Financing Local Systems of Care September 4, 2003

1. Financing Local Systems of CareSeptember 4, 2003 Jim Wotring Director of Programs for Children with a Serious Emotional Disturbance Michigan Department of Community Health Phone 517-241-5775 E-mail wotringj@state.mi.us

2. Year 1 “Yippee”

3. Year 3 “No Its My Money”

4. Year 6 “We can Work Together”or “ Too Tired to Fight Anymore”

5. Financing Local Systems of Care • 1995-98 -- RWJ Grant-Case Rate Pilots • 1997 -- SAMHSA Grant • 1998 -- Managed Care • 2001-- New Finance Project Started • 2003– New Governor

6. RWJ Grant-Case Rate Pilots • Two Counties - Livingston and VanBuren • $3,000 PMPM full risk • Combined Title XIX (Medicaid) and Title IV-A-EA (Now TANF) • Used existing State and Local Funds as match and flowed through the Federal funds to the CMHSP's. • Similar to Wraparound Milwaukee

7. SAMHSA Grant 1997/98 • Received SAMHSA Grant from Feds with Plan to Expand Finance Pilots using Medicaid to Sustain Grant. • First year of grant everything going very well, lots of new money, hiring staff. • County working collaboratively • State working collaboratively

8. Changes in the State Systems This is now 1998/99 • Managed Care (Health and Mental Health) • Leadership Changes at the State Level • Early Retirement • DCH Created (Medicaid, MH, SA, PH, Aging) • Child Welfare Changes • IV-A-EA gone

9. Changes in State System1999/00 • Proposed Managed Care Plan to Include Medicaid Case Rate Rejected by State Leadership Team • Worried About Upper Payment Limit • This Was Our Sustainability Plan • Child Welfare Submits IV-E Waiver • Juvenile Justice Staff remain Strong Partner at State Level

10. Changes in the County System1998-2003 • New Mental Health Director Every Year for the Next 4 Years (Continue to Provide Match for Grant) • Two New Child Welfare Director’s • Find stable Partner Inside the System • Two New School Superintendent’s • Never Recover Solid County School Partner • Juvenile Justice Director Partners with Southwest Community Partnership and State

11. Partnership with Juvenile Justice Becomes Critical to Grant • Juvenile Justice Provides Match for Grant • Juvenile Justice Uses Consultants from Grant • Technical Assistance Becomes Critical to Partnership with Juvenile Justice • County Level Collaboration Begins to Fall Apart Except Juvenile Justice

12. State Level Activities 2000/01 • Rested Some and Licked our Wounds • Developed a Juvenile Justice/Mental Health Committee • Continue to Partner with Families • Continue to Put Pressure on System from the Outside to Better Serve Children in Juvenile Justice and Child Welfare • Continue to Pressure System from the Outside About Need to Blend Funds

13. New Finance Effort at State Level Initiated 2001 • Director Feels the Heat and Wants a New Workgroup on Integrating Financing Across Systems • Child Welfare Reluctantly Participates • Education Reluctantly Participates • State Systems Fearful of Takeover • Juvenile Justice remains Strong Partner at State and County Level • Begin Building New Relationships at State and County Level with Systems

14. New Finance Planning Workgroup • New workgroup Child Welfare, Community Health, Education • New Finance and Program Staff • Finance Matrix • Functional Budget

16. Functional State Budget Across Systems MH, PH, ED, CW, JJ • Prevention/Early Intervention • Basic Needs • Medical/Health Services • Educational Services • Community-Based Services • Child Care • Out-of-Home Care • Child Protection and Investigation

17. Functional State Budget Across Systems-MH,PH,ED,CW,JJ

18. Findings from Functional Budget General Fund General Purpose (GFGP) funds that were not matched to Federal fund. Matched our mission and values. Matched our target population. -- Multi-system at risk of removal from home.  Cost Neutral to the State

19. Option’s Considered • Connecticut/New Jersey - No -- Fear of takeover. • Case Rate - Okay • Let’s just coordinate again.

20. Directors Support New Concept Paper • Case Rate • Medicaid and County Funds as match • $200,000,000 Below Upper Payment Limit • Child Welfare Reluctantly Agrees • Juvenile Justice Supportive • Education at the Table

21. Build Support for New Concept Paper • Continue to Build Supports Within State Departments and Outside State Departments • Juvenile Justice (State and County) • Community Mental Health Centers • Advocacy Groups • Family Groups

22. Election One Year Away • Decide to Slow Down Finance Pilots and Take Chance on New Governor • Continue to Build Support Across Systems and Sell Product to Anyone Who Will Listen • Continue to Meet with Staff Inside Department to Work out Details of Funding Flow, Audits etc.

23. New Governor Elected • Staff Supportive of Blended Funding get on Governors Various Transition Teams • Two New Directors Hired who Have Worked on Multi System Projects and Know About Multi System Children are Supportive. • Continue Building Support Outside of the System

24. New Governor Elected • Change in Department Directors • New Job to Sell Concept to New Directors and Governor • Child Welfare Tries to Deep Six Effort • Changes made in Child Welfare Staffing • Directors Love Project • Governor and Legislature to Support with Additional Funding From Child Welfare

25. Approached by Juvenile Justice Staff to Develop New Finance Committee Supportive of Blending Funds • Approach Child Welfare/Juvenile Justice Director’s New Administrative Assistant with Idea to Blend Funds. She is Supportive. • Project Now Includes Additional TANF Funding and Changes in State and Local Match Ratios • New Directors Support new Concept Paper

26. New Outside Committee Formed to Support and Advise on Project • Committee Reviewing Concept paper and Providing Support and Advise • Director’s Taking Proposal to Governors Office for Support • Plan to Begin Working with Communities this summer in preparation for implementation during FY 2004/5

27. New Plan • $34,000,000 to $50,000,000 in TANF funding. • $20,000,000 to $30,000,000 in Medicaid Funding

28. New Plan Cont. • TANF Passes Senate and House Finance Committees • TANF Removed in Senate and House Conference Committee and Never Reaches House and Senate for a vote this past summer so TANF is off the table in FY 04. • Plan to Ask for Additional TANF funds Again in FY 05. Have Directors Support.

29. New Plan Cont. • Plan to use Medicaid with Local Communities Putting up the Match Using Existing 1915(b)(c) Waiver, Being Renewed this Fall. • Adjustment to the Intensity Factor in the Waiver. • Traveling the State to Inform Communities of Medicaid Options

30. Medicaid Title XIX • Federal insurance • Eligibility • Poor • Disabled • Minor out of home over 30 days

31. Medicaid Title XIX • 56% Federal funds/44% State/local funds • Must track funds • Need to involve CMHSP as fiduciary

33. Case Rate • A set amount of money for each eligible child per month • Must provide covered services for eligible child • May also provide additional services and supports for child and family • Full risk model • Additional Federal and state dollars not currently in CMH budgets

35. Four creative examples identified • Enhanced Medicaid Case Rate • “Expanded” Child Care Fund • Combination • Blended Pool Enhanced Medicaid Case Rate

36. Creative Funding Example 1: Enhanced Medicaid Case Rate • Allows for collaboratively-governed funding and service partnerships to provide individualized services • New Medicaid dollars for Child Welfare and Juvenile Justice population • For Medicaid eligible children served by the case rate, pulls down additional Federal dollars new to the community • For every $44 dollars of local and state money, receive $56 in Federal dollars (44%/56% match)

37. Case Rate Model Other Court Example of How Blended Funds Work Using a Case Rate Model. Federal Medicaid 56% $1,904 CCF Local Match 44% $1,496 Schools CMH $3,400/Child/Month FIA Purchase Services

38. Creative Funding Example 2: “Expanded” Child Care Fund • Local agencies develop contracts/agreements with county commissioners/administrators for services and identify $$$ • $$$ added to the CCF ↝ “Expanded” child care fund • Purchase reimbursable services for CCF eligible children • For every $100 spent locally, receive $50 back (50%/50% match)

39. UW $248 $248 CMH $1,496 “Expanded” Child Care Fund $748 reimbursement Request FIA Option 2:“Expanded” Child Care Fund (through local contributions and interagency contracts) County $1,000 Commissioners Net county cost is $252 Expanded County Child Care Fund

40. Creative Funding Example 3: Combine 1 and 2 • Combine “Expanded” County Child Care Fund with the Enhanced Medicaid Case Rate • For CCF eligible children, “expanded” child care fund spends $100 and receives $50 reimbursement from CCF • For Medicaid eligible child, blended pool receives $44 local money and $56 in Federal match

41. Enterprise Fund $3,400 UW $248 CMH $1,904 Federal $248 $1,496 $1,496 Contracts for $1,496 “Expanded” County Child Care Fund DCH State $748 reimbursement Request FIA Option 3: “Expanded” Child Care Fund and Medicaid Case Rate County $1,000 Commissioners

42. Example 4: Blended funds in case rate model • Case rate is blend of local and state or Federal dollars depending on eligibility of child • Single local fiduciary with collaborative oversight • Finances support “community child” philosophy • Full array of services and supports for each child enrolled • Overall “savings” between 50% and 56% – depends on % of Medicaid and CCF children served

43. Option 4: Blended CCF/MA case rate • Blends multiple funding sources • Matches child eligibility to fund source • Keeps same case rate for each child • Allows community to draw down additional money from CCF and Medicaid • Do not monitor services to fund source by child, rather child eligibility to fund source

44. Child eligibility Medicaid CCF CCF and Medicaid Non-CCF or Medicaid

45. Schools $ United Way $ CMH $ Court $ FIA $ Other $ Child Care Fund $ Option 4: Blended Child Care Fund/Medicaid Case Rate Enterprise Fund

46. local $704 local and state $800 local $800 state $896 federal Option 4: Blended Case Rate for Medicaid/CCF eligible child Assume $3,400 Case Rate per child per month Non-covered Medicaid CCF $200 $1,600 $1,600

47. local $1,600 local $1,600 state Option 4: Blended Case Rate for CCF only eligible child Assume $3,400 Case Rate per child per month Non-covered CCF $200 $3,200

48. local $1,320 local $1,904 Federal Option 4: Blended Case Rate for Medicaid only eligible child Assume $3,400 Case Rate per child per month Non-covered Medicaid $200 $3,200

49. Option 4: Blended Case Rate for Non-CCF or Medicaid eligible child Assume $3,400 Case Rate per child per month Non-covered $3,400 local

50. Never Give Up, Never Give Up Be Like a Dog on a Bone