care Licensing Division or other state agencies that may license the facility.
When a child comes into TDPRS care, an integral part of providing services is the establishment of a permanency goal for the child. A permanency goal is an outcome, an end goal for the child's conservatorship around which all other services can be planned.
Most commonly, the permanency goal is for the child to return to their family of origin. This is accomplished by offering counseling and treatment to help the child's parents develop a home in which the risk of further abuse or neglect has been reduced. When reunification with the parents is not possible, the Department will then establish a goal of permanently placing the child with other family members such as grandparents, or aunts and uncles.
When placement with parents or extended family is not an option, TDPRS will move to achieve a permanency goal for the child outside the family of origin. Once legal steps have been taken to terminate parental rights, adoption may become the permanency goal. TDPRS actively recruits and screens potential adoptive homes for children in foster care. Often foster parents make the decision to adopt a foster child they've had placed in their home.
When neither return to the child's family nor adoption are realistic permanency goals, the Department will plan for the child's emancipation as an adult. This is a goal most common with adolescents. Emancipation occurs when the child turns eighteen, though children may stay in foster care past age eighteen to complete high school. TDPRS provides Preparation for Adult Living (PAL) programs to prepare children to live on their own. Teens who complete the program receive transitional living allowances to help them with initial household expenses. They are also eligible to attend Texas State colleges tuition-free.
Children in the conservatorship of the TDPRS may be eligible for Federal funding to cover the costs of placement depending upon the child's individual circumstances at the time of removal. TDPRS accesses Federal funds under Title IV-A and Title IV-E of the Social Security Act. TDPRS uses General Revenue to pay for placement costs for children who do not qualify for either IV-A or IV-E. PRS may access Medicaid, Title IV-B, or TANF to provide support services to children in addition to the services provided by a residential facility.
Title IV-E of the Social Security Act
The objective of the Foster Care program is to help States provide safe,
appropriate, 24-hour, substitute care for children who are under the
jurisdiction of the administering State agency and need temporary placement
and care outside their homes; and to provide Federal Financial Participation
(FFP) in costs related to the program.
Funds may be used for FFP in State or local foster care maintenance payments on behalf of eligible children, and for administrative and training costs; and costs related to design, implementation and operation of a statewide data collection system. Funds may not be used for costs of social services provided to a child, the child's family, or the child's foster family which provide counseling or treatment to ameliorate or remedy personal problems, behaviors, or home conditions.
FFP is available at the Federal Medicaid Assistance Percentage for foster care maintenance expenses. The Texas FMPA for Federal fiscal year 2002 is 60.17%. The FMAP for Federal fiscal year 2003 is 59.99%.
FFP is available at 50% for administrative expenses and 75% for training expenses.
Under Title IV-E, case management and case planning are considered administrative expenses.
Title IVA, as amended, of the Social Security Act
The objective of this program is to provide grants to States, Territories, or Tribes to assist needy families with children so that children can be cared for in their own homes; to reduce dependency by promoting job preparation, work, and marriage; to reduce and prevent out-of-wedlock pregnancies; and to encourage the formation and maintenance of two-parent families.
States, Territories, or Tribes have broad flexibility to use the grant funds in any manner that meets the purposes of the program (including providing low-income households with assistance in meeting home heating and cooling costs) and in ways that the State, Territory and Tribe was authorized to use funds received under the predecessor Aid to Families with Dependent Children (AFDC), Job Opportunities and Basic Skills Training (JOBS) and Emergency Assistance (EA) programs.
The State of Texas Emergency Assistance program as of September 30, 1995 included the following types of services for children at risk: information and referral; case planning and case management; counseling; support activities to normalize family functioning, and care in a foster family, shelter or other residential facility.
While States must spend general revenue to meet Maintenance of Effort (MOE) requirements there is no "match" rate per se with TANF. The TANF dollars used to pay for foster care placement are 100% Federal. TDPRS contributes to the State's MOE requirement when spending GR for other service programs.
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