Financial Claiming Under Family First

No. The new IV-E prevention candidacy and traditional IV-E candidacy are separate determinations. Administrative costs can be claimed for two different types of “candidacy” once Family First is in effect:

1. New IV-E reimbursement for administrative and training costs related to preventing entry into foster care for ANY child who is a “candidate for foster care” under the state’s candidacy definition, and
2. Traditional IV-E reimbursement for administrative activities related to pursuing the removal, or providing reasonable efforts to prevent the removal, of a candidate for foster care (conditioned on a child being eligible for Title IV-E foster care). The latter allowable use of Title IV-E Admin will continue to be an allowable use unchanged by Family First. We will still use traditional IV-E Determinations for foster care maintenance payments and admin dollars for youth in OOH or under traditional IV-E candidacy.

Per HB21-1248, the Colorado Human Services Directors Association (CHSDA), Colorado Counties Inc. (CCI) and Colorado Association of Local Public Health Officials (CALPHO) coordinated to appoint four new county leadership representatives to the Board, three of whom have expertise in human services and child welfare practice. The four appointees selected are:

1. Clifford Brown, Director of Public Health, Custer County, OD, MPH, FAAO(D)
2. Mary Berg, Executive Director of Jefferson County Human Services, LCSW
3. Martha Johnson, Director, La Plata County Department of Human Services and San Juan County Department of Social Services, LCSW
4. Matt Dodson, Director, Archuleta County Department of Human Services, LCSW

Yes! Medicaid should always be the first payor. Any services for families who are not medicaid-eligible can be covered by Core or other funds.

This continues to be a challenge. If someone on Medicaid is denied say MST through the RAE, then counties will have to decide whether to use CORE to offer those services as they do now or find a different funding stream. The RAEs will continue to use their own process for determining medical necessity. The Medicaid Subcommittee of the Delivery of Child Welfare Taskforce is also engaging in ongoing conversations around these topics. CHSDA is recommending that Medicaid start collecting data on denials of medical necessity and related metrics.

There is no set schedule in place. The Statewide Prevention Integration Subcommittee of the Child Welfare Prevention Task Group under Child Welfare SubPAC will be making recommendations for adding programs to the state’s five-year prevention plan going forward. The subcommittee meets monthly on the first Tuesday and details are still being worked out. More details about the subcommittee are available here.

The Colorado Department of Human Services (CDHS) submitted Colorado’s Family First Prevention Program Plan to the Administration for Children and Families on September 30, 2021. ACF has up to 45 days to review the plan for feedback or approval. Prevention Plan Link

If the provider is not a Medicaid provider and the family is not Medicaid-eligible, CDHS would drawdown for IV-E reimbursement after the service has already been paid for using CORE or other appropriate funding sources. If the provider is not a Medicaid provider but the family is Medicaid eligible, the RAE would want to touch base with HCPF and work through specific scenarios. In general if Medicaid isn’t covering a service, we can use other sources of funding.

CDHS’s Division of Child Welfare Staff have created a “Family First: Prevention Scenarios Tipsheet” to provide guidance for county staff around entering individual prevention plans into Trails.

CDHS is working to ensure we can create individual prevention plans at any level of involvement or case type. See the Family First: Prevention Scenarios Tipsheet.

According to the Title IV-E Prevention Services Clearinghouse website, at least annually, they will issue a public call for programs and services and send it to relevant listservs for dissemination. Submissions to the call will be added to the Prevention Services Clearinghouse database of recommended programs and services. The Prevention Services Clearinghouse will retain all submissions that are eligible for review. The public, including state or local government administrators and Tribes, will have the opportunity to submit program or service recommendations for potential review through electronic submission or mail directly to the Prevention Services Clearinghouse. Particular consideration will be given to programs and services recommended by State or local government administrators and Tribes; rated by other clearinghouses (such as CEBC or HomVEE); recommended by federal partners; and/or evaluated as part of any grants supported by the Children’s Bureau.

In CO, the process is managed through the Child Welfare Prevention Task Group.

Appendix A in Colorado’s five-year prevention program plan provides detailed descriptions of fidelity monitoring and CQI processes specific to each prevention service proposed in Colorado’s initial plan. For some services, there is already an existing tool or metrics used for monitoring fidelity of that service that are managed by provider intermediaries. Then there are other services where that infrastructure doesn’t already exist that will work directly with the state to determine how their programs will be monitored. Colorado is also looking at how we can use some state Family First Transition Funds for a contractor to develop and release a statewide CQI platform and create a process to standardize fidelity metrics across services. The goal of state-level CQI is to generate actionable data to inform state-level investments that promote high-quality delivery of services and performance-based contracting decisions.

Any new IV-E drawdown for prevention services will not go directly back to counties–it will go into the Trust Fund, where it will lose its “classification” as IV-E prevention funding. As such, there will not be an option to use prevention IV-E vs. Core specifically, but counties could use their Child Welfare block allocation, which includes traditional IV-E, to fund prevention services. Prevention IV-E for direct prevention service expenditures will be deposited into the trust fund after being claimed (originating from OEC line items that fund things like SafeCare and CW block such as. non-Medicaid expenditures for MST). There are a couple of key differences in how Core Services and the Trust Fund will operate. The Trust Fund will be set up in a grant-like format, so that counties and partners can apply for grant funding to use towards delivering Family First evidence-based prevention services or prevention services working towards meeting evidence standards. Whereas Core services funding can be used flexibly to fund child welfare prevention activities–typically on the secondary and tertiary prevention side (services to reunify families, services to prevent out-of-home involvement and further penetration, etc)– the Trust Fund dollars will fund activities more in the primary and secondary prevention sphere with some exceptions/overlap. For example, things like Multisystemic Therapy (MST) and Family Functioning Therapy (FFT) could be funded by both Core and Trust Fund dollars. MST and FFT are the only two Family First services *right now* that are on the federal clearinghouse and funded actively through Core services in Colorado. It comprises a pretty small amount of Core–not a big opportunity for drawdown. Any prevention service expenditures that come from Core services block, if we can drawdown prevention IV-E, that will be deposited into the trust fund. The overall impact to the core
services line item is pretty minimal in that, any existing IV-E in that line item is still going to continue to exist. We don’t drawdown much IV-E into Core services. It’s about $3 million of $57 million and that’s all related to staffing that’s captured through the Random Moment Sampling (RMS) system. So all in all, the core services block shouldn’t be affected. The only thing that will change is if counties choose to use core services for family first-eligible services, any added prevention drawdown in the future would go into the trust fund to be pooled for strategic capacity building and awarded out through an RFP process. The August 19 session covered guidance on Funding to Support Prevention Services & Cross-System Financing Strategies. For Medicaid-eligible services, always use Medicaid before Core.

The Trust Fund will be set up in a grant-like format, so that counties and partners can apply for grant funding to use towards delivering evidence-based prevention services or prevention services working towards evidence standards. The funding awarded through the Trust Fund will not have any effect on an individual family’s SSI/SSA payments. Please reach out to Heather Durosko (duroskhe@co.larimer.co.us) and Angelina Callis (angelina.callis@state.co.us) if you need further information.

CDHS does not currently maintain a list of providers that offer Family First eligible, evidence-based prevention services–we are looking into the most efficient way to provide that content. Reach out to your local county, Family Resource Center and provider network for up-to-date information on service providers available locally that offer Family First eligible prevention services.

From the perspective of the individual family, not much has changed to date. Family First allows the state to start claiming federal reimbursement for a small set of specific services that are already being delivered. Through this new source of federal reimbursement; over time, the evidence-based prevention continuum across the state will be expanded through existing services or new programs. Family First-eligible services only represent a small part of the prevention continuum available to families within their local area and the hope is that this new source of funding will be used alongside other sources of funding and initiatives to support expansion of prevention services and support for families in all regions.

TANF by federal law is allowed to carry a reserve. Colorado is one of ten states with a state-supervised, county-administered system and we have a county- and state-level TANF reserve. County reserves are determined based on your allocation. Counties with an allocation of over $250,000, have their reserve capped at 40% of their allocation. Counties with an allocation under $250,000 have a reserve cap of $100,000. In the case of an overexpenditure, you could draw from your county TANF reserve. If you underspend, you can bank into your county reserve up to those statutory limits. If every county hits the cap, any money that’s in excess of the total county-wide cap goes back into the state’s LTR as directed by law. Counties can also buy/sell TANF. If a county is overspent and needs TANF $, it can buy those funds from another county that is underspent. The participating counties must agree on the MOE transfers as well. There are a few other strategies/mechanisms as well.

Yes, Colorado does have the flexibility to use TANF $ for home visiting programs. We tend to see this done in Colorado more through contracting at the county-level. Since TANF is so flexible, the devil is often in the details, so please reach out to Andrew Rauch (andrew.rauch@state.co.us) if you want to talk through this. But yes, it’s generally allowed.

Colorado Community Response (CCR) is a voluntary program to prevent child maltreatment and strengthen families by targeting the protective factors of concrete supports and social connections. CCR is currently provided as a prevention service for screened-out referrals and closed assessments is being delivered at 21 sites encompassing 31 counties in rural and suburban areas across the state. CCR has not yet been rated by the Clearinghouse, and Colorado has determined that it does not yet meet Clearinghouse evidence standards. However, initial research does suggest that this service is beneficial to Colorado families; the program participated in a randomized control trial which recently ended June 30, 2021. Results of the randomized control trial will be available in the summer of 2022. To find out more about Colorado Community Response (CCR), you can contact OEC’s program manager, Katelyn Lammie (latelyn.lammie@state.co.us). In addition, CCR is an example of a prevention service used throughout the state that embeds Motivational Interviewing in all aspects of service delivery. As such, Colorado is exploring how to claim for Motivational Interviewing as a part of CCR delivery.

A few counties (Boulder, Denver and Jefferson) are working to launch Family Connects, a universal, evidence-based program that connects parents of newborns to the community resources they need through postpartum nurse home visits, as a part of their home visiting continuum. Colorado also has a Home Visiting Investment Task Force that has recently developed Task Force Recommendations and a Home Visiting Plan to scale the continuum of home visiting services in Colorado.

For programs funded through CDHS (including programs offered by the Office of Early Childhood and captured in Salesforce), we are planning to merge data at the state level and submit it to the Feds at specific points in time for claiming and Federal reporting purposes. For services delivered by providers outside of any internal systems, Colorado will continue to work with service providers and their intermediaries to determine the best way to collect and submit the information required by the Federal Government. It’s a longer runway to realize the broader definition of candidacy and maximize claiming for services delivered outside of any internal state system.

OBH released our Populations in Need study last summer which does a great job highlighting the needs in specific communities (more information is available here). We are also following the Governor’s Behavioral Health Task Force’s recommendations. Most recently, OBH released our SB 19-222 plan which aligns very closely with Family First. We are working to ensure that all communities have “safety net” services through technical assistance and targeted funding opportunities. You can find the 222 report here. In addition, in June 2021, Governor Jared Polis signed Senate Bill 21-137 which appropriated $9,000,000 to the Office of Behavioral Health (OBH) to provide matching grants to County Departments of Human Services or Social Services for the expansion or improvement of local or regional behavioral health disorder treatment programs. That RFA is currently open on the Colorado Vendor Self Service (VSS) system (Solicitation#: 2022000092) with applications due by November 8, 2021 at 5pm MT.

Full Question: The counties may be able to identify a need for behavioral health services, but it’s not necessarily their expertise or role to create the services themselves. With workforce and other challenges, is OBH exploring state-created services around behavioral health, paying higher salaries to incentivize local workforce capacity, etc. What are creative ideas of filling gaps in Colorado’s rural areas without relying on existing providers applying for various grants?

Answer: This is something Colorado hopes to work towards with the new Behavioral Health Administration (BHA) and SB222 efforts (services that should be accessible in all regions, regional approaches for expanding providers, etc).

For Momentum, you can go here: https://www.rmhumanservices.org/bh

Yes, CYMHTA is a voluntary program that allows for families to access mental health treatment services for their child or youth. CYMHTA funding can be available when there is no other appropriate funding source for treatment, such as private insurance. Professionals cannot apply on behalf of a family but can support their completion of the process. Here is the program’s website for more details on accessing the program.

CYMHTA funds have been fully spent in recent years. OBH has supplemented with Federal funds in the past three fiscal years. For direct questions or concerns. on CYMHTA please feel free to contact Stacey Davis at stacey.davis@state.co.us. Annual reports are published on the CYMHTA website. We have also seen roughly a 30% increase in the use of the CYMHTA program each of the last 3 years.

Full Comment/Question: It’s nice to see that many funding streams have a lead/expert at the state level. County staff often don’t have that privilege, especially in small counties, when a few people are responsible for understanding and executing the work to access all these different funding streams. If there could be a training that happened periodically to talk about different funding streams (especially that were applicable for Child Welfare, Early Childhood, and TANF), that would be awesome – there is historical knowledge that may no longer be current that some counties are depending on and updating would be fantastic. Often, counties ask other counties.

Answer: This is a great suggestion. CHSDA and CDHS are exploring what this could look like.

CDHS funding opportunities can be found on the Colorado Vendor Self Service (VSS) System.

Definitely take a look at Momentum. The RAEs will continue to use their own process for determining medical necessity for Medicaid. If medical necessity is denied for an individual trying to access a Medicaid-eligible Family First prevention service (such as MST), then counties and partners will have to decide whether to use CORE or a different funding stream to offer those services. The Medicaid Subcommittee of the Delivery of Child Welfare Taskforce is also engaging in ongoing conversations around these topics. CHSDA is recommending that Medicaid start collecting data on denials of medical necessity, etc. but it is likely that this will continue to be a challenge.

The short answer is no, there will not be enough of the right foster care placement settings available on October 1, 2021. There are limited family-like levels of care in Colorado that can serve children/youth with behavioral health needs and/or a history of juvenile justice involvement (Kinship, Foster homes, inc treatment and therapeutic; etc.). New rates for traditional (age-based), therapeutic and treatment foster care went into effect July 1, 2021 (Memo) and include respite. In addition, here are the separate rules pertaining to treatment and therapeutic foster care. The state released an RFP (#2022000042) that dedicates $500,000 of Colorado’s Family First transition funds to build out a comprehensive placement continuum across the state (efforts to serve high acuity youth in family-like settings; recruitment and retention of therapeutic and treatment foster homes; enhanced supports for foster parents and kinship families). The RFA closed on September 21, 2021 and awardees have not yet been selected. The state foster care workgroup has also been working on recruitment strategies for treatment and therapeutic foster care (transitioning previous group homes/centers).

Additional Background: In January, Colorado’s Department of Human Services convened four “placement continuum learning collaboratives,” to rightsize our placement continuum. One of the groups focused on Treatment and Therapeutic Foster Care (recording available here). From there, the state identified some next steps (“Learning Collaborative Summary” document) and began utilizing a Foster Care Workgroup to dig into the work. While treatment foster care has existed in the state, there were only two providers functioning at the time, which were close to shutting their doors. The Foster Care Workgroup worked with those providers to understand the historical challenges and barriers around the rates, which weren’t enough to sustain the programming. The group drafted new rates for treatment and therapeutic foster care and began presenting recommendations to the state and counties via our formal Child Welfare policy group in April and again in May. The new rates went into effect July 1, 2021 (Memo). The other thing to note is that the rates for treatment and therapeutic foster care were and will continue to be set outside of the state’s legislatively mandated actuarial analysis process for residential providers. The state advocated to keep the rate-setting process separate because they thought doing so would enable them to keep a higher baseline rate for treatment and therapeutic foster care.

As of early 2021 there were two active PRTFs in the state of Colorado, Devereux and Cedar Springs, which were primarily serving out of state residents. Effective July 1, 2021 the PRTF rate was increased to $750 per day. As of October 1, there are currently four other facilities working to transition to a PRTF licensed facility. This document provides more information about the facilities that are currently pursuing or already have a PRTF license. What it doesn’t capture, however, is whether new PRTFs will be building their programming to fill current gaps that Colorado has. Colorado needs facilities that can meet the need of Colorado’s residents programmatically through appropriate staffing, expertise, and
treatment. HCPF is working to address barriers to PRTF utilization on the practice side, including improving the process to incentivize in-state placement needs, as well as, improving actual practice with existing providers. CDHS released an action plan in August that they are working to update for October–it includes actions, timelines, and expected outcomes the department is pursuing related to resources for high-acuity behavioral health needs, including expanding PRTFs.

Through SB21-137, CDHS expects to contract for and manage 15-20 beds for high-acuity youth in PRTF or QRTP settings. Providers will be fully compensated with ARPA funding at a daily rate between $600/day and $850/day (depending on the level of care) and CDHS will manage all admissions/discharges. Beds are expected to come online in November/December 2021. In addition, SB21-276 expanded bed capacity and funding options for children/youth with intellectual and developmental disabilities (IDD) who are in need of residential treatment. The existing state-contracted intellectual and developmental disability (IDD) RCCF facility (10 beds) is serving 12-15 children/youth annually and is chronically on a waitlist. Through SB276, CDHS expects to contract with a second facility for another 10 beds for children/youth with IDD. The contract is expected to be in place by December 31, 2021, for likely 5 beds to start, which will be expanded to 10 as more CHRP funds are drawn down. The new facility is expected to serve 12-15 children/youth annually by 2023.

There are not any new funding sources for youth that are currently in placements that are not approved under Family First.