Form 1 survey

OMB Control Number 0915-XXXX

Expiration Date XX/XX/201X

Title V Maternal and Child Health State Formula Block Grant Services Survey

Federal Fiscal Year 2011

Return the Completed Survey to Melissa Romaire at RTI International, mromaire@rti.org.

If you have any questions, please call Melissa Romaire at (919) 541-6894.

State:___________________ Name:_________________________________________

Phone:__________________ Email:___________________ Date:________________

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average 36 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10‑29, Rockville, Maryland, 20857

Overview

This survey of State Title V, of the Social Security Act, Maternal and Child Health (MCH) programs is being conducted by RTI International for the MCH Bureau at the Health Resources and Services Administration (HRSA). The purpose of this survey is to determine how much of your state’s Federal fiscal year 2011 Federal Title V MCH Formula Block Grant funds were spent reimbursing services to infants and children, children with special health care needs (CSHCN), and pregnant women (hereafter referred to collectively as children and pregnant women).

With the health insurance coverage provisions to be implemented under the Affordable Care Act, the number of children and pregnant women who gain health insurance coverage is expected to increase and for some the source of health coverage is expected to change. With these coverage changes, there may be changes in the extent to which Federal Title V MCH Formula Block Grant funds are used to reimburse providers for services to children and pregnant women who are uninsured or underinsured through public or private insurance. Through the Title V MCH Services Block Grant Annual Report, MCH programs currently report the amount of Title V Federal-State Partnership expenditures made for certain broad categories of services. However, given the potential implication of the ACA on health coverage, the MCH Bureau needs to know how much of the Federal Title V MCH Formula Block Grant funds were used by MCH programs to reimburse services, the number and insurance status of the recipients of these services, and what types of services were reimbursed.

Survey Goals

The purpose of this survey is to assess:

• How much of the Federal Title V MCH Formula Block Grant was used to reimburse services to children and pregnant women?

• How many children and pregnant women received services reimbursed by Federal Title V MCH Formula Block Grant funds and what was their insurance status?

• What types of services provided to children and pregnant women were reimbursed using Federal Title V MCH Formula Block Grant funds, and what was the amount of reimbursement by type of service?

This survey is a one-time data collection effort. The data requested differ from what states currently report in the Title V Annual Report. Findings from this survey will provide a baseline for examining how the use of Federal Title V MCH Formula Block Grant funds to reimburse services may change after implementation of the Affordable Care Act.

Definition of “Services”

For this survey, a list of examples of “services” can be found in the following paragraph. Using your Federal Title V MCH Formula Block Grant funds, services would be paid for through a formal process similar to paying a medical billing claim. Federal Title V MCH Formula Block Grant funds provided to a partner, such as a clinic or local health department, for salary or operations support are not considered services for the purpose of this survey.

Services include, but are not limited to:

• primary care and specialty care doctor visits,

• emergency department visits,

• inpatient services,

• outpatient and inpatient mental health and substance abuse services,

• prescription drugs,

• occupational and physical therapy,

• speech therapy,

• durable medical equipment and medical supplies,

• lab services,

• radiology,

• medical foods,

• preventive care screenings,

• dental care,

• orthodontia,

• vision care,

• case management,

• transportation, and

• rehabilitative and habilitative services.

Reimbursement for services using the Federal Title V MCH Formula Block Grant funds could be made for children or pregnant women who are uninsured or who exceed coverage limitations if they do have public or private insurance. For example, suppose your state’s CHIP program reimburses for 20 physical therapy sessions for a child. However, the child needed 30 sessions, so the Title V program paid for the extra 10 sessions using the federal portion of Title V MCH Formula Block Grant funds. In this case, physical therapy is a reimbursed service as defined for this survey.

Please note that this definition of “services” is not the same as that of “direct services” used in the Title V Annual Report. According to the guidance document for the Title V Annual Report, direct services may include salary and operational support to a program or clinic that provides medical services; these funds are excluded from the definition of services used here. Furthermore, “services” include such services as transportation and case management that the guidance for the Title V Annual Report categorizes as “enabling services,” but because these enabling services can be reimbursed by private or public insurance, they are included in the definition of services used for purposes of this survey.

1. Did your State use Federal Title V Maternal and Child Health (MCH) Formula Block Grant funds to reimburse services that were not reimbursed by any other public/private insurer in Federal Fiscal Year 2011 for the following populations?

1. Infants and children Yes☐ No☐

2. Children with special health care needs (CSHCN) Yes☐ No☐

3. Pregnant women Yes☐ No☐

If you checked “No” for all three populations, proceed to Questions 8 and 9 on page 9. After you have answered these questions, you have completed the survey. Thank you!

If you checked “Yes” for at least one population, please answer Questions 2-6.

2. In the table below, provide the amount of Federal Title V MCH Formula Block Grant funds used to reimburse services to children and pregnant women in Federal Fiscal Year 2011, in total and by the recipients’ primary source of insurance coverage. The intent of this question is to capture the amount of Federal Title V MCH Formula Block Grant funds used to reimburse services for children and pregnant women who are uninsured or who may have health insurance but the insurance does not fully cover the claim for the service. Therefore, Federal Title V MCH Formula Block Grant funds have been used as “payer of last resort”. If you do not reimburse services provided to a particular population described below, write “Not Applicable” in the corresponding cell.

Three, mutually exclusive categories of women and children are considered in the table below:

1. Infants and children – Children from birth through age 21 who do not meet the criteria for either CSHCN or pregnant women.

2. Children with Special Health Care Needs – Infants or children from birth through age 21 whom the state has identified as having special health care needs for purposes of qualifying for services funded through Title V.

3. Pregnant women – Females of childbearing age from the time they conceive to 60 days after the pregnancy ends; this category will also include pregnant adolescents.

In Column A, please provide the actual amount of Federal Title V MCH Formula Block Grant funds that are used to reimburse services provided to children and pregnant women.

Please break out the funds reported in Column A by the primary source of insurance coverage of the children and pregnant women receiving services and provide these numbers in Columns B- F. For example, suppose your program reimbursed services using Federal Title V MCH Formula Block Grant funds in the amount of $5,000 for infants and children (Column A). Of that amount, $3,000 was spent on infants and children who were uninsured (Column B), $1,000 was spent on infants and children who were privately insured but whose private insurance did not cover the service or did not cover the quantity of the service needed (Column C), and $1,000 was spent on infants and children who had Medicaid coverage but whose particular service or the quantity of the service needed was not covered by Medicaid (Column D). If you cannot break out the number reported in Column A, write “Not Available” in the corresponding cells in Columns B-F. If children and pregnant women are covered by more than one source of insurance coverage, assign the funds to their primary source.

Federal Title V MCH Formula Block Grant Reimbursement for Services to Children and Pregnant Women, Federal Fiscal Year 2011

	Total Federal MCH Formula Block Grant Funds Used to Reimburse Services	Federal MCH Formula Block Grant Funds Used to Reimburse Services by the Recipients’ Primary Source of Insurance Coverage
Population	(A)	(B) Uninsured	(C) Privately Insured/Other	(D) Medicaid	(E) CHIP	(F) Unknown
e.g., Infants and Children	$5,000	$3,000	$1,000	$1,000	$0	$0
Infants and Children	$	$	$	$	$	$
CSHCN	$	$	$	$	$	$
Pregnant Women	$	$	$	$	$	$
Total	$	$	$	$	$	$

3. In the table below, provide the unduplicated number of children and pregnant women who received services reimbursed using Federal Title V MCH Formula Block Grant funds recorded in Question 2, in total and by the recipients’ primary source of insurance coverage. If you do not reimburse services for a particular population described below, write “Not Applicable” in the corresponding cell. If an actual number is not available, please estimate the number and briefly explain how the estimate was derived in a footnote directly below the table.

CSHCN should not be included in the count of infants and children. For children and pregnant women with more than one source of insurance coverage, use their primary source.

In Column A, please provide the unduplicated number of children and pregnant women who received services reimbursed using the Federal Title V MCH Formula Block Grant

Please break out the number reported in Column A by the primary source of insurance coverage of the children and pregnant women receiving services and provide these numbers in Columns B- F. For example, suppose the $5,000 reported in Question 2 was spent on 200 infants and children (Column A). Of these 200 infants and children, 100 were uninsured (Column B), 25 were privately insured (Column C), and 75 had Medicaid (Column D). If you cannot break out the number reported in Column A into actual numbers or estimates, write “Not Available” in the corresponding cells in Columns B-F. If infants and children, CSHCN, and pregnant women are covered by more than one source of insurance coverage, use the primary source.

Number of Children and Pregnant Women Receiving Services Reimbursed by Federal Title V MCH Formula Block Grant Funds, Federal Fiscal Year 2011

	Total Unduplicated Number of Children and Pregnant Women for Whom Reimbursement was Made with Federal MCH Formula Block Grant Funds	Unduplicated Number of Children and Pregnant Women for Whom Reimbursement was Made with Federal MCH Formula Block Grant Funds by Primary Source of Insurance Coverage
Population	(A)	(B) Uninsured	(C) Privately Insured/ Other	(D) Medicaid	(E) CHIP	(F) Unknown
e.g., Infants and Children	200	100	25	75	0	0
Infants and Children
CSHCN
Pregnant Women
Total

4. Please describe your program’s criteria for determining which children and pregnant women are eligible for services that are reimbursed by the Title V MCH/CSHCN program. If you do not use Federal Title V MCH Formula Block Grant funds to reimburse services for a particular population described below, include “NA” for “Not Applicable” after the question.

Infants and Children

a. Financial criteria (e.g., family income must be below 200 percent of the Federal poverty level):

b. Medical eligibility criteria (e.g., must meet certain medical condition or diagnostic criteria; if you have a Web link to a document or a policy, you may include the link here instead of providing the details of your medical eligibility criteria):

c. Other Criteria (e.g., residency requirements, age requirements):

Children with Special Health Care Needs

a. Financial criteria (e.g., family income must be below 200 percent of the Federal poverty level):

b. Medical eligibility criteria (e.g., must meet certain medical condition or diagnostic criteria; if you have web-link to a document or a policy, you may include the link here instead of providing the details of your medical eligibility criteria):

c. Other Criteria (e.g., residency requirements, age requirements):

Pregnant Women

a. Financial criteria (e.g., family income must be below 200 percent of the Federal poverty level):

b. Medical eligibility criteria (e.g., must meet certain medical condition or diagnostic criteria; if you have web-link to a document or a policy, you may include the link here instead of providing the details of your medical eligibility criteria):

c. Other Criteria (e.g., residency requirements, age requirements):

5. In the table below, list the types of services provided to infants and children, CSHCN, and pregnant women that were reimbursed by your Title V MCH/CSHCN program in Federal Fiscal Year 2011. Provide the amount of Federal Title V MCH Formula Block Grant funds used to reimburse each type of service, in total and by primary source of insurance coverage. If you need to add more rows to the table to record all services reimbursed, please do so.

In Column A, please provide the actual amount of Federal Title V MCH Formula Block Grant funds that are used to reimburse services by types of services provided to children, CSHCN, and pregnant women.

Please break out the funds reported in Column A by the primary source of insurance coverage of recipients receiving the service and provide these numbers in Columns B- F. For example, suppose your program reimbursed for physician office visits using $4,000 of your Federal Title V MCH Formula Block Grant funds (Column A). Of that amount, $1,000 was spent on recipients who were uninsured (Column B), $1,000 was spent on recipients who were privately insured but whose private insurance did not cover the service or the quantity of the service needed (Column C), $1,000 was spent on recipients who had Medicaid but for whom Medicaid did not cover the service or the quantity of the service needed (Column D), and $1,000 was spent on recipients who had CHIP but for whom CHIP did not cover the service or the quantity of the service needed (E). If you cannot break out the number reported in Column A, write “Not Available” in the corresponding cells in Columns B-F. If children and pregnant women are covered by more than one source of insurance coverage, assign the funds to their primary source.

Title V MCH Formula Block Grant Reimbursement for Specific Services Provided to Infants and Children, CSHCN, and Pregnant Women, Federal Fiscal Year 2011

Service	Total Federal MCH Formula Block Grant Funds Used to Reimburse for the Service	Federal MCH Formula Block Grant Funds Used to Reimburse for the Service by Primary Source of Insurance Coverage
	(A)	(B) Uninsured	(C) Privately Insured/ Other	(D) Medicaid	(E) CHIP	(F) Unknown
e.g., Physician Office Visits	$ 4,000.00	$ 1,000.00	$ 1,000.00	$ 1,000.00	$ 1,000.00	$ 0
e.g., Inpatient Hospitalizations	$ 20,000.00	$ 10,000.00	$ 5,000.00	$ 5,000.00	$ 0	$ 0
e.g., Physical Therapy	$ 45,000.00	$ 22,500.00	$ 11,250.00	$ 11,250.00	$ 0	$ 0
e.g., Transportation	$ 3,000.00	$ 1,000.00	$ 500.00	$ 1,000.00	$ 500.00	$ 0
e.g., Prenatal care visits	$10,000.00	$ 10,000.00	$ 0	$ 0	$ 0	$ 0
	$	$	$	$	$	$
	$	$	$	$	$	$
	$	$	$	$	$	$
	$	$	$	$	$	$
	$	$	$	$	$	$
	$	$	$	$	$	$

6. After implementation of the ACA in your state, what percentage of the Total number of infants and children, including CSHCN, identified as “Uninsured” (from Column (B) of the table for Question 3) do you estimate will receive health insurance coverage through

a. The private market ( your state’s health insurance exchange or employer based)/another coverage source,

b. Medicaid,

c. CHIP?

7. After implementation of the ACA in your state, what percentage of the Total number of pregnant women identified as “Uninsured” (from Column (B) of the table for Question 3) do you estimate will receive health insurance coverage through

a. The private market (your state’s health insurance exchange or employer based)/another coverage source,

b. Medicaid,

c. CHIP?

8. Are there current or upcoming changes in your state that may affect how you use or plan to use Title V resources for children, CSHCN and pregnant women? If yes, please describe.

9. Briefly explain what needs for MCH services your Title V MCH/CSHCN program is not able to currently meet. 

Thank you for completing this survey!

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