1. The Current Landscape for Children with Special Health Care Needs: Riding the Roller Coaster Laurie A. Soman Lucile Packard Children’s Hospital March 2, 2010

2. State FY 08-09 and FY 09-10: The Roller Coaster Accelerates FY 08-09 18-month budget plan for FY 08-09 and FY 09-10 18-month budget plan for FY 08-09 and FY 09-10 Governor signed budget clearing $41 billion deficit on 2/20/09 Governor signed budget clearing $41 billion deficit on 2/20/09 Longest budget battle and elimination of largest deficit in state history Longest budget battle and elimination of largest deficit in state history Numerous reductions in health and other services Numerous reductions in health and other services FY 09-10 Continued economic slide results in revised budget for current Fiscal Year 2009-2010 Continued economic slide results in revised budget for current Fiscal Year 2009-2010 Governor signed budget clearing $20 billion deficit on 7/28/09 Governor signed budget clearing $20 billion deficit on 7/28/09 Deep reductions in health and other services Deep reductions in health and other services

3. Budget Cuts and Their Impact on CSHCN: The Roller Coaster Ride in 2008-2010 Healthy Families Program Healthy Families Program California Children’s Services (CCS) California Children’s Services (CCS) Early Start Program Early Start Program In-Home Supportive Services (IHSS) In-Home Supportive Services (IHSS) Medi-Cal Medi-Cal

4. Reductions in Healthy Families Funding: Bad News, Good News Bad News: Major Funding Cuts $194 million deficit in program funding, including $50 million vetoed by Governor in July, 2009 $194 million deficit in program funding, including $50 million vetoed by Governor in July, 2009 MRMIB created wait list for new applicants MRMIB created wait list for new applicants -- >80,000 children on list as of September, 2009 -- >80,000 children on list as of September, 2009 -- total wait list estimated to reach 335,000 by June, -- total wait list estimated to reach 335,000 by June, 2010 2010 MRMIB voted to implement disenrollment of current program enrollees beginning October, 2010 MRMIB voted to implement disenrollment of current program enrollees beginning October, 2010 -- total disenrollment estimated to reach 585,000 by -- total disenrollment estimated to reach 585,000 by June, 2010 June, 2010

5. Reductions in Healthy Families Funding Good News: Deal Struck to Save Program State First 5 Commission contributed $81 million for coverage of children aged 0-5 State First 5 Commission contributed $81 million for coverage of children aged 0-5 Increases in HFP premiums and co-pays (e.g. health/vision/dental co-pays to $10) as of November 1, 2009 Increases in HFP premiums and co-pays (e.g. health/vision/dental co-pays to $10) as of November 1, 2009 State legislation created managed care plan provider tax for federal match generating funds for program State legislation created managed care plan provider tax for federal match generating funds for program MRMIB rescinded decision to begin disenrollments MRMIB rescinded decision to begin disenrollments MRMIB re-opened enrollment to new applicants and cleared children on wait list MRMIB re-opened enrollment to new applicants and cleared children on wait list

6. Reductions in Funding for California Children’s Services (CCS) Reductions in funding for Medical Therapy Program Reductions in funding for Medical Therapy Program “Capped allocations” to county CCS programs for local administration of CCS “Capped allocations” to county CCS programs for local administration of CCS Average reduction of 17% to counties but some counties reduced as much as 58% Average reduction of 17% to counties but some counties reduced as much as 58% Reductions resulted in loss of staff and activities: Reductions resulted in loss of staff and activities: -- PHLs eliminated in many counties -- PHLs eliminated in many counties -- Layoffs of social workers, eligibility workers, and -- Layoffs of social workers, eligibility workers, and nurse case managers nurse case managers -- Cutbacks to Medical Therapy Program services -- Cutbacks to Medical Therapy Program services -- Scaling back or elimination of family-centered -- Scaling back or elimination of family-centered care activities care activities

7. Reductions in Funding for Regional Centers/Early Start Program 3% reduction in funding for Regional Centers’ operations and for Purchase of Service payments to vendors (2/09) 3% reduction in funding for Regional Centers’ operations and for Purchase of Service payments to vendors (2/09) $100 million in “cost containment” for Regional Centers (2/09) $100 million in “cost containment” for Regional Centers (2/09) $234 million in additional “cost containment” for Regional Centers (7/09) $234 million in additional “cost containment” for Regional Centers (7/09) $50 million vetoed by Governor specifically for Early Start Program (7/09) $50 million vetoed by Governor specifically for Early Start Program (7/09) Cuts resulted in major changes to Early Start Program Cuts resulted in major changes to Early Start Program Families of young children now required to access private or public insurance before receiving most Regional Center therapies Families of young children now required to access private or public insurance before receiving most Regional Center therapies

8. Impact of Budget Reductions on Early Intervention Services for Children Aged 0-3 Developmental Status Age at Referral Program Eligibility Criteria High Risk Children* New Prevention Program * Previously eligible for Early Start Program 0-23 mos Presence of two or more risk factors using former at-risk criteria: prematurity, low birthweight, seizures, assisted ventilation, biomedical insult, prenatal drug exposure, etc. 24-35 mos 33-49% delay in any one area 0-35 mos Child’s parent has a developmental disability Developmental Delay Early Start Program 0-23 mos 33% delay in one or more areas 24-35 mos 50% delay in one area or 33% delay in two areas Established Risk Condition Early Start Program 0-35 mos Presence of Down syndrome, cerebral palsy, mental retardation, autism, or epilepsy

9. Reductions in In-Home Support Services Bad News: July, 2009 Final Budget Cuts Elimination of IHSS domestic and related services for recipients with Functional Index rankings below 4 Elimination of IHSS domestic and related services for recipients with Functional Index rankings below 4 Elimination of all IHSS services for recipients with Functional Index scores below 2 Elimination of all IHSS services for recipients with Functional Index scores below 2 Additional savings anticipated through “fraud prevention”, including requiring IHSS providers to be fingerprinted and have background checks Additional savings anticipated through “fraud prevention”, including requiring IHSS providers to be fingerprinted and have background checks Governor vetoed an additional $29.8 million from IHSS, meaning more reductions in IHSS eligibility Governor vetoed an additional $29.8 million from IHSS, meaning more reductions in IHSS eligibility

10. Reductions in In-Home Support Services Good News: Legislature/Courts Mitigate Some Cuts Legislature defeated Administration proposal to eliminate 90% of IHSS caseload Legislature defeated Administration proposal to eliminate 90% of IHSS caseload October 19, 2009: US District Court blocked implementation of eligibility cuts based on Functional Index scores October 19, 2009: US District Court blocked implementation of eligibility cuts based on Functional Index scores Another suit blocked reduction of IHSS worker wages Another suit blocked reduction of IHSS worker wages Third suit is challenging list of crimes that disqualify IHSS provider participation Third suit is challenging list of crimes that disqualify IHSS provider participation

11. Changing the Current Landscape: Federal 1115 Waiver and CCS Redesign Federal 1115 Waiver Federal 1115 Waiver Seniors and Persons with Disabilities and Managed Care (including children) Seniors and Persons with Disabilities and Managed Care (including children) CSHCN/CCS CSHCN/CCS Adults with Severe Mental Illness Adults with Severe Mental Illness Dual Eligibles (Medicare/Medi-Cal) Dual Eligibles (Medicare/Medi-Cal) Expansion of managed care to rural regions Expansion of managed care to rural regions

12. Changing the Landscape: Federal 1115 Waiver and CCS Redesign CCS Redesign CCS Redesign Title V Needs Assessment Title V Needs Assessment CCS Redesign: Technical Workgroup under 1115 Waiver Stakeholder Group CCS Redesign: Technical Workgroup under 1115 Waiver Stakeholder Group CHIPRA Grant Proposal: Provider-based model of care for CSHCN CHIPRA Grant Proposal: Provider-based model of care for CSHCN

13. Changing the Landscape: Federal 1115 Waiver and CCS Redesign Next Steps 1115 Waiver/CCS Redesign 1115 Waiver/CCS Redesign -- Legislature must approve waiver design -- Legislature must approve waiver design Federal CHIPRA Proposal Federal CHIPRA Proposal -- Special Care Center-based pilot project -- Special Care Center-based pilot project for CSHCN for CSHCN State Budget State Budget -- New roller coaster ride ahead -- New roller coaster ride ahead

14. Resources 1115 Waiver/CCS Redesign Resources State Waiver Renewal Website: http://www.dhcs.ca.gov/provgovpart/Pages/WaiverRenewal.aspx State Waiver Renewal Website: http://www.dhcs.ca.gov/provgovpart/Pages/WaiverRenewal.aspx http://www.dhcs.ca.gov/provgovpart/Pages/WaiverRenewal.aspx CCS Technical Workgroup Webpage: http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupCC S.aspx CCS Technical Workgroup Webpage: http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupCC S.aspx http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupCC S.aspx http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupCC S.aspx Seniors and Persons with Disabilities Technical Workgroup Webpage: http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSP Ds.aspx Seniors and Persons with Disabilities Technical Workgroup Webpage: http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSP Ds.aspx http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSP Ds.aspx http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSP Ds.aspx State Budget Resources California Department of Finance: http://www.dof.ca.gov/ California Department of Finance: http://www.dof.ca.gov/http://www.dof.ca.gov/ Legislative Analysts Office: http://lao.ca.gov/laoapp/main.aspx Legislative Analysts Office: http://lao.ca.gov/laoapp/main.aspxhttp://lao.ca.gov/laoapp/main.aspx California Budget Project: http://www.cbp.org/ California Budget Project: http://www.cbp.org/http://www.cbp.org/