The Administration’s budget proposes a clarification under the Family First Act, the relationship between al Qualified Residential Treatment Programs (QRTP), and the definition of Institutions for Mental Diseases (IMD) under the Medicaid program.

Additionally, the Administration would allow ACF to better align the ratings of child welfare programs under the California Evidence-Based Clearinghouse, the HHS Home Visiting Evidence of Effectiveness Project, and the new clearinghouse under the Family First Act.

In some parts of the country, state child welfare agencies are getting indications that if a child welfare residential program meets the requirements under the Family First Act as a QRTP, then Medicaid may classify that residential program as an IMD under CMS/Medicaid guidance.

The Administration says that this would be a joint legislative fix between CMS and ACF. The IMD definition under Medicaid dates back to that health care program’s inception in 1965 with a goal, at least in part, of limiting the use of large mental health institutions. If a QRTP is classified as an IMD under Medicaid policy, no child or youth residing in such a placement can be covered by Medicaid services either at the QRTP or off-site. Some members of Congress have been working to address this issue through guidance, but this action by the Administration suggests a legislative fix is required.

The budget document suggests no additional cost for this change. It would, in effect, exempt QRTPs from the IMD exclusion allowing children in foster care up to age 18 (or 21 if foster care is extended) to have Medicaid coverage in these QRTPs even if a QRTP qualifies as an IMD.
With the fix for the FFA clearinghouse, the Administration would align the FFA standards with those used by the California Evidence-Based Clearinghouse for Child Welfare. Title IV-E prevention services that are rated as having promising, supported, well-supported practices by the Title IV-E Prevention Services Clearinghouse, the California Evidence-Based Clearinghouse, and the Home Visiting Evidence of Effectiveness project would be eligible for reimbursement, subject to Administration for Children and Families (ACF) review and approval. HHS has argued (to Capitol Hill) the way the law was written was more rigorous than the California Clearinghouse, not necessarily the intent of some in Congress.

ACF would continue to administer the Title IV-E Prevention Services Clearinghouse to ensure ACF has control over the review process of which programs are eligible for federal funding is retained. Title IV-E prevention services would still be defined as time-limited, evidence-based prevention services for mental health, substance abuse, and in-home parent skill-based programs for candidates for foster care, pregnant or parenting youth in foster care, and their parents and kin caregivers.

Also significantly, the Administration for Children and Families proposal would allow tribal agencies operating under a title IV-E agreement with a state to implement the title IV-E Prevention Service program requirements that are adapted to the culture and context of tribal communities, exempting them from the requirement to use only programs rated as well-supported, supported, or promising. Under the law, only tribes directly operating the title IV-E program fall under this current FFA flexibility. Currently, seventeen tribes have been approved to operate the title IV-E program, and this action would help many more tribal governments and consortia of tribes.

For the fourth straight budget, the Administration proposes “the Child Welfare Flexible Funding Option,” Title IV-E agencies would be able to use Title IV-E foster care maintenance payments as a block grant. This would be similar to what some jurisdictions used under the just-expired waivers.

CWLA continues to oppose child welfare block grants, whether they have that label attached or are proposed as a waiver or flexible option. That is because of the ongoing history of SSBG and TANF block grants.

About the Author:

John Sciamanna is CWLA's Vice President of Public Policy.

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