Appendix K - Integrated Services Plan

Revenue Maximization Opportunities

In this time of tight funding and the need for expanding services the Office of Children, Youth and Families in
conjunction with the Revenue Enhancement Workgroup has identified five revenue maximization activities. Title IV-
E and Medicaid are entitlement programs, so where ever possible a service should be claimed to Title IV-E and
Medicaid. The State Fiscal Year Budget for 2004-2005 is built with these increased funding opportunities included.
The five opportunities are:

1. Increase recoveries under Non-Residential Purchase of Service Administrative Claiming

2. Increase recoveries under Title IV-E Maintenance and Administrative Claiming
3. Medicaid Claiming Under the Medicaid Rehabilitative Services Option
4. Medicaid Claiming Under the Targeted Case Management

CCYAs and JPOs must begin to think about the activities that will be involved with this work both for SFY 2004-
2005 and out years. A great deal of the initial work will be handled by a contractor but it will be necessary for county
staff to provide the necessary information to the contractor.

Non-Residential Purchase of Services Administrative Claiming (NR POS)

A pilot program for the Non-Residential Purchase of Services Administrative Claiming (NR POS) was begun in the
fourth quarter of SFY 2003-2004 with four counties (Allegheny, Centre, Chester, and Delaware). It is the expectation
that this initiative will go statewide during the upcoming SFY.

This opportunity will allow counties to claim Title IV-E federal financial participation for certain allowable costs in
NR POS contracts that a county children and youth agency or juvenile probation office will have with a private child
welfare agency. Title IV-E allowable administrative activities include:

1. "The determination and re-determination of eligibility, fair hearings and appeals, rate setting and other costs
directly related only to the administration of the foster care program are deemed allowable administrative
costs".
2. The following are examples of allowable administrative costs necessary for the administration of the foster
care program:
A. Referral to services
B. Preparation for and participation in judicial determinations
C. Placement of the child
D. Development of the case plan
E. Case reviews
F. Case management and supervision
G. Recruitment and licensing of foster homes and institutions
H. Rate setting and
I. Proportionate share of related agency overhead.
3. The following are examples of unallowable administrative activities include:
A. Counseling or treatment
 B. Medical or dental exam or treatment
C. Educational or vocational training
D. Parenting classes and
E. Recreational activities

Title IV-E administrative claiming is based on two factors: (1) the cost of Title IV-E allowable activities provided and
(2) Title IV-E eligible clients. If the contracted activities are not 100 percent Title IV-E allowable or the clients served
not 100 percent Title IV-E eligible, then the proportionate share of the cost must be allocated to Title IV-E and
state/county.

There are three primary methods for allocating the activities:

A. Random Moment Time Study statistics for contracts providing "administrative" support activities only;
B. Purchase of Service (POS) Time Study statistics which would involve private agencies participating in a
RMTS process similar to the one the CCYAs currently participate in.
C. Hourly/Event-Based Invoicing which requires hourly or event based invoices to identify the amount of time
spent on Title IV-E allowable activities.

The second key area is the eligibility of the clients. The term client applies to (1) children residing in their own homes
with parents, relative or other clients; (2) children in out-of-home placement or (3) children receiving services through
adoption assistance.

In order for the clients served by the in-home contract to be determined "eligible" there must be documentation of the
child’s "candidacy for Title IV-E foster care" in the agency records. For services to families at least one child in the
family must be determined to be a "candidate for foster care" in order for the family to be considered Title IV-E
eligible. There are three acceptable methods of documenting candidacy for foster care:

1. A Family Service Plan which clearly indicates that absent effective preventive services, foster care is the
planned arrangement for the child;
2. an eligibility determination which has been completed to establish the child’s eligibility under Title IV-E
Placement Maintenance or Adoption Assistance or
3. evidence of court proceedings in relation to the removal of the child from the home.

OCYF is working closely with MAXIMUS, Inc and the pilot counties to finalize the necessary policies and
procedures to allow this process to be utilized by all 67 counties. CYF Bulletin 3140-99-03 Policies and Procedures
for Claiming Federal Title IV-E Administrative Funds for Non-residential Purchase of Services Contracts is being
updated and will be reissued with the learning’s from the pilots by July 16, 2004.

The following list of tasks are being completed by OCYF, MAXIMUS and the pilot counties. These tasks are similar
to the tasks that the remaining counties will need to follow in the upcoming months. Those tasks include but are not
limited to:

Collect County Data

Assess NR POS Contracts
Identify current barriers and challenges to address
Finalize Time Study Approach and Direct Charging Policies
Develop Staff Roster Requirements
Develop Invoicing and Claiming Procedures
Develop and Update Bulletins
Review Draft bulletin with partners, including: CCYA/JPO/DPW
Bulletin processed with internal partners through signoff process
Develop Training Plan
Develop Training Curriculum
Conduct training

Additional information regarding the next steps for the remaining 63 counties will be disseminated over the next
several months by OCYF.

Increase recoveries under Title IV-E Maintenance Claiming and Title IV-E Administrative Claiming

There are three primary areas of maintenance and administrative claiming that will be focused on as part of the
revenue maximization opportunities. They are:

1. Ensure that all Title IV-E eligible cases are identified and claimed;
2. Ensure that all Title IV-E reimbursable cases and period are claimed; and
3. Ensure that all eligible expenditures are included in Title IV-E claims.

The tasks involved in these activities include but are not limited to:

Collect County Data

Finalize Case Review Management and Operational Procedures
Establish County Communications Plan and Review Schedule
Identify Cost Allocation Improvements
Meet with BFO Staff to discuss/review cost allocation plan
Implement Immediate Cost Allocation Process Improvement
Implement Longer Term Cost Allocation Process Improvements that Require Federal Approval
Incorporate activities in Department’s Cost Allocation Plan
Identify and Assess "gaps" in reimbursable periods
Identify Eligible Title IV-E Expenditures for Inclusion in Claim
Submit IV-E Claims

Medicaid Claiming Under the Medicaid Rehabilitative Services Option and Targeted Case Management

The two remaining opportunities involve the other remaining federal entitlement resource – Medicaid. The federal
government allows states to claim to Medicaid the costs associate with assisting children/juveniles in gaining access
to needed medical, social, educational, and other services and therapeutic treatment and counseling services provided
under two distinct programs – (1) Rehabilitative Services Option and (2) Targeted Case Management. In order to
participate in either of these options a Medicaid State Plan amendment will need to be submitted to the federal
government. The current administration is willing to support the submission of these plan amendments.

Rehabilitative Services Option

Federal Medicaid regulations define the benefit category of "Rehabilitative Services" as covering "any medical or
remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of
his or her practice under state law, for maximum, reduction of physical or mental disability and restoration or a
recipient to his or her best level." This broad description allows states to use Medicaid to recover for a wide range of
direct services in either inhome or out-of-home settings. Examples of reimbursable services include:

1. medical services, including medical screening and diagnostic functions;

2. crisis intervention and stabilization services;
3. individual, group and client centered mental health counseling services, and
4. hygiene and personal care services.

Currently for JCAHO approved families the Commonwealth pays the entire placement cost and claims the per diem
to Medicaid for eligible children, However, for the other types of placements, including emergency shelter, non-
JCAHO approved facilities and therapeutic foster homes none of the costs of those services are currently being
claimed to Medicaid. For each of these types of placements there is a component of the per diem that could be
claimed under Medicaid. Claiming to Medicaid is more beneficial to the counties because, for eligibility purposes,
Medicaid views a child in custody as being a "family of one" meaning only the child’s income is considered. Thus,
nearly all of the children in placement are Medicaid eligible, which means it is advantageous to designate as much of
the per diem as possible as covering rehabilitative services. T

he Rehabilitative Option can also be used to claim for various in-home child welfare services, i.e. crisis intervention
and counseling that counties may provide as part of their family preservation services or intensive family support.

The following tasks are some of the key tasks that must be accomplished in order to submit the Medicaid state plan
amendment which is the first step in being allowed to utilize Medicaid funds in this manner.

• Assess Current Programs and State Plans

• Assess Sample of County Practices and Provider Practices
• Identify current barriers and challenges to address
• Finalize Revenue Projections
• Update and Finalize Revenue Projections for this Initiative
• Determine Services to be Covered
• Determine Who will be Providers
• Determine how rates will be set
• Determine Population to be Covered
• Determine Admission process
• Draft State Plan Amendment
• Submit State Plan Amendment to CMS

The approval of the state plan amendment may take several months. There will be some additional preliminary work
that can be accomplished while the state plan amendment is pending approval.

Targeted Case Management

The second opportunity under Medicaid is Targeted Case management. Within the Social Security Act case
management services are defined as services which will assist an individual eligible under the State Medicaid plan in
gaining assess to needed medical, social educational and other services. Case management services are referred to as
Targeted Case Management (TCM) services when the services are provided to a class of individuals such as children
receiving child welfare or juvenile justice services with certain diagnoses.

By using TCM in conjunction with Title IV-E CCYAs and JPOs would be able to recover a significant amount of its
staff costs. The following services are examples of the types that can be claimed under TCM:

• assessment – evaluation of an individual to determine the need for any medical, educational, social and other
services including taking client history, identifying the needs of the individual, completing related
documentation and gathering information from other sources such as family members, medical providers and
educators;
• care planning – ensuring that the client actively participates in his/her care and working with the client and
others to develop goals and identify a plan of care to respond to the assessed needs of a client. The goals and
actions in the care plan should address medical, social, educational and other services needed by the
individual;
• referral and linkage – activities that help link clients with medical, social, educational providers and/or other
program and services that are capable of providing needed services. For example, making referrals to
providers for needed services and scheduling appointments may be considered case management;
• monitoring/follow-up – activities and contacts that are necessary to ensure the care plan is effectively
implemented and adequately addresses the needs of the client. The activities and contacts may be with the
client, family members, providers or other entities. This function includes making necessary adjustments in
the care plan and service arrangements with providers.

The Center for Medicare and Medicaid Services (CMS) has taken the position that Medicaid can not pay for any
services that are also reimbursable under Title IV-E. Therefore, Medicaid will only pay for the above mentioned
services for children who are NOT eligible for Title IV-E (which in Pennsylvania is approximately 25 percent of the
children in placement (varies from county to county). In addition, Title IV-E will not pay for the assessment, care
planning and monitoring of medical care and services, these services can be claimed under TCM even for Title IV-E
eligible children.

Until very recently CMS was not approving any new state plan amendments for TCM and scrutinizing existing
amendments. However, recently there appears to be some movement towards approving new amendments. Therefore,
OCYF believes that the efforts needed to submit a state plan amendment is an opportunity that should not be missed.
The following tasks will need to be completed in order to prepare a state plan amendment:

• Identify all activities which would be within the scope of an average work day performance of a case manager
• Determine extent to which services can be billed to Medicaid
• Collect and review policy and procedure documents
• Review current operations
• Identify current barriers and challenges to address
• Reviewed stored case management files
• Review for previous documentation and case planning activities
• Identify barriers and challenges with case file documentation
• Determine services to be covered
• who will be providers
• Determine how rates will be set
 • Determine population to be covered
• Draft State Plan
• Submit State Plan to CMS

Just like the Rehabilitative Service Option the approval of the state plan amendment may take several months. There
will be some additional preliminary work that can be accomplished while the state plan amendment is pending
approval.

OCYF hopes to begin working on many of the preliminary tasks for the four remaining revenue maximization
opportunities (work on the NR POS has begun) before the end of this fiscal year. It will be imperative that CCYAs
and JPOs work closely with both OCYF and MAXIMUS in order to obtain the necessary additional federal funds.

Questions regarding any of these opportunities should be directed to Cindi Manuel at (717) 783-7372 or
cmanuel@state.pa.us.
Last modified on: September 14, 2004