The Child and Family Services Agency Fy 2009 and Fy 2010 Spending Pressure

Government of the District of Columbia
Child and Family Services Agency
Testimony of
Roque R. Gerald, Psy.D.
Director
“THE CHILD AND FAMILY SERVICES AGENCY

FY 2009 AND FY 2010 SPENDING PRESSURE”
Committee on Human Services

Tommy Wells, Chair
Council of the District of Columbia
July 17, 2009
John A. Wilson Building

1350 Pennsylvania Avenue, NW
Room 400
Washington, DC 20004
2pm
Introduction
Good afternoon, Chairman Wells and members of the Committee on Human Services. I am Dr.
Roque Gerald, Director of the DC Child and Family Services Agency (CFSA). I appreciate the
opportunity to provide an update on the status of the Agency’s Medicaid claiming and the future
of child welfare services in the District. In my testimony, I will discuss (1) progress on
improving outcomes for the DC residents CFSA serves; (2) general background on Medicaid as a
resource for child welfare; and (3) the joint work of CFSA and the Department of Health Care
Finance (DHCF) to build the appropriate infrastructure for claiming.
To begin, I want to provide a brief update on our progress in improving outcomes for the
children, youth, and families we serve. Strengthening the safety net remains our collective goal
and passion. With our forward momentum continuing at a fast clip, here are some updates on the
strategic goals driving our actions this summer and beyond.
Safety: Improving both the timeliness and quality of child abuse/neglect investigations continue
to be top priorities. Child Protective Services has initiated a number of new internal quality
assurance procedures. Among these are regular supervisory review of handling of hotline calls
(about eight or 10 calls per worker per month) and in-depth review of progress on the 18th day of
open investigations. Objectives of the 18-day review are to ensure thoroughness and eliminate
barriers to safe, timely completion.
Permanence: Everyone needs a family, and we’ve never been more determined that every child
and youth will leave the system for reunification, guardianship, or adoption. CFSA was on a
mission to review the cases of every youth with the goal of Alternative Planned Permanent
Living Arrangement (APPLA) by June 30—about 600 cases in all. We beat that deadline by a
couple of weeks. More important, we found potential options for permanence that we’re now
working to bring to fruition for about 40 percent of those youth. Not only are we focusing on
permanency for older youth but we are involving them in our redesign of the Office of Youth
Development (OYD). This summer, eight youth are interning in OYD, learning skills to prepare
them for the future and helping us design an OYD that is optimal for youth engagement.
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Meanwhile, CFSA has also formed an internal team of permanency specialists who assist
ongoing workers in moving children and youth on their caseloads to permanence. Finally, we
continue to target finalization of 125 adoptions by the end of 2009.
Deepening Practice: Quality practice supports quality outcomes. A major goal this year (and
beyond) is strengthening frontline clinical skills and supervision. CFSA and the Collaboratives
are jointly engaged in implementing an In-Home Practice Protocol that deepens our partnership
in serving intact families at home. In September, CFSA will roll out training for our new Out-of-
Home Practice Protocol for social workers and supervisors serving children and youth in care.
The centerpiece of both protocols is teaming between families and professionals to increase
engagement, improve decisions, enhance support, and achieve better outcomes.
Medicaid Background
As you know, the results of recent audits revealed significant challenges in terms of how the
District’s public providers claim for Medicaid reimbursable services. Later, I will address the
District’s commitment to resolving these issues through extensive cross-agency collaboration.
I think it’s important that we begin with a discussion of what Medicaid is and its importance to
supporting services to vulnerable children, youth and families. In addition to relying on Medicaid
to pay for obvious health care services like surgeries and antibiotics that foster children need,
State Child Welfare agencies also rely on two important Medicaid services that are critical to
meeting the needs of children in CFSA care: Rehabilitative Services (Rehab) and Targeted Case
Management (TCM). Here is a brief description of those programs and what services are eligible
within each one:
Rehabilitative Services are services determined to be medically necessary and included

in a child’s treatment plan prepared by a qualified provider of rehabilitative services to
children. These services are designed to ameliorate psychological or emotional problems
related to neglect, abuse and/or delinquency, to restore psychological or emotional
functioning which was impaired by the problems related to neglect abuse and/or
delinquency, and to assist the child in improving and maintaining his/her highest
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functioning level. All children who come into care by virtue of maltreatment have been
injured and require rehabilitative services beyond the traditional MHRS (mental health)
counseling.
Targeted Case Management (TCM) is the provision of case management, defined as

services which assist eligible individuals in gaining access to needed medical, social, and
educational and other services, to a "targeted" population such as child welfare, foster
care, and adoption. It is important to note that TCM is assessment and facilitation of
meeting service needs, not the provision of the called-for services.
The other critical component of our approach to federal funding is Title IV-E of the Social
Security Act. By law, Title IV-E Foster Care and Adoption Assistance is available for the
care and support of eligible children. This 'care and support' includes room, board, school
supplies, supervision, and transportation. It does not include treatment of a child's medical
condition or the provision of social services. Medicaid covered services are those that treat a
recipient's medical condition, with 'medical' encompassing both physical and mental health
conditions. It does not include meeting the child's physical needs. Simply put, Title IV-E may
pay for food, clothing, and shelter, but not treatment; Medicaid may pay for treatment, but not
food, clothing, and shelter.
Child Welfare Medicaid Claiming: A National Perspective

To provide some context for the current challenges we are working collaboratively to rectify, , I
would now like to talk generally about what is required to efficiently and effectively claim for
Child Welfare Medicaid services and some of the challenges that Child Welfare systems face in
doing this. You can think of Medicaid as a three-legged stool; in order to claim for a service you
need the following:
(1) a Medicaid enrolled child or youth;
(2) a Medicaid covered service; and
(3) a Medicaid enrolled provider.
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Additionally, you must document the service provided to show who provided the service, when it
was provided, where it was provided, and what service was provided. While this may seem
relatively simple, there must be a robust infrastructure in place to ensure compliance with federal
and local laws and regulations, and staff must be appropriately trained to document the services
they provide.
Large Medicaid disallowances for Child Welfare services in states such as Georgia, Iowa,
Kansas, Maine, Massachusetts, Minnesota, Oklahoma, and now the District, demonstrate the
complicated nature of claiming for Medicaid services and the need for close collaboration
between child welfare and Medicaid agencies.
CFSA and DHCF Collaborative Efforts

CFSA and DHCF have been working closely to build the infrastructure that is required to
accurately and effectively claim Medicaid Services. Also, to ensure that CFSA has effective
internal oversight of our federal claiming, I created the position of Deputy for Revenue
Operations. Heather McCabe is acting in the position.
When CFSA became aware of the disallowances, we immediately began working with the
Department of Health Care Finance (DHCF) to develop corrective action plans which include
randomized audits of case files, remediation of case records that are found to be deficient and
training of social workers on appropriate documentation of Medicaid services. Despite these
efforts, we reached the conclusion that future disallowances would more than likely occur unless
there was a substantial change in our overall approach to claiming Medicaid. Therefore, CFSA
stopped claiming Medicaid as of January 31, 2009.
As I detailed in my June 30th correspondence to you regarding the OCFO’s estimated spending
pressure for the Agency, we continue to work closely with DHCF to prepare for claiming
Medicaid again. In particular, we are focusing on ensuring compliance with District and Federal
regulations and laws and redesigning the Rehabilitative Services option. This work is slated to
be completed in December 2009, and we anticipate re-starting claiming for these services by the
second quarter of FY 2010. Additionally, DHCF is improving oversight and technical assistance
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to CFSA. DHCF is also implementing an Administrative Services Organization in September
2009; the RFP was released on Monday July 13th.
Conclusion
In closing, Medicaid funding is a critical resource that public child welfare agencies rely upon to
provide essential services to children and families. In cooperation with DHCF, we’re working to
establish a claiming infrastructure that will allow CFSA to take full advantage of opportunities
for Federal funding. This is an important step in strengthening the local safety net for vulnerable
children and families and one in which we’re determined to succeed. I’ll now answer any
questions you may have.
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The Child and Family Services Agency Fy 2009 and Fy 2010 Spending Pressure

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The Child and Family Services Agency Fy 2009 and Fy 2010 Spending Pressure

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Government of the District of Columbia

Child and Family Services Agency

“THE CHILD AND FAMILY SERVICES AGENCY

Committee on Human Services

July 17, 2009

John A. Wilson Building

Rehabilitative Services are services determined to be medically necessary and included

Targeted Case Management (TCM) is the provision of case management, defined as

Child Welfare Medicaid Claiming: A National Perspective

CFSA and DHCF Collaborative Efforts

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