1. “The Fiscal Big Picture” First – Federal IV-E “Placement Maintenance” - (uncapped) eligibility and reimbursibility required - (uncapped) eligibility and reimbursibility required - does not apply to secure facilities, detention, or state facilities - does not apply to secure facilities, detention, or state facilities Second – Act 148 – Needs Based Budget - (capped) given to counties based on different %’s - (capped) given to counties based on different %’s - varies from 50% to 100% - varies from 50% to 100% - day treatment – 80%, juvenile detention 50%, - day treatment – 80%, juvenile detention 50%, secure residential - 60%, YDC – 60% secure residential - 60%, YDC – 60% Once you reach the limit on 148 funds, you are in overmatch and all costs after this are incurred by county!!

2. Medicaid Realignment The Department of Public Welfare (DPW) implemented its Integrated Children’s Services Initiative-often referred to as “Medicaid Realignment”-to maximize the use of federal Medical Assistance funding for “medically necessary” treatment services to dependent and delinquent youth. Through this initiative, DPW identified behavioral health treatment services provided by residential treatment facilities (RTFs) that could be funded through the Medical Assistance program. The Department of Public Welfare (DPW) implemented its Integrated Children’s Services Initiative-often referred to as “Medicaid Realignment”-to maximize the use of federal Medical Assistance funding for “medically necessary” treatment services to dependent and delinquent youth. Through this initiative, DPW identified behavioral health treatment services provided by residential treatment facilities (RTFs) that could be funded through the Medical Assistance program.

3. Medicaid Realignment Accredited Facilities Some programs may have added more credentialed staff to become accredited Some programs may have added more credentialed staff to become accredited This resulted in a higher per diem rate This resulted in a higher per diem rate Medical Necessity must be determined (and re-determined) by a psychiatrist Medical Necessity must be determined (and re-determined) by a psychiatrist No cost to the county (50% federal / 50% state) if Medical Necessity is determined No cost to the county (50% federal / 50% state) if Medical Necessity is determined The county’s HealthChoices provider (if there is one) will approve Medical Necessity The county’s HealthChoices provider (if there is one) will approve Medical Necessity State 148 and county dollars will pay for service is determined to not be Medically Necessary (i.e. when the judge sends a juvenile there anyway, or when the judge keeps a juvenile there when the HMO says he/she doesn’t need the service anymore) State 148 and county dollars will pay for service is determined to not be Medically Necessary (i.e. when the judge sends a juvenile there anyway, or when the judge keeps a juvenile there when the HMO says he/she doesn’t need the service anymore)

4. Medicaid Realignment Non-Accredited Facilities Medical Necessity must be determined (and re- determined) by a psychologist Medical Necessity must be determined (and re- determined) by a psychologist Minimal cost to the county (MA pays for treatment, but county pays for room and board with federal, state, and local dollars) if Medical Necessity is determined Minimal cost to the county (MA pays for treatment, but county pays for room and board with federal, state, and local dollars) if Medical Necessity is determined The county’s HealthChoices provider (if there is one) will approve Medical Necessity The county’s HealthChoices provider (if there is one) will approve Medical Necessity State 148 and county dollars will pay for service is determined to not be Medically Necessary (i.e. when the judge sends a juvenile there anyway, or when the judge keeps a juvenile there when the HMO says he/she doesn’t need the service anymore) State 148 and county dollars will pay for service is determined to not be Medically Necessary (i.e. when the judge sends a juvenile there anyway, or when the judge keeps a juvenile there when the HMO says he/she doesn’t need the service anymore)

5. Medicaid Realignment Issues Not really any new services, simply a change in payor and more paperwork / timeframes Not really any new services, simply a change in payor and more paperwork / timeframes Poor implementation by DPW…..not well thought out ahead of time Poor implementation by DPW…..not well thought out ahead of time Counties were given reduced 148 allocations, with the assumption of federal funds being used Counties were given reduced 148 allocations, with the assumption of federal funds being used

6. “The Fiscal Big Picture” $100 a day at Glen Mills Funding Balance Funding Balance $100 – 55% (IV-E Eligible) - $55 $45 – ACT 148 – ACT 148 80% “Community Res.” $-- $-- 80% “Community Res.” $-- $-- _____ _____ Total Cost to County $-- Total Cost to County $-- MA Realignment applied: Medical necessity at accredited facility - No cost to the county (50% federal / 50% state) - No cost to the county (50% federal / 50% state) Medical necessity at non-accredited facility - Minimal cost to the county (MA pays for treatment, but county pays for room and board with federal, state, and local dollars) if Medical Necessity is determined - Minimal cost to the county (MA pays for treatment, but county pays for room and board with federal, state, and local dollars) if Medical Necessity is determined NO Medical necessity at either type of facility - State 148 and county dollars will pay for service - State 148 and county dollars will pay for service