In December 2000, Casey Family Services and the Annie E. Casey Foundation sponsored the first National Post-Adoption Services Conference. State adoption program managers with teams of adoption professionals and adoptive families from across the country attended the conference. They recommended that a document identifying and describing the mix of funds available for post-adoption services would help public and private agencies to meet the ongoing, and often complex, needs of adopted children and their families. Adoptive families passionately described the need for quality adoption-competent social supports and mental health services to help them address the developmental adjustments that emerge prior to, during, and throughout the adoption experience. These challenges have lifelong implications for adopted children and their families.

Purpose and Focus. This paper outlines and describes existing core federal funding streams that can be blended at the state and local level to develop a foundation of fiscal support for the services that are so vital to sustaining the increasing number of special needs adoptions. Further, this paper provides a framework for states to maximize federal reimbursements for child welfare services by finding savings in state general funds. These savings can be used to support a comprehensive mix of post-adoption support, education, training and therapeutic and treatment services. Our experience suggests that adoptive families need a variety of services and supports which are funded from an array of current resources. But more effort is needed to blend the funding and services into a comprehensive system of care.

While it is understood that most adoptive families need some level of services, education and support to sustain their adoptions (domestic, international and state-facilitated), this paper focuses on federal funding for post-adoption services for children adopted from state foster care systems. Additionally, this paper serves as a guide for public child welfare systems, in partnership with state mental health and Medicaid systems, to respond to the increasing demands for post-adoption services that stabilize special needs adoptions and prevent adoptive placement disruptions and adoption dissolutions.

Audience. This paper proposes a road map for state child welfare directors, their fiscal managers, and adoption program managers as they creatively promote and support the adoption of special needs children from public child welfare programs. This paper also charts a course for collaborations among child welfare, Medicaid and mental health program managers to sustain a comprehensive array of community post-adoption services.

The Casey Center for Effective Child Welfare Practice is available to provide technical assistance and training to states on how to maximize existing fiscal resources to support an array of post-adoption services and improve the likelihood that families who adopt special needs children will thrive.

Raymond L. Torres
Executive Director
Casey Family Services

Sarah B. Greenblatt
Director
The Casey Center for Effective Child Welfare Practice

In 1996, the Adoption 2002 Initiative was launched to double the number of adoptions of children in foster care by 2002. The Adoption and Safe Families Act of 1997 (ASFA) was passed by Congress just one year later. ASFA builds on the permanency planning policy and practice framework established in 1980 with the Adoption Assistance and Child Welfare Act (P.L. 96-272). ASFA places greater emphasis on children's need for permanency through preventive and early intervention supports, intensive reunification and concurrent planning services. If these efforts fail within established time frames, ASFA mandates that states then move more quickly to adoption or other family permanency options.

As far-reaching as the ASFA legislation has been, it neglected to adequately address the post-permanency needs of children leaving the foster care system. Specifically, little emphasis was given to the ongoing and special needs of adopted children and their newly formed families. ASFA has provided a limited commitment to a planned, effective and funded post-adoption service array to: 1) sustain the anticipated increase in special needs adoptions; 2) prevent the re-entry into out-of-home care of these vulnerable children; and 3) serve as a recruitment tool for children waiting for adoption.

Casey Family Services and the Annie E. Casey Foundation believe that all families need an array of community supports to meet the developmental needs of their children. The families who come forward to adopt special needs children have an even greater need for an array of services and supports to address the often traumatic experiences children have had prior to their adoptions. These experiences have a significant impact on how children and their new families adjust after their adoptions are legalized.

Implications of an Increasing Number of Adoptions. Each year since 1996, adoptions of children from the public child welfare systems across the country have increased dramatically: from 27,000 in Fiscal Year (FY) 1996 to 51,000 in FY 2000.¹ It is estimated that another 50,000 children were adopted in FY 2001.² States have come close to meeting the Adoption 2002 challenge, assisted by the incentives built into the Adoption and Safe Families Act of 1997. With the increasing number of families coming together through adoption, states have an urgent obligation to provide a mix of community-based, culturally sensitive, family-centered and adoption-competent services and supports. States also have an ethical obligation to share the lifelong commitment of these families to provide for their children's complex health, mental health, educational, developmental, and family adjustment needs.

The best way to understand the present need and to predict the future number of public agency special needs adoptions is to examine the immediate past. The number of children in foster care has increased steadily since the early 1960s, when the nation began to focus on the needs of abused and neglected children and federal child welfare legislation was passed. In 1962, 272,000 children were in foster care; by 1972, the number had grown to 319,800; by 1977, there were 502,000 children in foster care across the country.³ This growth in the number of children in foster care persists today, with approximately 565,000 children in out-of-home care on September 30, 2001.⁴

Adoptions of foster children have also increased sharply, as indicated above. Those children adopted in FY 2000 were on average 6.9 years of age when adopted, had been in foster care an average of 3.3 years prior to their adoption finalization and had experienced 2.9 moves while in out-of-home care.⁵ The majority had entered foster care due to a finding of neglect or abuse.⁶ Eighty-eight percent of the children adopted in FY 2000 received a special needs adoption subsidy related to one or more of the following characteristics or conditions: age (31 percent); medical/psychiatric or emotional conditions (21 percent); membership in a sibling group (20 percent); and minority status (12 percent).⁷ Thirty-nine percent of the children adopted in FY 2000 were Black/non-Hispanic, 38 percent were White/non-Hispanic, 14 percent were Hispanic, 5 percent were unknown, 2 percent were Asian/Pacific Islander/non-Hispanic and American Indian/non-Hispanic, and 2 percent of the children were of two or more races/non-Hispanic.⁸

While the number of children being adopted has increased, 131,000 foster children were waiting for adoption in FY 2000 (defined as children under age 16 with a goal of adoption and/or freed for adoption). An estimated 118,000 children were waiting to be adopted at the end of FY 2001.⁹ Those children waiting for adoption in FY 2000 had been in foster care for an average of 3.75 years, were on average 8.1 years of age, and were disproportionately children from African-American and Hispanic backgrounds.¹⁰

Given the 131,000 children awaiting adoption in FY 2000 (as well as those estimated to be waiting in FY 2001), it is predicted that there will be an increasing number of children finding permanent families through adoption in the coming fiscal years. The Congressional Green Book estimates that the number of foster children receiving Title IV-E adoption subsidies will more than triple between FY 1995 and FY 2004: from 106,200 to 369,900.¹¹

Although difficult to track because consistent data are not kept, adoption dissolution rates are estimated to be between 10 to 15 percent for children who are adopted through the foster care system.¹² The National Adoption Information Clearinghouse¹³ estimates that adoption dissolution rates range from 10 to 12 percent for children adopted at 3 years or older¹⁴ but will depend on the group being studied and the research techniques used.¹⁵

While the federal Adoption 2002 Initiative has been successful, the infrastructure to support these public agency special adoptions has been inadequate. Adoption professionals and adoptive families across the country report a lack of adoption-competent services to support these adoptive families. Without the availability of these services, it can be anticipated that:

• many potential adoptive families may choose not to adopt;
• the number of people coming forward to adopt special needs children may begin to decrease; and
• those adoptions already legalized may be at greater risk of dissolving.

These data speak to the complex special needs of children being adopted through the public child welfare system. Many are older children of color who are part of sibling groups and who have had multiple moves and relationship disruptions. In many ways, they are the most vulnerable of an already vulnerable population. They will need families who can understand their past experiences and present adjustment needs, and who can form nurturing relationships that help them manage their feelings of loss and grief. In many cases, they will need an ongoing mix of family-centered, culturally sensitive and adoption-competent services and supports to sustain their adoptions over time and prevent adoptive placement disruptions and adoption dissolutions.

Federal and state leaders have an obligation to understand and anticipate the service needs, as well as the fiscal needs, emerging from this explosive increase in public agency special needs adoptions. They need to plan now to assure that adoption-competent services are funded to support the network of adoptive families, schools and community providers who must together meet the complex needs of the increasing number of adopted children across the country. As most states face serious budget deficits, many are questioning whether they can afford post-adoption service programs or even maintain the current levels of their existing Adoption Assistance Programs. Yet, if children's urgent need for a permanent family is to be met through adoption (when that is the appropriate goal) states can not afford not to plan for and/or expand their post-adoption services. The need has never been greater for states to creatively find the mix of federal, state and even private funds to provide post-adoption services and supports so adoptive families can sustain a lifetime of safe, healthy and supportive family relationships and connections for children: true permanency.

In October 2000, the Association of Administrators of the Interstate Compact on Adoption and Medical Assistance, Inc. (AAICAMA) published its Report on Post-Adoption Services in the States.¹⁶ The findings of the report were based on the results of a survey responded to by the State Adoption Program Managers in 42 states, plus the District of Columbia and the U.S. Virgin Islands. The identified services and their definitions from the AAICAMA report, plus other services identified by Casey Family Services' National Advisory Group for this paper are included here. The services and definitions taken from the AAICAMA report are indicated by an asterisk (*).

For purposes of this paper, "post-adoption services" are separated into two categories: 1) administration, case management and services/treatment, and 2) training. While adoption subsidy assistance is considered a fundamental and critically needed post-legal adoption support that should be negotiated fairly and comprehensively with each family, it is not a post-legal adoption service that states can find more creative funding streams to support. Thus, the following sections focus on funding streams to support services and support other than adoption subsidy assistance.

Administration, Case Management and Services/Treatment

Adoption Assistance Payment. A monthly subsidy paid to the adoptive family for the care of a special needs adopted child which is negotiated on a child-by-child basis.

Adoption Resource Centers. A center that provides a wide array of supportive services to adoptive families. These may include training, information and referral, support and case management.

Adoption Search.* A program that provides non-identifying medical information and/or "facilitates, on a voluntary mutual request basis, the reunion of biological parents and adoptees, biological siblings or other biological relatives of adoptees through a centralized network."

Case Management. Case plan development, case reviews, permanency hearings, monitoring and general management of the case after an adoptive placement. This may include negotiation of an Adoption Assistance Agreement.

Chemical Abuse Treatment. Clinical treatment for an adopted child who has been diagnosed with chemical abuse problems. Treatment may be provided either on an inpatient or outpatient basis.

Child/Family Advocacy. Assisting the adoptive family gain access to needed services for the adopted child. The need for this is often in special education or completing the school IEP (Individualized Education Plan). This may include mental health or chemical abuse treatment or needed medical appliances.

Crisis Intervention.* Short-term, intensive services to assist an adoptive family through a crisis.

Day Treatment.* A comprehensive, highly-structured service alternative to placement or more restrictive placement that provides therapy or education for children.

Educational Support.* Reimbursement for tuition to attend a school that addresses the special needs of the adopted child, tutoring costs or computers.

Eligibility Determination. Process to determine if a special needs child is eligible for a Title IV-E adoption subsidy or Title XIX Medicaid.

Family Therapy.* Therapeutic contact with the adopted child and adoptive family, including parents and siblings, ranging from 30 minutes to two hours.

Flexible Funding for Family Support. Limited flexible funds, when other resources have been exhausted, that are available to the adoptive family during times of crisis to prevent adoption disruption.

Group Therapy. Therapeutic contact with two or more adopted children in a group setting.

Individual Therapy.* Therapeutic contact with one client - parent or child - ranging from 30 minutes to two hours.

Information and Referral to Adoptive Family. The provision of information and, when appropriate, referral services to current and prospective adoptive parents. This may include toll-free numbers and websites.

Intensive In-Home Supervision.* The child's condition requires one-on-one, 24-hour supervision, and the parents must hire someone to come into the home for a portion of the day to provide this supervision so that parents can sleep or tend to other personal family needs.

Medical/Behavioral Health Services. Medical, preventive and rehabilitation care provided by an authorized medical provider in accordance with the state Medicaid plan.

Medical/Physical Health Services. Basic medical care including clinic, hospitalization, surgery, dental, vision and medication.

Mental Health Treatment. Clinical treatment by an authorized mental health professional. Child must have a DSM IV diagnosis. Treatment may be provided inpatient or outpatient.

Recreation Therapy. Treatment using recreation and provided by a practitioner of the healing arts based on a DSM IV diagnosis.

Residential Treatment.* An institutional boarding facility that provides special treatment for children whose needs exceed the normal limits of in-home or community-based care. Treatment can include special education; psychiatric services; clinical social work; and psychological, medical or consultative services for physical or emotional disability, retardation, or drug and alcohol problems.

Respite Care.* Child care services provided for a brief time to families who have adopted children with special needs. Respite care may be provided for all or part of a 24-hour period, either in or out of the home.

Social Skills Training. Training provided to children with special needs and adjustment issues to assist in verbal and communication skills.

Special Camps.* A short-term day or overnight program that provides recreational, socialization, therapeutic, educational, or peer support opportunities for a child and respite for both the parents and the children. Camp may be for a few days, a week, a month or longer, but is considered short-term in duration and is usually held during the summer months.

Supplies and Equipment.* Any type of materials needed to integrate a special needs child into the home of an adoptive family, including house modifications, adaptive equipment and supplements (e.g., vitamins, nutritional supplements, diapers and pads).

Support Groups.* Access to support groups that help families and children deal with issues related to adoption and caring for children with special needs. Often staffed by case managers (case management) or parent volunteers (might also include "buddy families" or "warmline" programs).

Targeted Case Management for Adopted Children and Families. Services that will assist adopted children (and their families) who are Medicaid-eligible gain access to needed medical, social, educational, and other services. (SSA, section 1915 (g) (2)). May include activities such as needs assessment, development of specific case plans, referral to needed services, and monitoring.

Training

Community Education Regarding Needs of Adopted Children. Training provided to the broad community regarding adoption and the needs of adopted children. This is often provided to school personnel, attorneys, physicians, probation officers, and the public at large.

Training of Adoptive Parents. Training current and prospective adoptive parents. The training may include basic training (i.e. PRIDE, MAP or PATH), conferences, seminars/retreats, or child condition (i.e. FAS, FAE, SED) specific training.

Training of Private Agency Adoption/Case Management Staff. Non-clinical training of case managers of private agencies that carry out some of the state agency responsibilities under a "purchase of service contract (reimbursable by IV-E administration)."

Training of Providers of Service. Clinical and diagnostic training provided to clinicians who work with adopted children and their families.

Training of Public Agency Adoption/Case Management Staff. Non-clinical training provided to staff of the public Title IV-E agency.

The funding of post-adoption services is complicated, but it can be done! It is complicated because there are very few federal revenue sources targeted just for adoption and post-adoption services. Yet, funding for post-adoption services can be done because the services that adoptive families need can be funded with a combination of existing revenue sources that are already being used for a variety of child welfare services and adoption programs.

Because of the complexities of funding requirements, states will need to work with their federal regional office of the Children's Bureau to implement new funding strategies to assure they are claiming within federal regulations and guidelines. Doing this up front reduces the potential for a federal claim disallowance later. While access to federal funds and how they are administered varies from state to state, the reality that funds are available makes it imperative that states establish a priority for funding post-adoption services and the mechanisms to draw down the funds to develop the post-adoption service array that can best meet the needs of adopted children and families.

The following chart, Financing Post-Adoption Services: Matching Services with Federal Funding Sources, identifies a list of administrative, case management and services/treatment, as well as training components of an array of post-adoption services needed by adoptive families, and the major federal revenue sources available as of October 2003 to fund them.

The Adoption Assistance Subsidy is considered to be one of the most fundamental and critically needed post-adoption services. The subsidy must be negotiated fairly and comprehensively with each family to realistically reflect each child's special needs. Failure to be fair and realistic may result in adoptive families feeling they have to "beg" for necessary assistance. This, in turn, may result in mistrust on the part of the adoptive family and a greater risk of disruption if the child's needs are not adequately supported. For purposes of this paper, ways to access funding for post-adoption services other than Adoption Assistance Subsidy are explored in depth, assuming that states are familiar with how to claim Title IV-E for adoption subsidies.

As a general rule, states should use open-ended funding streams first (Titles IV-E and XIX/Medicaid revenue sources). The other capped funds can be used to support the cost of serving adopted children who are not IV-E or Medicaid-eligible. Each state may have its own limitations on how the capped federal funds can be utilized. However, this approach maximizes federal revenue and may potentially reduce the state general fund obligation. It is important to realize that some post-adoption services can be funded with a blend of revenue sources. States must decide which "mix" works best for them and the adopted children they are obligated to serve.

The research for this paper indicates that states have not realized how they can fund a comprehensive array of ongoing post-adoption services. While each revenue source has its own set of rules, regulations and policy interpretations, they can be used in combination to support the complex and far-reaching needs of adopted children and their families. Some revenue sources are open-ended entitlements; others are capped entitlements; still others are specialized, focused or block grants.

It is critical that child welfare leadership and state adoption program managers identify post-adoption services as a priority and learn about the funding streams available to the public adoption program. While access to these funds and how they are administered will vary from state to state, the funds can substantially support states' responsibility to make services accessible. States must establish the priority and the mechanisms to draw down these funds and develop the post-adoption service array to meet the needs of adopted children and families.

In this section, each existing federal funding stream that can be used to support post-adoption services is described in detailed, official language. This description is written in explicit language so that state child welfare leadership adoption program managers and revenue enhancement staff can use these funding descriptors to make an argument for post-adoption services funding and identify the state match that is needed. A more fluid description of how states are creatively using these funds can be found in a later section (see Creative Application of Existing Federal Funds for Post-Adoption Services, page 46).

The following are the primary federal funding sources for adoption and post-adoption services.

Title IV-E Adoption Assistance Programs

Description. The federal Title IV-E Adoption Assistance Programs are administered by state and local public child welfare agencies so children with special needs whose parental rights have been terminated can be adopted. These are open-ended entitlement programs funded with a combination of federal and state/local matching funds and authorized under Title IV-E of the Social Security Act.

Eligibility. To be eligible for Title IV-E Adoption Assistance the child being served must meet three criteria, including:

1. "The State has determined that the child cannot or should not be returned to the home of his parents; and¹⁷
2. "The State has determined that there is some factor or condition that makes it reasonable to conclude that the child cannot be placed with adoptive parents without providing adoption assistance or medical assistance under Title XIX. These factors or conditions include the child's ethnic background, age, membership in a minority group, part of a sibling group, and medical condition (physical, mental or emotional handicap); and¹⁸
3. "The State has determined that, except where it would be against the best interests of the child because of such factors as the existence of significant emotional ties with prospective adoptive parents while in the care of such parents as a foster child, a reasonable, but unsuccessful, effort has been made to place the child with appropriate adoptive parents without providing adoption assistance or medical assistance under Title XIX."¹⁹

In addition, to be eligible for Title IV-E Adoption Assistance, the child served must meet one of the following criteria:²⁰

1. Child meets the Aid to Families with Dependent Children standards that were in place in the state on July 16, 1996.
   • Child must meet the criteria both at the time of removal and in the month the adoption proceedings are initiated.
   • If the child is removed from the birth home pursuant to a judicial determination, such determination must indicate that it was contrary to the child's welfare to remain in the home; or
   • If the child is removed from the birth home pursuant to a voluntary placement agreement, that child must actually receive Title IV-E foster care payments to be eligible for Title IV-E adoption assistance.
2. Child is eligible for Supplemental Security Income (SSI) benefits.
3. Child is eligible as a child or a minor parent who is in foster care and receiving IV-E foster care maintenance payments that cover both the minor parent and the child at the time the adoption petition is initiated.
4. Child is eligible due to prior IV-E adoption assistance eligibility when a legal adoption ends.

Title IV-E provides federal reimbursement for some of the federally eligible adoption expenses that the state has already paid. Title IV-E is not a grant. Reimbursement is limited to three areas (i.e., Adoption Subsidy (45CFR1356.60 (a)), Administration (45CFR1356.60 (c)), Training (45CFR1356.60 (b)).

A discussion of each component of the Title IV-E Adoption Assistance Program and its corresponding funding formula follows:

Title IV-E Adoption Subsidy Program includes the payment made to adoptive parents. The amount of the payment may be as much as, but no more than, the amount that would be paid for foster care. The actual amount is negotiated between the adoptive parents and the state agency and is included in the adoption agreement prior to finalization. This amount can be adjusted as the child's needs change. For children who are Title IV-E eligible, the federal government reimburses the state between 50 percent and 83 percent of the costs and the state pays the balance. The federal portion is called the "Federal Financial Participation" (FFP). If the child is not Title IV-E eligible, the state is responsible to pay the entire cost of Adoption Assistance with other funding sources.

The FFP for Title IV-E adoption subsidy is the same percentage as Medicaid (Title XIX) that is called the "Federal Medical Assistance Percentage" (FMAP). A specific state's FMAP is based primarily on the state's per capita income. The higher the state's per capita income, the lower the FMAP. Each state's FMAP for the following federal fiscal year is published in the Federal Register in the fall.²¹

Title IV-E Administration includes those activities necessary for the proper and efficient administration of the Title IV-E state plan for adoption. These are not traditionally considered administrative costs in other funding programs. Examples of reimbursable administrative activities included in federal regulations (1356.60 (c))²² and federal policy²³ include:

• Referral to services
• Determination and redetermination of eligibility
• Fair hearings and appeals
• Grievance procedures
• Negotiation and review of adoption agreements
• Post-placement management of subsidy payments
• Recruitment of adoptive homes
• Adoptive family home studies
• Adoption exchanges
• Preparation for and participation in judicial adoption hearings
• Placement of the child
• Development of the case plan
• Case reviews conducted during a specific pre-adoptive placement for children who are legally free for adoption
• Case management and supervision prior to the final degree of adoption
• Case management performed to implement an adoption assistance agreement
• Rate setting
• Costs related to data collection and reporting
• Proportionate share of related agency overhead
• Other costs directly related only to the administration of the adoption assistance program

With the exception of "determination and redetermination of eligibility," the state/local agency currently makes its federal claim to provide the above activities based on the total administrative cost x the results of the Random Moment Time Study (RMTS) x the percentage of Title IV-E eligible children (often known as the penetration rate) x 50 percent FFP for administration. All costs attributable to "determination and redetermination of eligibility" are reimbursable at 50 percent FFP.²⁴

When states contract with private agencies to help them carry out public child welfare responsibilities (such as post-adoption case management), they can claim reimbursement based on the cost x the percentage of Title IV-E eligible children receiving adoption assistance x 50 percent FFP for administration.

Title IV-E Training funds include costs for the following activities:

• Short- and long-term training at educational institutions as well as in-service training for personnel employed by or preparing for employment by the state or a local public agency administering the Title IV-E state plan;
• Short-term training for current or prospective adoptive parents and members of state-licensed or approved child care institutions providing care to foster or adopted children;
• Training of public agency staff, which can include "the full range of activities necessary to meet the state maintenance and service requirement of Title IV-E."²⁵ This does not include clinical or treatment training (which is covered by other funding streams);
• Training of current and prospective parents that can be specific to a child's needs, an adoption conference or seminar or a more general conference/seminar that has components related to adoption or adoption issues. The purpose is to provide information and to help current or prospective adoptive parents care for their adopted child. Initial and ongoing training should be encouraged. (Families tell us this is certainly one of the most cost-effective methods of preventing the disruption or dissolution of adoptive placements.) The adoptive parents' travel and per diem associated with training (meals, lodging and registration fees) can be funded with Title IV-E training funds.

The FFP for Title IV-E training reimbursement is based on the total training cost x the percentage of Title IV-E eligible children receiving an adoption subsidy x 75 percent FFP for training. The state or local public agency is responsible for the balance or non-federal share.

The cost of training private agency staff who provide Title IV-E reimbursable services such as post-adoption case management is not reimbursable as a training expense. However, these costs are reimbursable as administration expenses in accordance with the administration funding formula at 50 percent reimbursement rate.

A description of the training must be included in the state's jointly developed and approved Title IV-B Child Welfare Services Plan, which links the Title IV-E with the Title IV-B state plans. The IV-B State Plan can be amended anytime during the year to allow for training that was not included when the annual plan was first developed.

The Title IV-E Adoption Incentives Payment Program

The Title IV-E Adoption Incentives Payment Program is a provision of the Adoption and Safe Families Act of 1997 intended to promote an increase in adoptions. The program, authorized through FY 2003, provides an incentive payment to states of up to $4,000 for each foster child adoption over an established baseline. There is an additional incentive payment of up to $2,000 for the adoption of special needs foster children with adoption assistance agreements over the established baseline. The baseline, as prescribed by federal statute, is based on the average of each state's reported foster care adoptions for fiscal years 1995, 1996 and 1997. If the number of adoptions qualifying for the incentive payment exceeds the appropriation by Congress for a full incentive payment ($4,000 and $2,000), payments to states will be prorated.²⁶ The Adoption Incentives Program will change once it is reauthorized in 2003.

States are eligible to receive the adoption incentive payments only if they are considered to be an "incentive-eligible state" by meeting the following requirements as specified in section 473A (b & c) of the Social Security Act:

• The state has an approved IV-E Plan for the fiscal year.
• The number of foster child adoptions exceeds the base number of foster child adoptions for the fiscal year.
• The state meets the data requirements.
• For fiscal years 2001 and 2002, the state provides health insurance coverage to any child with special needs for whom there is in effect an adoption assistance agreement between the state and an adoptive parent or parents.²⁷

The funds may only be expended for allowable costs under part B (including post-adoption services) and part E of the Social Security Act.²⁸

Title IV-B, Subpart 1 - Child Welfare Services

Title IV-B, Subpart 1 - Child Welfare Services was passed by Congress as part of the 1962 amendment to the Social Security Act. The services must be available on the basis of need for services and there is no means or residency test.²⁹

Specific purposes of Title IV-B, Subpart 1 include:

1. Protecting and promoting the welfare and safety of all children, including individuals with disabilities; homeless, dependent or neglected children;
   
   
2. Preventing, remedying or assisting in the solution of problems which may result in the neglect, abuse, exploitation, or delinquency of children;
   
   
3. Preventing the unnecessary separation of children from their families by identifying family problems and assisting families in resolving their problems and preventing the breakup of the family where the prevention of child removal is desirable and possible;
   
   
4. Restoring to their families children who have been removed and may be safely returned by the provision of services to the child and the family;
   
   
5. Assuring adequate care of children away from their homes, in cases where the child cannot be returned home or cannot be placed for adoption; and
   
   
6. Placing children in suitable adoptive homes, in cases where restoration to the biological family is not possible or appropriate (emphasis added).³⁰

Congress is authorized to appropriate $325 million annually; in FY 2002 Congress appropriated $291,986,000. The allotment to each state is based on the state's population under age 21 as compared to other states and the "allotment percentage of the state" (primarily the state's per capita income). States must submit a five-year Child Welfare Services Plan that is jointly developed with the federal government. The Plan requires several assurances and commitments by the state. Funds received may be spent on a wide variety of child welfare-related services, including pre- and post-adoption services, and are considered very flexible.

Annual status reports regarding the Plan are required. States are limited to the amount of Title IV-B, Subpart 1 money they can spend on combined foster care maintenance payments, adoption assistance payments and day care necessary for employment, to the total amount of Title IV-B money the state received in FY 1979. At that time, the total national Title IV-B appropriation was $141 million.

Federally recognized Indian tribes that submit a five-year Child Welfare Services Plan, along with the necessary assurances, are eligible for a portion of the state's allotment based on an enhanced population factor. There is a 25 percent non-federal match required for both states and tribes.

Title IV-B, Subpart 2 - Promoting Safe and Stable Families Program

The Title IV-B, Subpart 2 - Promoting Safe and Stable Families (PSSF) Program was originally passed as a part of the Omnibus Reconciliation Act of 1993 and is authorized through Federal FY 2006. The amendments continue the mandatory capped entitlement funding of $305 million. In addition, the amendments authorize discretionary funding of $200 million through FY 2006; of this amount, Congress appropriated $70 million for FY 2002. Thus, there is a total of $375 million appropriated for PSSF in FY 2002. In addition to state and territory funding, there are funds set aside for Indian tribes, the Court Improvement Project and federal research, evaluation and technical assistance.

Each state's share is based on the average monthly number of children receiving food stamp benefits for the most recent three federal fiscal years. As a general rule, at least 20 percent of the money must be spent in each of four categories: 1) family preservation, 2) community-based family support services, 3) time-limited family reunification services, and 4) adoption promotion and support services. A description of how these funds are to be expended must be included in the state's five-year Child Welfare Services Plan. There is a 25 percent non-federal match required.

Section 430 (a) (4) of the Social Security Act (42 U.S.C. 629) recognizes the "...growing need for post-adoption services and for service providers with the particular knowledge and skills required to address the unique issues adoptive families face." The program provides guidance to states as to how they should spend the adoption portion: "...enable states to develop and establish or expand and to operate coordinated programs." One objective of Title IV-B, Subpart 2 is "to support adoptive families in providing support services as necessary so that they can make a lifetime commitment to their children."³¹ The law encourages states to be creative and flexible in the design of effective programs.

The funding set aside for research includes a priority for "the outcomes of adoptions finalized after enactment of the Adoption and Safe Families Act of 1997." Technical assistance will be provided to states and Indian tribes to "...establish mechanisms to ensure that post-adoption services meet the needs of the individual families and develop models to reduce the disruption rates of adoption."³²

Title XIX Medicaid Program

The Title XIX Medicaid Program is an open-ended entitlement program that provides medical services to Medicaid-eligible children under certain conditions. Each state's Medicaid program is unique to that state. The Federal Medical Assistance Percentage (FMAP), which is established at the beginning of each federal fiscal year, is based primarily on the state's per capita income and ranges between 50 percent and 83 percent.³³

The federal reimbursement for Medicaid services is the unit payment x the FMAP. States can define a unit in a variety of ways including 15 minute or hour (i.e., mental health treatment), one day (i.e., residential treatment) or monthly encounter (i.e., targeted case management). The unit payment can be no more than the actual cost.

Within the federal regulations, states have great flexibility about how they administer Medicaid. Some Medicaid services are mandated while others are optional. States vary greatly in which services they select under the optional category. All Title IV-E eligible special needs adopted children have categorical eligibility for Medicaid. In addition, states have the option to provide Medicaid coverage for non-IV-E eligible children where there is a current Adoption Assistance Agreement between the state and the adoptive parents and where it "...has been determined that the child can not be placed with the adoptive parents without Medicaid because the child has special needs for medical or rehabilitative care."³⁴ Mandated Medicaid services include hospital, physician, laboratory and x-ray, home health, nursing home, nurse practitioner, and Early Periodic Screening Diagnosis and Treatment.

There are a variety of "optional services" that states may choose from to include in their Medicaid program. Medicaid-eligible children may receive these services when prescribed by a "practitioner of the healing arts." Usually this is a physician or a clinical psychologist, but some states may also include a social worker or other specified professional. Optional services include, but are not limited to, prescription drugs, dental, optometric, other practitioner, rehabilitative and preventive services, and targeted case management.³⁵

Early Periodic Screening Diagnosis and Treatment (EPSDT) is a mandatory Medicaid service that offers the best opportunities for treatment for adopted children and their families. It is designed to assure that eligible children under age 21 receive comprehensive medically necessary services. Every state must include EPSDT in their Medicaid State Plan.³⁶

How EPSDT works. A Medicaid-agency-appointed EPSDT screening team or practitioner (generally a physician) initially and periodically assesses the health needs of the foster or special needs adopted child. Their job is to ensure that any health needs are diagnosed and treated before they become more complex and their treatment more costly. They usually have the authority to order diagnostic and treatment services in those instances where a prior authorization is necessary before services will be paid by the Medicaid agency.

The EPSDT provider can authorize any medically necessary service. Even if the service is not included in the state's Medicaid plan, the costs for providing the authorized service are still eligible for federal Medicaid reimbursement for that particular Medicaid-eligible client as long as the Medicaid agency has determined that the requested service meets its established medical necessity criteria. For example, some states provide orthodontic services if a referral is made through an EPSDT screening, but only if the orthodontic condition meets or exceeds a severity index established by the Medicaid agency.³⁷

A copy of each state's Medicaid plan can be accessed through www.cms.hhs.gov/medicaid. Examples of services that are of particular interest to families that adopt include:

• Mental health services provided in the child's own home
• Chemical abuse treatment
• Inpatient psychiatric hospital
• Medical equipment (some) not otherwise covered
• Residential treatment
• Targeted case management
• Respite care
• Private duty nursing services
• Orthodontic services

States vary in the extent they describe which Medicaid services are included in their state plan under the section dealing with EPSDT. For example, some Medicaid state plans list several services included under EPSDT and conclude with "...any other medical or remedial care allowed under state law."³⁸ Other plans state, "...will provide all medically necessary diagnostic and treatment services even if the services are not included in the State Plan"³⁹ without listing any specific services. The use of EPSDT as a vehicle to access needed medical services is flexible as long as the service is medically necessary and prior authorization has been obtained when required.

Medicaid Targeted Case Management (TCM) Services. Under Medicaid, TCM Services is one of the optional services that some state child welfare agencies have negotiated with the state's Medicaid Division. TCM Services refers to services which help eligible individuals gain access to needed medical, social, educational and other services. "Targeted Case Management" allows the state to provide case management to a targeted group such as pre- and post-adopted children. The state Medicaid plan must address: "target group, areas of the state in which services will be provided, comparability of services, definition of services, qualifications of providers, free choice of providers, and assurance that payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose."⁴⁰

Targeted Case Management, including targeting pre-and post-adopted children, offers an excellent source of federal reimbursement for case management especially after an adoption is legalized. A word of caution: At the time this paper is going to press, Centers for Medicare and Medicaid Services (CMS) have not been approving state's Medicaid State Plan amendments to include TCM for children in foster care who are in the custody of a public child welfare or juvenile justice agency. Although the provision of TCM for pre- and post-adopted children is much different, it is important for state child welfare managers to be aware of the recent CMS actions.

Medicaid Rehabilitation Services. Some state child welfare agencies have negotiated with their Medicaid Division to support post-adoption services, including Medicaid Rehabilitation Services. The federal definition of rehabilitation service is "rehabilitation service, except as otherwise provided under this subpart, includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts within the scope of his practice under the state law, for maximum reduction of physical or mental disability for restoration of a recipient to his best possible functional level."⁴¹ This very broad definition provides many opportunities for children served in the public and private child welfare system. Examples of Medicaid reimbursable rehabilitation services that relate to child welfare currently being funded in some states include residential treatment centers, therapeutic family foster care and intensive in-home services.

Title XX Social Services Block Grant

The Title XX Social Services Block Grant is authorized by Congress for $2.38 billion and usually appropriates less annually. It is not an entitlement. The funds are usually administered by the state social service umbrella agency. There is considerable flexibility about how the funds can be expended. Most states use the block grant for a combination of day care, child welfare and services to the elderly.

States can use Title XX to fund post-adoption services that cannot be funded under Title IV-E or XIX. (e.g., respite care). The amount of money granted to each state is based on the state's share of the national population. There are minimal requirements. A total of $1.725 billion was appropriated in FY 2001 and $1.7 billion for FY 2002. When there are national budget reductions, this source of federal appropriation is very vulnerable to the reductions. There is neither a non-federal match nor a "maintenance of effort" requirement for Title XX funds.

Temporary Assistance for Needy Families (TANF)

The Temporary Assistance for Needy Families (TANF) program is a capped block grant ($16.7 billion per year)⁴² that replaced Aid to Families with Dependent Children (AFDC) in 1996. TANF provides assistance to eligible families with children and was established by Congress with the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. There is no state/local match required, but there is a state/local "maintenance of effort" (MOE) requirement. States have the option of how to use their share of the money within federal regulations.

The block grant covers benefits, administrative expenses and services for eligible, needy and non-needy families with a child to meet one of the four purposes of TANF:⁴³

1. Provide assistance to needy families;
2. End the dependence of needy parents by promoting job preparation, work and marriage;
3. Prevent and reduce out-of-wedlock pregnancies; and
4. Encourage the formation and maintenance of two-parent families.

TANF and MOE funds can be used for any and all of the four purposes. The first two have an economic means test, but the last two can be for anyone. States have a great deal of latitude in determining eligibility, benefit levels and services provided to families.

For example, since most adoptions are with two-parent families and children with special needs can bring added stress to the stability of the family, virtually any post-adoption service to prevent an adoption dissolution is directly related to the "formation and maintenance of two-parent families." This could include adoption resource centers, crisis intervention, respite care, support groups, training, or counseling to name a few. Further, special initiatives to improve the motivation, performance and self-esteem of special needs adopted children can be shown to help prevent and reduce out-of-wedlock pregnancies.⁴⁴ These services include, for example, mental health treatment, counseling, recreation therapy, social skills training, special camps, and adoption search.

In addition, the TANF Emergency Assistance (EA) component of the old AFDC Program and its open-ended entitlement status was eliminated with the establishment of TANF. The funds expended on the AFDC-EA program were included when each state's share of TANF was determined. States that had an EA program in their Title IV-A (AFDC) state plan prior to September 30, 1995, or at state option, August 21, 1996, are able to use the state's TANF funds for any of the purposes that were included in that state plan. Not every state established an EA program.

State Emergency Assistance plans vary greatly in eligibility requirements including, but not limited to, kinds of emergencies covered, length of time the services can be provided and the types of services included. Federal eligibility requirements limit the funds and services to needy children under the age of 21 and any other member of the household in which he or she is living. States have the option of defining a "needy child" as long as "...child is without resources immediately accessible to meet his needs."⁴⁵In most states, the definition was usually broad resulting in many middle-income families qualifying.

The kinds of emergencies included those "...necessary to avoid destitution of such child or to provide living arrangements for him in a home."⁴⁶ In many states this was defined to include children in, and those "at risk" of, out-of-home care. The definition of "at risk" can be broad. It might include families caring for children with "special needs" where there are a lot of pressures on a family and where services can prevent the need for an out-of-home placement.

Each State Plan defines the services that are provided in that state. Examples of those that would assist families who have adopted a child with special needs include case management, counseling, training and in-home family services such as respite care, child care and family support.⁴⁷ In many states, the child welfare agency administers the emergency assistance portion of TANF.

The only limit on the amount of TANF funds (including the four purposes of TANF and emergency assistance) that can be invested in these services is the priority given by each state on the multiple issues fundable by TANF. State child welfare and adoption leaders and adoption advocates can advocate for a greater portion of the TANF funds particularly as the economy improves or when the state TANF agency receives a performance bonus.

The Administration for Children and Families (ACF), Office of Financial Assistance (OFA) has a Policy - Questions and Answers website that helps clarify regulations and policy.⁴⁸

Adoption Opportunities Grants Program

The Federal Discretionary Grants - Adoption Opportunities Grants Program funds research and demonstration projects on a competitive basis in three major areas:⁴⁹

1. The development and implementation of a national adoption information exchange program;
2. Increasing services in support of the placement in adoptive families of minority children who are in foster care and have the goal of adoption, with a special emphasis on the recruitment of minority families; and
3. Increasing post-legal adoption services for families who have adopted children with special needs.

Grants may be awarded "...through a competitive process to states, local government entities, federally recognized Indian tribes and tribal organizations, faith-based and community-based organizations with experience in working with minority populations, colleges and universities, public or private non-profit licensed child welfare or adoption agencies and adoption exchanges."⁵⁰ The grants require a 10 percent non-federal match and are usually renewable from three to five years.

In FY 2003, approximately $11 million is available within the following four priority areas:

1. Adoptive Placement for Children in Foster Care
2. Project to Improve Recruitment of Adoptive Parents in Rural Communities
3. Developing a National Network of Adoption Advocacy Programs
4. Administration of the Association of Administrators of the Interstate Compact of Adoption and Medical Assistance (AAICAMA)

Approximately $8.4 million was available in five priority areas for FY 2002:

1. Developing Projects for Increasing Adoptive Placements for Minority Children
2. Developing Projects for Post-Legal Adoption Services
3. Developing Projects for Respite Care as a Service for Families Who Adopt Children with Special Needs
4. Cross-Jurisdictional Placement
5. National Adoption Internet Photo-listing Service –AdoptUSKids, the National Adoption Information-Exchange System, and Special Needs Adoption Recruitment and Adoptive Family Support Project (over half of the grant money available is designated for this priority area)⁵¹

During FY 2001 approximately $3.1 million was awarded to 16 recipients in five priority areas:

1. Achieving Increased Adoptive Placements for Children in Foster Care
2. Field Initiated Demonstration Projects
3. Advancing the State of the Art of the Adoption Field
4. Quality Improvement Centers on Adoption
5. Evaluations of Existing Adoption Programs

Information regarding the availability of the Adoption Opportunities Grants Program is listed on the Children's Bureau website for funding.⁵²

Federal Funds Under the Administration of Other Agencies

The families and children served by public child welfare agencies often have needs that make them eligible to be served by an array of health, mental health, education and social service agencies. Thus, child welfare agency leadership is encouraged to work collaboratively within their child and family service systems to identify other federal funds that can be accessed to meet the complex and comprehensive needs of adopted children and their families. Ongoing relationships with multiple child- and family-serving agencies are critical to maximizing resources and achieving positive results for children, families and their communities.

Many of these services may be either provided by the public agencies collaboratively or purchased from private agencies. Some examples include:

• Title II of the Keeping Families and Children Safe Act (formerly CAPTA);
• Foster Independence Act - Education and Training Vouchers for Youths Aging Out of Foster Care (youth adopted at 16 years and older are eligible for this educational assistance);
• Mental Health Service Block Grant;
• Substance Abuse Block Grant;
• Federal Discretionary Grants;
• Title V of the Social Security Act (Maternal and Child Health);
• The Individuals with Disabilities Act (IDEA), which authorizes The Early Intervention Program for Infants and Toddlers with Disabilities (Early Intervention Program) and The Preschool Grants Program (Preschool Program).⁵³

The following discussion highlights selected services that adoptive families have identified as critical to building and sustaining their newly formed families. Information is provided about how states can maximize a blend of existing federal and state funding to create and/or expand their array of post-adoption services and supports.

Respite Care

Adoptive families report that respite care⁵⁴ with known and trusted providers who understand the needs of their adopted children is a service that in many cases has contributed to their ability to sustain their family's functioning. Many states, such as Arizona, Georgia, Massachusetts, Oregon, South Carolina, Utah, and Virginia, support respite care opportunities for adoptive families. State adoption program managers report that states are funding respite care or family respite activity options largely with state general funds as well as Title IV-B, Subpart 2 and federal Adoption Incentive funds.

However, there are additional funding alternatives that include federal funding streams which can make the state general fund dollars go further. While Title IV-E cannot be used to pay for respite care, Medicaid, based on an EPSDT screen, is a potential resource based on the child's medical condition. Additional alternatives include some blending of Title IV-B, Subparts 1 & 2, Adoption Incentive, Adoption Opportunities, TANF, Title XX, and other federal discretionary funds.

In Georgia, respite care is available to any adoptive family who receives adoption assistance and has adopted a child who had been in state custody. There are 11 contracted programs in the state that provide some form of respite care. Adoptive families prefer to pick their own respite care provider, at times creating a challenge for the state to plan and organize an array of respite care options. Selected families are eligible for 20 hours of respite care per month. The actual amount authorized is based on the needs of the child, with more respite care provided if needed and documented. Families can carry over unused time, but do not always use it. The Georgia Respite Care Program began under an Adoption Opportunities Grant in 1996.⁵⁵

Gail Greer, director of adoptions for the Georgia Department of Human Resources, states that "respite care is one of the most important services to help families in crisis. One adoptive family was about to end their adoption, but respite care helped save it ... respite care is one of the primary services adoptive families have asked for."⁵⁶

Adoption Resource Centers

A particularily exciting "new" development in meeting the needs of adopting families is the emergence of the Adoption Resource Center. Several states — including Alabama, Georgia, Idaho, Massachusetts, Michigan, and Wisconsin — have some form of adoption resource center program. Some states focus on children adopted from the public system while others, such as the Massachusetts Crossroads program, are available to all adopting families. Adoption Resource Centers usually provide a broad range of services for adoptive and prospective adoptive families such as: case management and family supports, respite care, family advocacy, information and referral, recruitment and home studies, lending libraries, research and training opportunities. A few provide adoption-related counseling and behavior management treatment.

Adoption resource centers can be funded with a mixture of federal and state funds depending on the service provided and if the service is for the general population or children adopted or to be adopted from the public system. If a mix of funds is used, adoption resource centers must be able to allocate their time and costs to the various services provided. Often, state child welfare agencies fund private providers to develop adoption resource centers, but states might also coordinate and provide their own array of services through an adoption resource center at the community level. If a private provider is used, the provider should keep a time-study log to thoroughly allocate the costs to different funding streams so that funding is maximized.

The funding formulas for the array of services available through an adoption resource center would depend on the eligible funds for that particular type of service, for example:

• Pre- and Post-Adoption Case Management as well as Information and Referral or Research can be funded through Title IV-E Administrative dollars. The adoption assistance non-IV-E penetration rate portion can be claimed to other federal sources (i.e., Title IV-B or Adoption Incentive funds).
  
  
• Respite Care can be funded through Medicaid, based on an EPSDT screen, Title IV-B, Subparts 1 & 2, Adoption Incentive, Adoption Opportunities, TANF, Title XX, and other federal discretionary dollars.
  
  
• Behavioral Management Treatment can be funded through Title XIX, Medicaid or Title IV-B, Subparts 1 & 2, TANF, and Adoption Incentive funds.
  
  
• Crisis Intervention that is a part of the Medicaid/Targeted Case Management Program can be billed to Medicaid. It could also be billed to Title IV-B, Subparts 1 & 2, Adoption Incentive and TANF.
  
  
• Training Opportunities can be funded with the following federal funding streams: Title IV-E Training funds, Title IV-B, Subparts 1 & 2 and Adoption Incentive funds, which can be claimed for non-IV-E eligible ratio.

In Massachusetts, the Adoption Crossroads program, an adoption resource center model, was funded with state dollars in October 1997 for all citizens who have legalized adoptions or guardianships from state, private or international sources. The Massachusetts Department of Social Services contracts with a "lead" private agency to provide an array of post-adoption services throughout the state. The lead agency in turn sub-contracts with five "affiliate" agencies to assure statewide coverage. The lead agency is responsible for overall program management and also delivers direct services in one region of the state. In addition, the lead agency contracts with the Salem State College Graduate School of Social Work to evaluate the progress of Adoption Crossroads. An evaluation of the first five years was completed in June 2002.

Any person who calls the toll-free number at the lead agency will talk with an adoption-competent professional who can provide information and make a referral for specific services in the caller's region. Services may include respite care, clinical and counseling services (response teams), family support, advocacy, and training. According to Mary Gambon, assistant commissioner for Foster Care and Adoption, Massachusetts Department of Social Services (DSS) began Adoption Crossroads because of the efforts of a coalition of adoptive parents, the Department, private agencies, adoption advocates and volunteers who had sought post-adoption services for the previous 12 years and were not able to secure the needed funding to provide post-adoption services. This coalition, led by adoptive parents, worked with the legislature to secure the funding in the DSS budget. Post-adoption funding was put out to bid and there were six responses to be the lead agency. Adoptive parents were involved in the selection and the grant was awarded to New Bedford Child and Family Services to fund Adoption Crossroads. As one would expect, there have been some growing pains, but now, five years later, legislative funding has been sustained, the program has been very successful and the satisfaction rate on surveys from the adoptive families has been "incredibly high."⁵⁷

In the state of Michigan, Jean Hoffman reports that since June 2001 the Family Independence Agency (FIA) has contracted for seven Post-Adoption Resource Centers throughout the state. The focus is entirely on post-adoption services and includes crisis intervention, information and referral, coordination of community-based services, training and development of community-based recreation.⁵⁸

According to Shelia Marquardt, deparment analyst for Michigan FIA, Adoption Services Division, any Michigan family who receives or is eligible to receive an adoption subsidy from the state, and who has adopted a special needs child, is eligible for the services of the Adoption Resource Centers. There is no means test. The centers are all operated by private nonprofit (501(c)(3)) organizations. They are selected on the basis of a competitive Request for Proposal (RFP). Each center has a board of adoptive parents from the region that monitors the activities and helps establish priorities. The centers are not all the same. The services they provide and how they are provided vary based on the uniqueness of each center's geographic area. Center activities need to be family-driven and not agency- or worker-driven.

The first six centers are funded with a total of $500,000 in TANF funds based on meeting two of the TANF purposes: to encourage the formation and maintenance of two-parent families and to prevent and reduce out-of-wedlock pregnancies. The seventh center was initially funded with Adoption Incentive funds. The state is now shifting the federal funding source of that center to Title IV-B, Subpart 2 because additional TANF funds are not available. In addition to the funding received from the state, the centers are expected to raise other community financing to expand the program and services.

The state is in the process of completing the analysis of a "satisfaction survey" of adoptive parents. According to Marquardt, the responses have been very favorable and have included, "The Center gives us the platform to address our own issues." "We can go as a family." "We like it."⁵⁹

Michigan has been creative in the use of TANF funds for the operation of the centers. This is a solid, replicable model for other states to emulate.

Adoption-Competent Training Opportunities: Adoptive Families, Adoption Staff and Mental Health Professionals

Increasingly, states are developing extended training opportunities for both professionals and adoptive families to strengthen, support and sustain adoptive families post-legalization. As such, states are beginning to develop training programs that increase the adoption competence of existing public and private agency child welfare staff as well as public and private community mental health providers - professionals who will come in contact with adoptive families at the community level.

The costs of training adoptive families, public and private adoption staff and community mental health providers are reimbursable with a blend of federal and state or local funds depending on the training topic and the population being trained. Usually, because it is an open-ended entitlement, Title IV-E is the funding source of choice for training public agency adoption staff, adoptive parents and contracted private agency staff who carry out the public agency adoption function.

Training current and prospective adoptive parents.

Training opportunities with current or prospective adoptive parents can be general or specific. For example, training can include individual discussions with adoptive parents or ongoing classes, topic seminars, films or other vehicles for sharing information related to children's needs and conditions. In addition to initial training, some states provide annual or semi-annual adoptive parent conferences, and weekend family retreats that provide training to adoptive parents and children on a variety of topics that are helpful to them as adoptive families.

"The adoptive families absolutely love it. And the kids love it, too. They have never been in a group where everyone has been adopted," says Georgia Director of Adoptions Gail Greer.⁶⁰The Title IV-E training formula is applied to the costs of training adoptive parents while Titles IV-B and XX and Adoption Incentive can be used for other family members.

Training public agency adoption staff. States routinely provide training for their public agency adoption staff on a variety of non-treatment post-adoption issues, such as case management and adoption assistance agreements. The Title IV-E training formula is applied.

Training private agency staff. When providing IV-E allowable non-clinical training (i.e., case management) to contracted private agency adoption staff and public and private clinicians, the Title IV-E Administration funding formula is applied.

Training adoptive parents and adoption staff through a public educational institution. The inclusion of the public educational institution's federally approved indirect rate when calculating Title IV-E reimbursement provides a fiscal incentive for states to form these "partnerships" by contracting with public colleges and/or universities. This reduces the general fund expenditures for the state. When this is done, in addition to the appropriate Title IV-E formula for the direct training costs, the state may include the public educational institution's federally approved indirect rate for "instruction" and claim this cost using the Title IV-E Administration funding formula.

Adoption-competency training with clinical staff.

Training for clinical staff/providers regarding adoption treatment-related clinical skills cannot be reimbursed through Title IV-E. However, states may be able to use a variety of other federal funding sources. Some of these funding sources require a non-federal share as specified elsewhere in this paper. The state choice should depend on previous commitments for the funds and their current availability. They include:

• Title IV-B, Subparts 1 or 2
• Adoption Incentive funds
• Adoption Opportunities Program funds
• Title XX funds
• TANF funds
• Title XIX (Medicaid) for public agency clinicians

Adoption Certification Training Program. One of the more unique emerging strategies to train child welfare and mental health professionals regarding adoption-competent practice has emerged at the Rutgers University School of Social Work in its Continuing Education Program in a partnership with the New Jersey Division of Youth and Family Services (DYFS). The New Jersey DYFS received an Adoption Opportunities Grant in FY 2001 and formed a partnership with Rutgers to develop an "Adoption Certification Training Program" related to adoption and clinical/treatment issues for public and private agency adoption staff and community mental health providers. The program meets over nine months for one day a month and includes sessions devoted to helping professionals understand the context of adoption today; clinical issues of adoptive families and children; and helping adoptive families deal more effectively with issues related to the trauma of separation, loss, grief and relationship disruptions. The DYFS and Rutgers program is currently funded through an Adoption Opportunities Grant, state general funds and tuition from the community mental health providers. They plan to expand the program with Adoption Incentive funds.⁶¹

Other states can replicate this effort to train both public and private agency adoption staff and community mental health providers in an array of administrative, theoretical and clinical skills related to working with adoptive families. However, a state would need to separate the costs for specific course topics and use a variety of funding formulas for each type of training offered.

The state should evaluate the course content and then allocate the costs of specific course topics within the Adoption Certification Training into IV-E reimbursable and non-IV-E reimbursable training. Examples of IV-E reimbursable training include, but are not limited to, information about case management, adoption data collection, federal adoption policies and regulations, adoption assistance agreements, adoption recruitment and preparing adoption home studies. Adoption treatment skills training cannot be claimed to IV-E but can be supported by alternative funding sources such as IV-B, Subparts 1 & 2, Adoption Incentive, TANF, Title XX, potentially XIX and, of course, state general funds.

The funding formula would include the following steps for the various populations:

1. Evaluate the course content and allocate into allowable IV-E related training and non-IV-E related training.
2. Calculate the costs of providing IV-E related training for public employees and current or prospective adoptive parents and apply the appropriate funding formula.
3. Calculate the costs of providing IV-E related training for contracted private agency staff who are carrying out the public agency responsibility and apply the appropriate funding formula.
4. Calculate the costs of providing non-IV-E related training and apply the appropriate (non-IV-E) funding formula.

Web-based and booklet reference guides. Another creative training-related activity that states might want to promote includes the development and distribution of a clinician referral booklet or a website listing sources of professionals who provide services and supports with adoptive families and special needs children, including clinicians who may have been certified as adoption-competent. The Title IV-E Administration funding formula should be applied for these costs.

The combination of these examples of training emphasizes the availability of funding for training when the costs are properly allocated and used in concert with each other.

Mental Health Treatment Services

Medicaid is the best resource for purchasing behavioral health care for special needs children. This should be the first funding stream because it is an open-ended entitlement.

The federal funding formula for Medicaid services is included in the previous description of the Medicaid program on page 34.

For mental health treatment that is not covered by Medicaid or private insurance, states can use any of the following:

• Title IV-B, Subparts 1 or 2
• TANF funds
• Adoption Incentive funds
• Title XX funds

The availability and accessibility of adoption-competent mental health treatment services is an increasing concern for adoptive families. States can be creative in how they design their Medicaid Plan to address this growing need. An example is the Adoption Clinic of the Kinship Center located in Orange County, California, which offers a unique operating and funding solution. According to Carol Biddle, executive director of the Kinship Center, the Adoption Clinic grew out of collaboration between the Center and County Social Services and County Health Care of Orange County based on needs identified by Orange County adoptive parents.

The Adoption Clinic began operating in February 2000, and its experienced therapists provide individual, family and group counseling in such problem areas as depression and grief, attachment issues, behavior difficulties, ADHD, anger management, and family conflict. All adoptive families with children adopted from Orange County Social Services are eligible for the services. The child must have a DSM IV diagnosis and be 18 years old or younger. Referrals can be made by Orange County Social Services, adoptive family self-referral or other sources. During the first month, the Center saw 65 children, and now they see 125 children per week. Biddle reports that adoptive families have responded with, "This is a godsend." "Do you have any idea how long we've waited for this?" "What took you so long?"⁶²

The funding strategy is particularly unique. According to federal law, all IV-E eligible children for whom an Adoption Assistance Agreement is in place between the adoptive parents and the state are categorically eligible for Medicaid. In addition, many states have elected the Medicaid option to provide Medicaid to non-IV-E eligible adopted children who meet federal requirements. The Adoption Clinic is a Health Care Organization (Medicaid provider) and can conduct EPSDT screenings and authorize treatment for children eligible for Medicaid. The Clinic bills Medicaid monthly on a unit-cost basis and receives payment through Orange County.

Federal funding for the Clinic comes from Medicaid through EPSDT. The non-federal share comes from Proposition 10 (a non-federal funding source unique to California). This federal funding strategy is transferable to all other counties and states. The challenge will be for states to commit to the non-federal share of providing the treatment. However, this example is certainly more economical and efficient than inpatient hospitalization.

Medicaid Targeted Case Management. Several states, including South Carolina, Maine and North Dakota, include Targeted Case Management (TCM) services in their state Medicaid plans. This may be the fastest way to generate federal revenue for the case management services provided by state/local agency staff or contracted with a private provider. It is clear that targeted case management can be provided after adoption finalization. Title IV-E policy requires it for the implementation of the adoption assistance agreement. The definition of targeted case management is broad and can also meet the requirements of family support, advocacy and resource to the child and family. All special needs adopted children are categorically eligible for Medicaid.

Maine provides more traditional Targeted Case Management through the Maine Department of Behavior and Development Services. In addition, a more unique form of targeted case management is provided through the Maine Adoption Guides Project, "a collaborative effort of the U.S. Department of Health and Human Services, Maine Department of Human Services, University of Southern Maine, Casey Family Services, and families that are adopting children out of the Department's care."⁶³The Project is scheduled to end in April 2004, but state officials hope to extend it beyond that date.

The Maine Adoption Guides Project is based on family systems theory, and one of the key services is clinical Targeted Case Management. The case managers must be licensed MSWs. They must complete Adoption Support and Preservation training provided through the Child Welfare Training Institute at the University of Southern Maine. The curriculum is adapted from the "Adoption Support and Preservation" curriculum developed by the National Resource Center for Special Needs Adoption at Spaulding for Children in Michigan. "This ensures the case managers are adoption sensitive, adoption competent and better assures families and children will receive quality services," according to John Levesque, former adoption program manager, Maine Bureau of Child and Family Services.⁶⁴

The Targeted Case Management services can be provided by either public or private agency qualified staff. The case managers provide information and referral, case study and assessment, advocacy, case supervision and develop case plans. Targeted Case Management services are reimbursed by Medicaid with a monthly family rate of $700. The Maine Bureau of Child and Family Services is responsible for the non-federal share of the cost of TCM. John Levesque reports that "targeted case management has gone a long way in keeping families together. It assures families are able to provide for their child's needs in the least intrusive way possible. It has been phenomenally successful."⁶⁵

The funding formula for Medicaid TCM is included in the prior description of the Medicaid program on page 37. The cost of training the Targeted Case Management case managers can be included in the targeted case management unit rate. This provides a greater federal reimbursement rate than Title IV-E. It is also possible to train the case managers with Title IV-E training funds if the course content relates to Title IV-E allowable activities.

The dramatic increase in the need for post-adoption services comes at a challenging time for states. All across the country, state budgets are being cut resulting in staff being laid off and many essential state programs and purchase-of-service contracts being reduced or eliminated. The following recommendations are made with these challenges in mind. They involve the progressive steps that states can take to creatively finance post-adoption services, even in times of great economic uncertainty. These recommended strategies are guided by the assumption that the funding of post-adoption services may require state leadership (program and fiscal together) to review and analyze their overall approach to claiming federal child welfare resources to better maximize the application of limited state general funds as well as other available federal resources.

1. Establish a statewide priority to provide ongoing post-adoption support for every child adopted from the public agency. This priority is linked to the agency's vision and mission and is included within the state's strategic plans.

The provision of post-adoption services can be linked to the state agency's mission and vision to protect and serve vulnerable children and families. In establishing this priority, states should include staff, and especially, adoptive families to acknowledge and document the need for post-adoption services and to consider which mix of services will have the greatest impact in the context of existing resources. The priority focus on post-adoption services can be included in states' strategic Child Welfare Services (Titles IV-B and IV-E) and Medicaid State Plans. In short, funding will be driven by what is included in these strategic State Plans.

2. Establish a Program and Finance Review Team to jointly review and analyze the options to maximize the reimbursements for all child welfare and post-adoption services.

The team of program and fiscal staff can jointly review and analyze the funding sources and formulas for all state-provided and purchased (contract) child welfare services to determine if the state has been under-claiming federal reimbursement for foster care and adoption services. Then the team can maximize the application of state general funds by properly claiming the highest revenue source for these services.

Public adoption policy and finance staff responsible for allocating costs and matching funding sources with programs/services together can review all adoption-related expenditures including:

• How expenses of public agency adoption staff are being allocated;
• How the adoption subsidy IV-E ratio is being used;
• If the Random Moment Time Study (RMTS) definitions are current, and if staff are properly trained as to their meaning and application;
• How the expenses for training current or prospective adoptive parents are being paid;
• If the state is purchasing post-adoption services, whether the services are reimbursable under IV-E regulations, and which funding formula is being used (i.e., adoption resource centers, case management, respite care and training);
• How the fiscal "cost centers" or "codes" that link purchase of service contracts to the best funding source and formula are determined;
• How IV-E reimbursement for services provided to IV-E eligible children and utilizing other federal funds (i.e., IV-B, Subparts 1 & 2, TANF and Adoption Incentive for non-IV-E eligible children) are claimed.

When states use Title IV-E Administration or Training funds, they can use other federal funds for the non-IV-E eligible portion of the training costs. For example, if training is being provided to adoptive parents and 60 percent of the children are IV-E eligible, the state can claim 60 percent of the costs at 75 percent IV-E (25 percent state/local). The remaining 40 percent of the costs can be paid using such funds as Title IV-B, Subparts 1 or 2, Adoption Incentive, or Title XX. The net will be less general funds used and an increase in federal funds claimed.

In addition, states can use flexible grant funds for services that cannot be funded with IV-E or XIX (e.g., training for private clinical staff or non-medical respite care). States can also provide training for current and prospective adoptive parents in coordination with a public college and use the college's federally approved indirect rate for securing additional Title IV-E reimbursement. This will reduce the amount of state or local funds required for the federal match.

3. Use savings generated through the federal reimbursement maximization process to support and sustain an array of post-adoption services.

Maximizing federal reimbursements for child welfare services should provide states with savings in their state funds, which can be applied to the state match needed for the comprehensive array of post-adoption services able to be funded through Title IV-B, Subparts 1 & 2; Title IV-E; and Title XIX Medicaid. Thus, existing state general funds can be used more creatively to both sustain the current array of child welfare services and to support the newly funded post-adoption services needed by the increased number of adoptive families today.

4. Use open-ended Titles IV-E and XIX Medicaid "entitlement" resources whenever possible, and include "Targeted Case Management" for post-adoption services in the state Medicaid Plan.

State fiscal and program staff can jointly review the funding sources and formulas for all state-provided or purchased post-adoption services to be sure that the maximum federal resource is being billed whenever possible. The first dollar resource should be open-ended entitlement federal funds whenever possible. This means using Titles IV-E and XIX-Medicaid whenever possible. If a state has the option of using either Title IV-E or XIX-Medicaid, XIX-Medicaid should be sought first for the following reasons: 1) the FFP (Federal Financial Participation) is at least as good (never less than 50 percent); 2) all special needs children are categorically eligible for XIX; and 3) there is no need to cost allocate based on the ratio of those that are Title IV-E eligible. States can then shift any state or local general fund savings resulting from a higher federal match to develop or strengthen its post-adoption services program. Additionally, states can include Targeted Case Management post-adoption services within their State Medicaid Plans, with a minimum federal reimbursement of 50 percent FFP. Yet states should keep in mind the "cautions" that are included in the "Title XIX - Medicaid Program" description in this paper.

"Can Do" Recommendations

Every State Can ...

1. Make post-adoption services a statewide priority linked to the agency's mission and philosophical vision. Assess the needs of the growing number of adopted children and their families to guide the provision of an ongoing array of post-adoption services and supports for the children and families who need them.
   
   
2. Involve adoptive families and staff in planning for the inclusion of a specific plan for post-adoption services within its Child Welfare Services (Titles IV-B and IV-E) and Medicaid State Plans.
   
   
3. Provide training and ongoing support for senior management regarding the intricacies of various federal funding streams, regulations governing the acceptance of the federal funds, and creative strategies to maximize the application of state general funds as well as available federal funds for post-adoption services.
   
   
4. Establish a Program and Finance Review Team to jointly review and analyze the options for funding of all child welfare and post-adoption services.
   
   
5. Review and analyze the funding sources and formulas for all state-provided and purchased (contract) child welfare services to determine if the state has been under-claiming for foster care and adoption services. Then, maximize the application of state general funds by properly claiming the highest revenue source.
   
   
6. Use savings generated through the fund-maximization process to support and sustain an array of post-adoption services, with greater ability to provide the state match for Title IV-B, Subparts 1 & 2; Title IV-E; and Title XIX, Medicaid.
   
   
7. Negotiate with the state Medicaid agency regarding opportunities to provide services to adopted children within the Medicaid State Plan, especially the inclusion of Targeted Case Management services for adopted children and their families.
   
   
8. Negotiate with the state Medicaid agency for ways to use EPSDT to provide treatment services for adopted children, as well as for adoption-competency requirements in the managed care contracts for mental health providers.
   
   
9. Provide training to current and prospective adoptive parents utilizing, primarily, Title IV-E federal funds. Provide adoption-competency training to public and private agency adoption staff and mental health providers with a blend of federal funds, including Title IV-E; Title IV-B, Subparts 1 & 2; TANF; Title XX; Adoption Incentive and Title XIX. These training opportunities may be conducted through a public educational institution to maximize federal reimbursement.
   
   
10. Conduct outcome-based research regarding special needs adopted children with Title IV-E funding in coordination with a public educational institution to leverage federal reimbursement and to minimize conflict of interest.

1. Department of Health and Human Services, Administration for Children and Families, Children's Bureau, AFCARS Report #7.
2. Preliminary AFCARS Report #8.
3. Barbell, K. and Freundlich, M. (2002) Foster Care Today. Casey Family Programs.
4. AFCARS Report #7.
5. AFCARS Report #7.
6. Barbell, K. and Freundlich, M.
7. AFCARS Report #7.
8. Ibid.
9. Preliminary AFCARS Report #8.
10. AFCARS Report #7.
11. U.S. Congress, House of Representatives, House Ways and Means Committee, 2000 Green Book, Section 11, Child Protection, Foster Care and Adoption Assistance.
12. Chapin Hall (June 2001). Evidence Base for Child Welfare Policy.
13. The National Adoption Information Clearinghouse website: http://www.calib.com/naic/pubs/s_disrup.cfm
14. Barth, R.P. and Berry, M. (1990) quoted in National Adoption Information Clearinghouse website. June 2003.
15. Stolley, K.S. (1993). Statistics on Adoption in the United States, The Future of Children: Adoption, 3(1), 26-42.
16. Oppenheim, E. Gruber S., Evans, D. (October 2000) Report on Post-Adoption Services in the States. American Public Human Services Association. Washington, D.C.
17. Social Security Act, 42 U.S.C. § 673(c)(1)-(2) (2003).
18. Ibid.
19. Ibid.
20. ACYF-CB-PA-01-01, January 23, 2001, Adoption Assistance Eligibility.
21. Federal Register website for Department of Health and Human Services Medicaid Federal Medical Assistance Percentages: http//aspe.dhhs.gov/health/fmap/htm
22. 45 C.F.R. § 1356.60(c) (2003).
23. Department of Health and Human Services, Administration for Children and Families, Children's Bureau, Child Welfare Policy Manual, Chapter 8.1H, "Title IV-E - Administrative Functions/Costs - Training," http://www.acf.dhhs.gov/programs/cb1/cwpm.
24. Department of Health and Human Services, Administration for Children and Families, Children's Bureau, Child Welfare Policy Manual, Chapter 8.1C, "Title IV-E, Administrative Functions/Costs, Calculating Claims," http://www.acf.dhhs.gov/programs/cb1/cwpm
25. Department of Health and Human Services, Administration for Children and Families, Children's Bureau, Child Welfare Policy Manual, Chapter 8.1H, "Title IV-E - Administrative Functions/Costs - Training," http://www.acf.dhhs.gov/programs/cb1/cwpm.
26. ACYF-CB-PI-99-04, March 5, 1999, "Adoption Incentive Payments, Grants"
27. Social Security Act, 42 U.S.C.S. § 673b (2003).
28. ACYF-CB-PI-99-04, March 5, 1999, "Adoption Incentive Payments, Grants"
29. Code of Federal Regulations, 45 CFR 1357.10, "Scope and Definitions Requirements Applicable to Title IV-B."
30. Ibid.
31. Social Security Act, 42 U.S.C.S. § 629 (2003).
32. Adoption and Safe Families Act of 1997, 42 U.S.C.S. § 675 (2003).
33. Federal Register website for Department of Health and Human Services Medicaid Federal Medical Assistance Percentages: http//aspe.dhhs.gov/health/fmap/htm.
34. Code of Federal Regulations, 42 C.F.R § 435.227, Individuals under age 21 who are under state adoption assistance agreements.
35. Social Security Act, 42 U.S.C.S. § 1396a-v (2003).
36. 42 C.F.R. § 441.50-62 (2003).
37. David Zentner. March 2003. Director, Medicaid Services Division, North Dakota Department of Human Services.
38. South Dakota Medicaid State Plan, EPSDT, June 2002.
39. North Dakota Medicaid State Plan, Targeted Case Management, January 14, 2000.
40. Social Security Act, 42 U.S.C.S. § 1396n (2003).
41. 42 C.F.R. § 440.130(d).
42. Department of Health and Human Services, FY 2003 President's Budget Proposal, Page 148.
43. Department of Health and Human Services, Administration for Children and Families,
44. Office of Family Assistance, Helping Families Achieve Self-Sufficiency - A Guide on Funding Services for Children and Families Through the TANF Program, http://www.acf.hhs.gov/programs/ofa/funds2.htm
45. Ibid.
46. Emergency Assistance to Needy Families with Children, 45 C.F.R. § 233.120 (1997) (removed 1997).
47. Ibid.
48. Title IV-A, Emergency Assistance to Needy Families with Children, State Plans, Idaho, North Dakota, South Dakota, Washington.
49. Department of Health and Human Services, Administration for Children and Families, Office of Family Assistance, Policy Q's & A's - Use of Funds, http://www.acf.hhs.gov/programs/pfa/polquest/usefunds.htm
50. DHHS-ACF Program Announcement No. CB-2002-01 regarding availability of financial assistance and request for applications to support projects under the Adoption Opportunities Program.
51. Ibid.
52. Ibid.
53. Website for Adoption Opportunities funding: http://www.acf.hhs.gov/programs/cb/funding/cb2002/cb2002p2.htm
54. See AAICAMA Issue Brief 26 (December 2002). Resources for Adoptive Families - Early Intervention and Preschool Program Services for Children with Special Needs. APHSA.
55. See AAICAMA Newsletter Bridges (Spring 2003). Sharon McCartney, JD. "Outside the Box: Where to Look for Respite Resources." APHSA.
56. Gail Greer, Director of Adoptions, Georgia Department of Human Resources. Interview, September 2002
57. Ibid.
58. Mary Gambon, Director of Foster Care and Adoption, Massachusetts Department of Social Services. Interview, September 2002.
59. Jean Hoffman, former Director, Adoption Services Division, Michigan Family Independence Agency. Interview, February 2003.
60. Shelia M. Marquardt, Department Analyst, Adoption Services Division, Michigan Family Independence Agency. Interview, March 2003.
61. Gail Greer, Interview, September 2002.
62. Eileen Crummy, Assistant Director, Adoption Operations, Division of Youth & Family Services, New Jersey Department of Human Services. Interview, February 2003.
63. Carol Biddle. Director, Kinship Center. Orange County, California. Telephone interview, October 2002.
64. Maine Department of Human Services, Project Description. "Maine Adoption Guides Project - Resource Philosophy"
65. John Levesque, former Adoption Program Manager, Maine Bureau of Child and Family Services, Department of Human Services. Telephone interview, July 2002.
66. John Levesque, Telephone interview, July 2002.