September 24, 2007 The Basics The Title V Maternal and Child Health Block Grant Program Title V is a broadly defined but limited source of federal funds that states can use to help address the social, financial, behavioral, and structural barriers to health care for women, children, and families. Federal Title V funding, together with state and local funds, supports an array of public health and community-based programs designed to serve as a safety net for uninsured and underinsured children, including children with special health care needs (CSHCN). Federal funding—$693 million in fiscal year (FY) 2007—accounts for a small portion of the total funding for Title V activities. In FY 2005, states served 33.1 million women and children under Title V, including 1.3 million CSHCN, with a total budget of approximately $5.2 billion. Of the children served, 10.1 million had Medicaid or State Children’s Health Insurance Program (SCHIP) coverage. This paper highlights the key components of Title V and its legislated interaction with Medicaid and SCHIP. OVERVIEW Title V funds are used in a variety of initiatives. These include public health training, nutrition, oral health, substance abuse, health and safety in child care, injury and violence prevention, pediatric and adolescent AIDS, lead poisoning, preventive health, standards and guidelines, and public/private partnerships for health promotion and disease prevention.1 Operating as a federal-state partnership since it was established as part of the Social Security Act in 1935, Title V has been amended, expanded, and consolidated over the years to reflect changing national approaches to maternal and child health and welfare. In 1981, Title V programs were converted to the Maternal and Child Health (MCH) Services Block Grant program.2 The Maternal and Child Health Bureau (MCHB) within the Health Resources and Services Administration (HRSA) at the U.S. Depart- ment of Health and Human Services (HHS) administers the two funding components of the MCH block grant:  Formula grants to states are awarded to state health agencies on the basis of the amount awarded to states in 1981 for the individual programs con- solidated into the MCH block grant (total $422 million) and the number of children in poverty in the state in relation to the total number of such children nationally. Funds allocated to states under the formula grants national health policy forum Facilitating dialogue. Fostering understanding. The Basics: Title V MCH Block Grant September 24, 2007 are available for two years. States are required to contribute $3 for every TABLE 1 $4 of federal funds awarded under the formula grants. States use grant Title V Appropriations, funds to provide a variety of MCH programs and services (see below). FY 2003–2007  Federal discretionary grants are awarded by the Secretary of HHS on a competitive basis to a variety of applicant organizations. These grants Fiscal Federal Year Appropriation comprise the special projects of regional and national significance (SPRANS) program and the community integrated services systems 2003 $730,710,000 (CISS) program. A $1 match for every $2 of federal funds provided 2004 $730,817,000 through SPRANS is required. Through grants, contracts, and other 2005 $723,928,000 mechanisms, SPRANS funds support projects—such as MCH research, 2006 $692,521,000 MCH training, genetic disease testing and counseling, and hemophilia diagnostic and treatment centers—to improve the health of mothers and 2007 $693,000,000 children. “Bright Futures,” a comprehensive set of child health guidelines Source: Health Resources and Services for practitioners, was developed and promoted under a SPRANS grant. Administration, “Fiscal Year 2008 CISS funds have been used to support a variety of service delivery activi- Justification of Estimates for Appro- priations Committees”; available ties, including the development of home visitation services, outreach and at www.hrsa.gov/about/budget education efforts to increase provider participation under Title V, and justification08/mchblockgrant.htm. expansion of services to rural populations. TITLE V FUNDING The majority of the funding for Title V activities comes from state and local sources, including the state match3 (and overmatch) for the federal Title V funds; MCH dedicated funds collected from local jurisdictions; and other sources, such as foundations and income collected from insurance pay- ments and Medicaid. HRSA refers to the total combined funding for Title V activities as the Federal-State Title V Block Grant Partnership Budget (Figure 1, next page). Distribution of annual federal appropriations under Title V is defined in Section 502 of the Social Security Act. Of the amounts appropriated, up to $600 million, 85 percent is for formula grants to states; 15 percent is for SPRANS activities.4 In recent years, Title V has received federal authoriza- tions of $850 million; however, as shown in Table 1, actual appropriations have been lower. In 2007, federal allotments to states for the formula grants totaled $567 million. Federal, state, and local expenditures under the MCH formula grants amounted to $5.6 billion. Nonfederal shares of total Title V budgets vary by state. Individual state Title V total block grant budgets range from National Health Policy Forum $13.2 million (including a $1.1 million federal allotment) for Alaska to $1.9 Facilitating dialogue. billion (including a $44 million federal allotment) for California. Fostering understanding. 2131 K Street NW, Suite 500 TITLE V-FUNDED ACTIVITIES Washington DC 20037 202/872-1390 Because Title V is a block grant program, it gives states greater latitude in 202/862-9837 [fax] determining how allotted federal funds are used for the provision of health nhpf@gwu.edu [e-mail] services and related activities than they are allowed under Medicaid and www.nhpf.org [web] National Health Policy Forum | www.nhpf.org The Basics: Title V MCH Block Grant September 24, 2007 SCHIP. For example, the terms “health care” FIGURE 1 and “preventive and primary care services” FY 2007 Federal-State Title V Block Grant are not defined under Title V, and states may Partnership Budget by Source of Funding use their own definitions of these services in their grant applications. States also determine the eligibility criteria used for services they Federal* provide under the block grant. Program Income‡ 10.6% 26.1% There are very few prohibitions on state use of Title V federal MCH formula grant funds.5 The State Match and Other† Local MCH Funds statute identifies several purposes for which the 11.3% 51.9% federal funds are to be used: (i) assure access to quality MCH care, especially for those with low incomes or limited availability of care; (ii) reduce infant mortality; (iii) provide rehabilita- Total Budget = $5.6 billion tive services for blind and disabled children under the age of 16 who receive Supplemental Security Income; (iv) provide * Includes federal allocation and unobligated balance access to pre- and postnatal care; (v) provide and promote family-centered, †Funds other than Title V Block community-based systems of coordinated care for CSHCN; (vi) increase the Grant Funds under control by number of children receiving health assessments and diagnostic and treat- individual(s) responsible for ad- ment services; and (vii) provide assistance in applying for Medicaid services. ministration of Title V program. Some states have designated Title V agencies to administer their programs, ‡Includes insurance payments, HMO payments, Medicaid while others structure their Title V-funded programs as targeted grants reimbursements to state-defined qualified communities and entities such as health clinics, Source: Maternal and Child Health health centers, and hospitals. Title V funds are often used in funding staff, Bureau, “Federal-State Title V Block infrastructure, and program development under these arrangements. Grant Partnership Expenditures by Source of Funding”; available at https://perfdata.hrsa.gov/mchb/ Services mchreports/search/financial/ finsch01_result. States are required to use at least 30 percent of their federal funds for preven- tive and primary care services for children and at least 30 percent for CSHCN. Beyond these federal minimums, states determine the actual services provided and expenditures by service and service category vary widely. MCH block grant services are categorized into four groups:  Direct health services — “gap filling” basic health services provided where services are lacking. These are generally delivered one-on-one between a professional and a patient. They accounted for 58 percent of total Title V expenditures in FY 2005.  Enabling services — services that facilitate access to care, such as case management, transportation, translation services, purchase of insur- ance, and coordination with other programs. These accounted for 21 percent of total Title V expenditures in FY 2005.  Population-based services — preventive interventions and personal health services, such as newborn screening, lead screening, immunization, oral health, injury prevention, for a state’s entire MCH population. These accounted for 11.1 percent of total Title V expenditures in FY 2005. National Health Policy Forum | www.nhpf.org The Basics: Title V MCH Block Grant September 24, 2007  Infrastructure-building services — support for the development and maintenance of comprehensive health services systems such as training, data collection, developing guidelines, applied research, information systems and other functions. These accounted for 9.3 percent of total Title V expenditures in FY 2005. State Reporting Data on state use of Title V funds comes from states’ funding applications and annual reports. State applications for block grant funds include a statewide needs assessment (updated every five years) for preventive and primary care services for pregnant women, mothers, and children and for family-centered, community-based services for CSHCN and their families. Applications identify state MCH priorities based on the needs assessment and systems capacity, provide a plan to meet the identified needs, and ex- plain how federal funds will be used. States submit annual reports on Title V activities that demonstrate progress made toward specific MCH status indicators (for example, live birth rate, birthweights, child death rates due to motor vehicle crashes, and poverty levels). Evaluations of state Title V activities are based on performance and outcome measures. INTERACTION WITH MEDICAID AND SCHIP Federal requirements for coordination between Title V, Medicaid, and SCHIP are limited. At the federal level, the MCHB has been designated as the administrative organization with responsibility for coordinating activi- ties authorized under Title V, Title XIX (Medicaid, especially the Early and Periodic Screening, Diagnosis and Treatment [EPSDT] benefit), and related health activities under SCHIP (Title XXI). Medicaid and SCHIP are admin- istered by the Centers for Medicare & Medicaid Services. The Title V statute requires state agencies to “participate in the coordination of activities between” the state Title V program and the Medicaid EPSDT benefit to avoid duplication of services and effort.6 In addition, state Title V agencies are required to provide services to identify pregnant women and infants who are eligible for Medicaid and assist them in applying for benefits.7 There are no similar requirements on state Title V agencies with regard to SCHIP. The Medicaid statute (Title XIX) requires state Medicaid agencies to enter into agreements with state Title V agencies, allowing the Title V agency, or its grantees, to participate in Medicaid and thus receive reimbursement for Medicaid-covered services. State Medicaid agencies must make “appropri- ate” provisions for reimbursing the Title V agency, or its grantees, for covered services provided to Medicaid beneficiaries. Finally, state Medicaid agencies are required to provide for “coordination of information and education on pediatric vaccinations and delivery of immunization services” with state Title V agencies.8 Title V has reciprocal requirements for state Title V agencies.9 National Health Policy Forum | www.nhpf.org The Basics: Title V MCH Block Grant September 24, 2007 There are no specific federal coordination requirements between state Title V agencies and SCHIP programs. Title XXI, however, does require partici- pating states to describe how they coordinate administration of the SCHIP program with “other public and private health insurance programs” and to provide a “review and assessment” of state coordination activities of SCHIP with other programs, including Medicaid and MCH services.10 While the coordination requirements are limited, the statute clearly indi- cates that Title V is the payer of last resort with respect to Medicaid and SCHIP. If a child receives a Title V service (for example, a home visit) that is covered by Medicaid (or SCHIP), then Medicaid (or SCHIP) pays for the service, not the Title V program. Title V funds are used to pay for services for which Medicaid (or SCHIP) funds are not allowed or available.11 ENDNOTES 1. The Personal Responsibility Work Opportunity Reconciliation Act of 1996 (P.L. 104-193) created a separate Title V program of formula grants to states for abstinence education. This program is not part of the Maternal and Child Health Block Grant program under Title V. 2. Omnibus Budget Reconciliation Act (OBRA) of 1981 (P.L. 97-35). Programs consolidated into the block grant were rehabilitation services for children receiving Supplemental Security Income, services to screen and identify children for lead poisoning, programs for identifying genetic diseases, sudden infant death syndrome prevention programs, hemophilia treatment centers, and adolescent pregnancy prevention. 3. The statute includes a maintenance of effort requirement to provide state-only funding equivalent to the level provided in FY 1989. 4. If appropriated amounts exceed $600 million, 12.75 percent of the amount in excess is distributed to CISS activities; of the remaining amount, 85 percent is for formula grants to states and 15 percent is for SPRANS activities. 5. With respect to delivery of services, states cannot use Title V funds to make cash payments to intended recipients of services or to pay for inpatient services other than for children with special health care needs or for high-risk pregnant women or infants. 6. Section 505(a)(5)(F)(i) of the Social Security Act. 7. Section 505(a)(5)(F)(iv) of the Social Security Act. 8. Section 1902(a)(11)(B) of the Social Security Act. 9. Section 505(a)(5)(F)(ii) of the Social Security Act. 10. Section 2108(b)(1)(d) of the Social Security Act. 11. Section 501(a)(1)(C) of the Social Security Act Prepared by Christie Provost Peters. Please direct questions to cppeters@gwu.edu. The National Health Policy Forum is a nonpartisan research and public policy organization at The George Washington University. All of its publications since 1998 are available online at www.nhpf.org. National Health Policy Forum | www.nhpf.org