Minnesota Department of Human Services family experiences Introduction: Jim Koppel – new Assistant Commissioner for Children and Families at MN DHS Commissioner Jesson provided an overview of DHS yesterday. Today is to provide some context for how families can move toward economic self-sufficient/stability. Overview for Joint House Health and Human Services Finance and Health and Human Services Reform Committees January 14, 2015

Mary and her children Mary just lost her job in retail sales. She has two children, Tony, 7, and Diane, 4, and is separated from her husband. She is not eligible for unemployment insurance, and applies for the Minnesota Family Investment Program (MFIP) and Child Care Assistance Program (CCAP) while she looks for work. Mary and her children are a fairly typical family coming to us for help.

MFIP and CCAP With no other income, Mary will receive $532 in cash assistance (MFIP) and $459 in food assistance (Supplemental Nutrition Assistance Program or SNAP) per month for a total of $991. Federal poverty level for a family of three is $1,649. While looking for work, Mary also receives Child Care Assistance. Child Care Assistance payment amounts vary based on: age of child, amount of time, location and type of care provided. The statewide average payment in state fiscal year 2013 was approximately $962 per family per month.

People who receive MFIP and CCAP services Of the 90,804 individuals in an average month served by MFIP, 71 percent are children. About one-third of these children are 5 years old or younger. Child Care Assistance is provided for 31,219 children in an average month. MFIP is our primary cash assistance program for low-income Minnesotans. MFIP participants must participate in work activities in order to receive benefits. Many of the families who receive our services are low-income individuals who often work non-traditional hours in minimum wage jobs, making it difficult to find child care. Of the 90,804 individuals receiving MFIP, about 61,500 are children and 26,300 are adults. MFIP/Diversionary Work Program/ Work Benefit Cases Persons 2015 Projected Expenditures Cases Persons Total Expenditures MFIP 33,636 90,804 $294 million Includes SNAP which is about half the total or $150 M DWP 2,623 7,841 $13 million WB 1,047 3,699 $352 K (Work benefit program which is suspended in 2015 TOTAL 37,306 102,344 $307 million The overall caseload for MFIP, including MFIP, DWP and child only cases has fallen. In 1999 the caseload was over 135,000 In 2015 it is projected at 99,000 Child Care Assistance Programs Cases Persons 2015 Projected Expenditures MFIP Child Care Assistance 8,646 16,161 $138 million Basic Sliding Fee 8,468 15,285 $93 million TOTAL 17,114 31,446 $231 million

Food supports In 2013, more than 533,000 Minnesotans in an average month received food via SNAP, and even more via food shelves. Total value was over $750 million with an average monthly SNAP benefit of $118 per person. Almost all food supports are federally funded. ELIGIBILITY 165% FPG ($2,721 for a family of three) No asset test

Health Care Mary claims both children as tax dependents and has no other income (MFIP, SNAP, and CCAP excluded). Mary and both children are eligible for Medical Assistance (MA). Eligibility for MA is based on 133% FPG ($2,193 per month) for a household size of three for a parent, and 275% FPG ($4,535 per month) for a household size of three for a child, age 2-18. Under the ACA rules that went into effect 1/1/2014, MA eligibility for families with children and adults is based on the Modified Adjusted Gross Income (MAGI) income methodology. With some exceptions, the income used in the eligibility determination is based on a tax-filing household’s taxable income.

Medical Assistance for Families with Children Medical Assistance (MA) is Minnesota’s Medicaid program. It is the largest of Minnesota’s publicly funded health care programs. The average monthly enrollment of individuals enrolled in MA was 739,000 in FY 2015. 59% are families with children. Most enrollees get their health care through health plans. The rest get care on a fee-for-service basis, with providers billing the state directly for services provided. MA is funded jointly with federal, state and county funds. There is no asset test for families with children and adults. MA funding – Yes, there are some county funds in MA but they are very minimal.  They are usually for long term care. 

Melissa and Jenny Melissa is a single mother of Jenny, age 14. Jenny was diagnosed with a developmental disability shortly after birth. Melissa has been able to support her without other services, but as Jenny’s gotten older she’s found Jenny needs more help than she can provide.

Medical Assistance and DD Waiver Melissa requests the Developmental Disabilities waiver for her daughter to receive case management, teaching and training services to help her be more independent, and respite for herself. In order to receive the DD Waiver, her daughter needs to be eligible for Medical Assistance.

Medical Assistance If the family’s income is too high for Medical Assistance, Melissa can apply through the TEFRA option for her daughter. If the child is found to have a disability, and require institutional level of care, the TEFRA option will look at the child’s income alone to determine eligibility for Medical Assistance. Once found eligible for Medical Assistance, Jenny can receive services she has a need for, including Personal Care Assistance to help with daily activities Medical Assistance eligibility is based on family’s income. For children with significant disabilities, they may be eligible for Medical Assistance, even if their family’s income is too high. Parents of children who are found eligible under the TEFRA option must pay a parental fee based on their income. A person on Medical Assistance can receive services when they meet the medical necessity criteria. For PCA, that includes receiving an assessment to determine where the person has dependencies. Institutional level of care means they need the type of services provided in an institution.  Another way of saying it is if they didn’t receive the supports needed for them to live in the community, they may need to live in an institution.  Institutions include nursing facilities, hospitals, and intermediate care facilities for people with developmental disabilities (ICF/DD).

Home and Community-Based Services Waivers HCBS waivers provide community alternatives to institutionalization There are 4 HCBS waivers in Minnesota for people with disabilities Brain Injury waiver Community Alternative Care for people who require hospital level of care Community Alternatives for Individuals with Disabilities for people who require nursing facility level of care Developmental Disabilities waiver The home and community-based services waivers are available when people have higher needs than what is available through Medical Assistance. The waivers prevent people from being institutionalized or help people move out of institutions, and receive similar supports in their home and community. Because waiver resources are limited, there are priorities for access to waivers. The priorities include: People moving out of institutions People who no longer need the level of services provided where they are living People who have an unstable living situation People who need protection from abuse, neglect or exploitation

HCBS Waivers for people with disabilities Avg. Monthly Enrollment (FY14) Avg. Monthly Cost (FY14) Avg. Monthly Cost for people living in their own home (FY14) Brain Injury (BI) 1,342 $6,039 $1,872 Community Alternative Care (CAC) 357 $6,166 $4,485 Community Alternatives for Individuals with Disabilities (CADI) 17,396 $2,751 $1,119 Developmental Disabilities (DD) 15,879 $5,629 $3,084 These numbers show the average monthly spending for each of the disability waivers. All together, the disability waivers support almost 35,000 people in an average month. The costs listed here do not include home care costs, although many of the people accessing waiver services are also accessing home care services. Home care services include PCA, Home Health Aide, Home Care Nursing, and Home Health Therapies.  The range of cost varies significantly depending on the service needs of the person receiving services. It is much less costly for people living in their own home than people living in a residential setting owned or controlled by a service provider. Also, research shows that people living in their own home have a better quality of life than people living in an institutional-type setting.

Robert and Justin Robert is a single father who earns $27,000 a year at his job, but that’s not enough to pay for child care. He doesn’t know much about child care, but wants the best for his son, Justin, age 4. Child Care Assistance Program and Parent Aware can help.

Child Care Assistance – Basic Sliding Fee Program The Child Care Assistance Program can help pay for the costs of child care.  Families who are not currently or recently receiving assistance through the Minnesota Family Investment Program are eligible for Child Care Assistance through the Basic Sliding Fee Program. CCAP-Basic Sliding Fee Funding: Basic Sliding Fee funds are allocated to counties. Basic Sliding Fee is a capped allocation, and some counties maintain a waiting list. As of November 2014, 17 counties maintained waiting lists that included a total of 6,157 families. Access to high-quality care may be limited by long waiting lists for funds. In Robert’s case, based on his annual income of $27,000 per year, he would be responsible to pay $47 every two weeks to pay for child care.

Parent Aware Quality Rating Improvement System for child care and early education programs Provides information to parents on quality Technical assistance and training available for center-based child care providers, family child care providers, Head Start programs and school-based pre-kindergarten programs Expansion statewide in progress The Department of Human Services leads implementation of Parent Aware in coordination with the Minnesota Office of Early Learning.  Parent Aware is a system for improving and rating the quality of child care and early education programs, and then providing that quality information to parents in an easy-to-use format of One-to Four Star Ratings. The ratings synthesize research on early childhood development to provide an objective assessment of quality that improves kindergarten readiness.  The ratings measure if and how child care and early learning professionals are using best practices that are most predictive of kindergarten readiness. Child Care Aware of Minnesota, Minnesota’s network of child care resource and referral agencies, coordinates local level implementation of Parent Aware.  An early childhood program must be participating in Parent Aware in order to be eligible to accept an early learning scholarship. The Child Care Assistance Program includes a quality differential for 3 and 4-star Parent Aware rated providers, and to providers holding certain accreditations. Services provided through Parent Aware include: Ratings information for parents to help them determine how well a program will prepare their child for kindergarten Technical assistance, training and coaching for child care programs and providers to help them improve their quality. Parent Aware Funding Provided through a combination of federal Child Care and Development Block Grant funds, and Race to the Top and private funds totaling over $6.5M in 2014.

Health Care Robert earns $2,250 per month from his job (172% FPG for household size of 2). Robert is eligible for MinnesotaCare because his income is under the income limit of $2,621 per month (200% FPG for household of 2). Robert’s coverage will begin the month following the month eligibility is approved. He must pay a $38 monthly premium for his coverage. Robert’s 3-year-old son Justin is eligible for MA. The income limit for MA for children is 275% FPG. People who are eligible for MA cannot be enrolled in MinnesotaCare. Many families have some household members in MA and some in MinnesotaCare. The benefit set is essentially the same in both programs.

MinnesotaCare MinnesotaCare covers people who do not have access to affordable health insurance and have higher income levels than those served on the MA program. The average monthly MinnesotaCare enrollment in FY 2013 was 125,000. Eligibility rules changed in 2014 to align with the Affordable Care Act. Under the new rules, primarily parents and adults without children are enrolled in MinnesotaCare. Most children and pregnant women are now eligible for MA. Access to minimum essential coverage such as coverage through Medicare and employer-sponsored plans is a barrier to MinnesotaCare coverage. MinnesotaCare is still in place and it is receiving BHP funding – still referred to as MinnesotaCare. Changes for MinnesotaCare as BHP include no hospital cap, no un-insurance waiting period, lower premiums and lower hospital copays.

MinnesotaCare Funding and Service Delivery MinnesotaCare is paid for by enrollee premiums and draws on appropriations from the Health Care Access Fund and federal Basic Health Program funds (beginning in 2015). MinnesotaCare expenditures were $571 million in FY 2013. This represented 4.7% of DHS overall budget. The average medical payment per enrollee was $4,571 a month. All MinnesotaCare enrollees are served through health plans. MinnesotaCare health care program is the first state program awarded funding under the federal Basic Health Plan (BHP) beginning Jan. 1, 2015.

Jacob Teachers notice that 7th-grade Jacob is more withdrawn than usual. Harsh outbursts intersperse with his silence. His guidance counselor calls in the school’s contracted mental health clinic for an assessment. School-linked mental health grants

Mental health services in school The licensed psychologist gives a preliminary diagnosis and Jacob’s Individual Education Program (IEP) Team adds treatment sessions to his IEP. Since Jacob’s family has Medical Assistance coverage, the school bills MA for the community psychologists' services. Lacking MA, the School-Linked Grant could be used. The public stigma against mental health fades when it can be offered in a so-called “normal” setting, like a school. The easiest way to get mental health services into schools is for the School District to contract with a local, community mental health clinic or mental health center. The school opens a room for an outside clinician to meet with a student. Depending on the student’s health coverage, several payment options are available. For low-income students with an IEP (Individual Education Program), the school bills the DHS Medical Assistance (MA) program and pays the provider. For a higher-income student with a disability, the school also can bill Medical Assistance. If the student’s family has employer insurance, the provider agency bills private insurance directly. For a student who lacks both public and private health insurance, mental health care can be covered with a School-Linked Mental Health Grant.

Marcus Marcus is a veteran who has been in and out of work due to difficulties with depression and chemical dependency. He is homeless and living on the streets. He may qualify for benefits to get shelter. He is likely eligible for chemical dependency treatment.

Housing benefits Marcus is eligible to stay at a shelter where his room and board is covered by Group Residential Housing. He receives $97 a month for personal needs through the General Assistance (GA) program. Marcus is assisted with getting on Supplemental Security Income (SSI, $733/month), Minnesota Supplemental Aid (MSA, $81/month), SNAP ($16/month) and Medical Assistance for a total of $830 in benefits. Federal poverty level for one person is $972.50 monthly. Due to the tight rental market and lack of available Section 8 vouchers, Marcus will need some assistance paying for stable housing – either a state rental subsidy program or income supplement program, or a program funded through HUD McKinney-Vento. Housing Benefits: These programs are for people with disabilities or people who are elderly and who live in licensed settings. In this example, once Marcus moves from the shelter to an apartment he receives SSI, MSA and SNAP and has those resources to pay for his own housing in the community. GRH pays $876/month for room and board to the shelter. Assistance to get on SSI – DHS has contracts to pay organizations, including counties, to assist individuals to obtain SSI benefits. *** NOTE: Info to use if asked - There are more than $25 million in HUD McKinney-Vento grants awarded throughout the state annually. People access these housing and/or supportive service funds through a nonprofit agency in the community. HUD is requiring regions to develop coordinated assessment processes to streamline applications and access to make sure people get the right level of care. Minnesota is mid-way through implementing these new systems throughout the state.

Housing programs Group Residential Housing, pays for room-and-board for adults living in licensed or registered settings who are elderly or have disabilities and who have low incomes Minnesota Supplemental Aid Shelter Needy, provides assistance to adults with disabilities who have low incomes, high housing costs and live in their own home State and federal grants to local service providers for shelter, transitional housing, and permanent supportive housing GRH and MSA Shelter Needy are our state income supplement programs for housing. We have several other programs that are housing related (DHS alone has 27 different programs).

People who receive housing services Families with children, youth, single adults. Most of the adults served have disabilities (developmental and physical/mobility disabilities, mental illness and chemical dependency)  Children and youth make up 46 percent of Minnesota’s homeless population, per 2012 Wilder report. Per the 2012 Wilder Report on homelessness: Young people are most at risk for homelessness. Children and youth age 21 and younger make up 46 percent of Minnesota’s homeless population. According to the census, they make up just 30 percent of the overall population.  Housing Funds for Group Residential Housing (GRH) and Minnesota Supplemental Aid (MSA) Shelter Needy Group Residential Housing: $130 million in 2013 Minnesota Supplemental Aid Shelter Needy: $1.3 million 2015 estimates GRH Persons: 20,628 GRH expenditures: $151 million Annually $25 million in homeless funding from the US Department of Housing and Urban Development is awarded to counties, cities and non-profits across the state to address homelessness.  (previously mentioned)

General Assistance and Minnesota Supplemental Aid General Assistance helps individuals with little or no income meet their basic needs. Minnesota Supplemental Aid is an income supplement for people who receive federal Supplemental Security Income (SSI), or who are just over the SSI income limit GRH is for people who either are GA- or MSA-eligible

People who receive GA and MSA General Assistance 23,216 people received GA in an average month in 2013. Typical monthly benefit is $203 for an individual and $260 for a couple. Minnesota Supplemental Aid 30,344 people received MSA in an average month in 2013. Typical monthly benefit is $81 for an individual and $111 for a couple. General Assistance and Minnesota Supplemental Aid Funding (2015 projections) General Assistance $54 million, state funds Minnesota Supplemental Aid $39 million, state funds MSA is part of a Maintenance of Effort agreement with the Social Security Administration.  GA is part of our Interim Assistance Agreement, meaning that people receiving GA sign an Interim Assistance Agreement allowing DHS to recoup state benefits paid with back payments from Social Security. 

Chemical dependency treatment Marcus wants to get help with his chemical dependency. He is eligible to get a “Rule 25” assessment at his county office to determine whether he needs a referral to chemical dependency treatment. Chemical Dependency Benefits: Individuals may approach their county of residence, tribe or managed care organization in order to receive a “rule 25” assessment for substance use disorder. If referred for treatment the individual would receive appropriate services, which might be residential or outpatient treatment. Persons are eligible to receive Consolidated Chemical Dependency Treatment Fund services if at or below 133% of Federal Poverty Guidelines for household income. An individual eligible for the Consolidated Treatment Fund may receive treatment without any co-payment. There are approximately 54,000 admissions to chemical dependency programs each year, of which about 42% are Consolidated Chemical Dependency Treatment Fund and 22% are Managed Care Organization Admissions.

Health Care While Marcus is waiting for his SSI determination he is eligible for MA as an adult without children. Marcus does not have an asset test and the income limit is 133% FPG ($1,293 per month). Marcus will continue to be eligible for MA if he is approved for SSI. People who are age 21 through 64, do not have dependent children, are not receiving SSI, and who are not eligible for Medicare may be eligible for MA as an adult without children. People who are certified disabled but who are not yet eligible for Medicare or receiving SSI may choose either the adult without children or disability basis of eligibility. The adult without children basis does not have an asset test so may be the better option for some people. Marcus will continue to be eligible for MA if he is approved for SSI but will now be eligible under the disability basis. WHY is the FPG lower for someone with a disability than for an adult without children? State law has different income levels for different groups.  It is true that the disability income level is lower.  This is an issue that advocates are well aware of and are working on fixing.  Disability Basis The income limit under the disability basis is $973 per month for a household of 1 (100% FPG). Marcus will be subject to an asset test under the disability basis. The asset limit is $3,000 under the disability basis.

Marcus and Bill Marcus’ father Bill is 88 years old, has multiple chronic conditions and limitations in daily activities but strongly desires to remain in his own apartment. Bill and Marcus both wish to reconnect with one another.

Elderly Waiver (EW) Bill is on Medicare and is financially eligible for Medical Assistance. He has a care coordinator through his health plan. His care coordinator assesses his need for assistance and determines he is eligible for Elderly Waiver, which will pay for services to help him remain in his apartment. Through EW, Bill chooses to receive home delivered meals, homemaking, assistance with bathing, and a weekly nurse visit to set up medications and monitor his health conditions. Bill’s goal is to reconnect with his son Marcus. EW pays for transportation for Bill to visit Marcus in his new apartment.

Elderly Waiver and Alternative Care for older adults Provide community alternatives to nursing homes for people age 65 and older. Elderly Waiver (EW) is for people who are financially eligible for long term care under Medical Assistance, and who meet level of care (need) requirements Alternative Care (AC) is for people with low income and assets who are not eligible for Medical Assistance and who meet level of care requirements. There are no ‘waiting’ lists for either EW or AC. Persons in each program have a monthly budget that is capped at a specific amount in order to manage the state’s portion of the program costs.

Elderly Waiver and Alternative Care Program Avg. Monthly Enrollment (FY14) Avg. Monthly Cost (FY14) Elderly Waiver (EW) 23,011 $1,198 Alternative Care (AC) 2,888 $768

Medical Assistance (MA) for Persons Over Age 65, Blind, or Disabled Elderly and people with disabilities made up only 31% of total enrollment, but 66% of total MA expenditures in FY 2013. People with disabilities who work and earn more than $65 a month may be eligible for MA for Employed Persons with Disabilities (MA-EPD). There is no income test for MA-EPD. There is a $20,000 asset limit and eligible people must pay a monthly premium for coverage. People who receive Medicare may also be eligible for a Medicare Savings Program (MSP) that may help pay Medicare premiums and cost-sharing. There are different income and asset limits for the MSPs than for MA.

Questions and answers