The federal agency that oversees health care entitlements has made it easier for states to use Medicaid dollars in some large group facilities for youth in foster care.
The Centers for Medicare and Medicaid Services, in a document issued in mid-October, announced that it had greatly expanded the terms of a Medicaid waiver for qualified residential treatment programs, or QRTP, a new designation of congregate care facilities created as part of the Family First Prevention Services Act. With few exceptions, Medicaid funding cannot be used to cover costs associated with congregate and institutional care.
States can now pursue what’s known as a 1115 waiver to use Medicaid funds for up to two years of care for a youth living at a QRTP, well past the six months permitted in waiver rules set up in October of 2019, when the Family First Act’s central provisions initially took effect. Most states elected to take a delay on implementing the law, and that delay ended at the beginning of October.
There is a significant caveat in the waiver offer that remains from the original 2019 outline: In order to qualify, a qualified residential treatment program must meet the federal requirements to be a psychiatric residential treatment facility, which demands an on-site, 24-hour nursing staff and stringent policies around the use of seclusions and restraints.
It is unclear how many states currently operate a 1115 waiver for qualified residential treatment programs; Youth Services Insider is told Oklahoma does for sure. There are several other states with ongoing Medicaid waivers, including Idaho, Indiana, Utah, Vermont and Washington.
The extended time period for up to two years is expected to make the offer more attractive to states worried about meeting the demands outlined in the QRTP model of service.
The expanded waiver touches on a thorny issue in child welfare as Family First begins to roll out across the country. The law’s central objectives involve revising the Title IV-E child welfare entitlement program to incentivize more family preservation work — avoiding foster care in more cases — while disincentivizing the use of congregate care facilities by limiting federal funds for placements in them to two weeks.
The qualified residential treatment program model was established as an exception to that two-week limit. But any QRTP must become accredited and demonstrate that it has an on-call nursing staff and facilitates aftercare planning with families to help a youth return home, among other requirements. There must also be periodic assessments by the court of whether the residential placement is still appropriate; after a year, the state’s child welfare director would have to personally attest to it on paper.
Those supporting the use of Medicaid in qualified residential treatment programs argue that this money is necessary to make the model work for serving youth with significant behavioral health needs, which is the point of the exception.
Critics of Medicaid use in QRTP feel states are gearing up to make them an exception that eats the rule, which is only helped by making them a financially attractive option that can run with lots of federal money.
“Please stand firm against any proposed modifications to the Institutions for Mental Disease (IMD) rule or delays in implementing the qualified residential treatment program (QRTP) standards,” said William Bell, president and CEO of Casey Family Programs, testifying earlier this year before the House Committee on Ways and Means. “Investing in proven prevention strategies makes considerably more sense than allowing for the ongoing use of these facilities as placement settings.”
Legislation to permanently allow Medicaid in qualified residential treatment programs has been introduced in the Senate by Dianne Feinstein (D-Calif.) and Richard Burr (R-N.C.), and a companion bill recently dropped in the House.