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HHS Overview PRESENTED TO THE HOUSE COMMITTEE ON HUMAN SERVICES LEGISLATIVE BUDGET BOARD STAFF February 2019 Presentation Overvie iew Overview of Article II; Medicaid financing, caseloads, and cost drivers; State Supported

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SLIDE 1

HHS Overview

  • LEGISLATIVE BUDGET BOARD STAFF
  • PRESENTED TO THE HOUSE COMMITTEE ON HUMAN SERVICES

February 2019

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SLIDE 2

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 2

Presentation Overvie iew

  • Overview of Article II;
  • Medicaid financing, caseloads, and cost drivers;
  • State Supported Living Centers;
  • DFPS overview;
  • Foster care funding and caseloads;
  • TANF cash assistance and caseload;
  • House Bill 1 as Introduced
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SLIDE 3

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 3

Art rticle II II General Revenue Expenditures, , FY FY 2009-2018

NOTE: Amounts for fiscal year 2018 are estimated.

$- $10.0 $20.0 $30.0 $40.0 $50.0 $60.0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Billions

HHS Statewide

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SLIDE 4

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 4

Art rtic icle le II II All ll Funds Exp xpendit itures, FY 2009-2018

NOTE: Amounts for fiscal year 2018 are estimated.

$- $20.0 $40.0 $60.0 $80.0 $100.0 $120.0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Billions

HHS Statewide

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SLIDE 5

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 5

Medic icaid Overview

  • Medicaid is a jointly funded State/Federal program

providing health insurance primarily to low-income parents, non-disabled children, pregnant women, the elderly, and people with disabilities. As a requirement of participation, states must cover certain groups and have the option to cover additional groups.

  • The Health and Human Services Commission (HHSC) is the

single state agency responsible for Texas’s Medicaid program, but services are administered by a variety of state agencies.

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SLIDE 6

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 6

Med edic icaid Average Mon

  • nth

thly Full ll-Benefit t Ca Caseload by Enroll llmen ent t Group Fis iscal l Yea ears 2009 to

  • 2018

NOTES: (1) Other adults includes TANF Adults, Pregnant Women, Medicaid for Breast and Cervical Cancer, and Medically Needy clients. (2) Amounts for fiscal year 2018 are estimated.

69.7% 69.7% 69.6% 70.1% 71.5% 72.4% 72.1% 71.5% 71.4% 73.0% 11.8% 11.8% 11.8% 11.4% 10.6% 10.1% 10.0% 10.0% 9.9% 9.2% 10.4% 10.9% 11.3% 11.5% 11.2% 11.0% 11.2% 11.5% 11.4% 10.5% 8.1% 7.6% 7.3% 7.0% 6.7% 6.5% 6.8% 7.0% 7.2% 7.2%

1 2 3 4 5

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

IN MILLIONS

Children Aged Disabled Other Adults

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SLIDE 7

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 7

Budget Driv ivers: Caseload and Cost

  • Medicaid expenditures are primarily a function of two factors:

caseload and cost.

  • As caseloads increase or decrease (due to factors such as

population growth, the economy, or policy changes), Medicaid expenditures fluctuate.

  • Medicaid expenditures also fluctuate as a result of cost

growth (tied to rate changes, medical inflation, utilization, and acuity), which can be negative or positive.

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SLIDE 8

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 8

Fin inancin ing

  • Financing of the Medicaid program is based on an array of matching rates that

determine the amount of state funds (General Revenue, General Revenue-Dedicated, and Other Funds) and the amount of Federal Funds.

  • The primary matching rate for client services is the Federal Medical Assistance

Percentage (FMAP).

  • Each state has a different FMAP based on its per capita personal income (PCPI) relative to the

nation’s PCPI.

  • Federal Fiscal Year (FFY) FMAP is generally announced in November of the previous FFY.
  • FMAP is based on the three most recent years of income data available.
  • FFY 2020 FMAP was announced in November 2018 based on PCPI data for calendar years 2015

through 2017.

  • State FMAPs can range from 50 to 83 percent.
  • Below 55 percent: states with PCPI higher than the national average.
  • Above 55 percent: states with PCPI below the national average.
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SLIDE 9

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 9

Medicaid id Fu Fundin ing by y Method of

  • f Fin

Finance Fisc Fiscal l Years 20 2000 00 to 20 2021 21

$- $5.0 $10.0 $15.0 $20.0 $25.0 $30.0 $35.0 IN BILLIONS GR-Related Federal Funds Other Funds

NOTE: Fiscal years 2000 to 2017 are expended, fiscal years 2018 through 2021 are amounts included in the Legislative Budget Estimates, House. SOURCE: Legislative Budget Board.

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SLIDE 10

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 10

State Supported Liv ivin ing Centers

  • Texas operates 13 intermediate-care facilities known as state supported living

centers (SSLCs). Residents at SSLCs are individuals with severe or profound intellectual disabilities and those with intellectual disabilities who have behavioral health conditions or are medically fragile.

  • Nationwide trends have been toward deinstitutionalization and the expansion of

community-based services. As demand for institutional services has decreased and community-based services are made available in Texas, the population served at SSLCs has decreased.

  • From 1977 to 2018, the average monthly census for all SSLCs has decreased by 75.6

percent, from 12,132 to 2,962.

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SLIDE 11

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 11

SS SSLC Average Month thly ly Ce Census and St Strategy Fundin ing, g, FY 2009-2018

29.4% 32.6% 38.7% 42.1% 41.6% 41.8% 42.1% 43.1% 42.8% 42.5% 70.6% 67.4% 61.3% 57.9% 58.4% 58.2% 57.9% 56.9% 57.2% 57.5%

$590.5 $639.4 $659.7 $667.8 $659.7 $674.8 $681.9 $700.2 $687.9 $694.0 4627 4337 4071 3880 3650 3411 3240 3125 3026 2962 1000 2000 3000 4000 5000 6000 $0 $100 $200 $300 $400 $500 $600 $700 $800 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Census Millions

SSLC Census and Strategy Spending, Fiscal Years 2009-2018

General Revenue Non-GR Census

NOTE: Amounts for fiscal year 2018 are estimated.

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SLIDE 12

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 12

Overview of Child ild Protective Services

  • The Department of Family and Protective Services (DFPS) pays a daily rate

for the care and maintenance of children who have been removed from their homes and placed in foster homes or residential treatment facilities as a result of abuse or neglect allegations.

  • In 2012, DFPS began implementing a redesign of the foster care program

that utilizes single-source continuum contractors in a DFPS catchment area to provide a full continuum of services to children in foster care.

  • In the Eighty-fifth Legislature, Regular Session, 2017, Senate Bill 11 was

implemented to outsource case management and Full-time-equivalent (FTE) positions and continue expansion of Foster Care Redesign, now known as Community-based Care to continue to provide child welfare services.

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SLIDE 13

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 13

Child Protective Services Expenditures by Category Fiscal Years 2009 to 2018

$- $200 $400 $600 $800 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 Millions Direct Delivery and Program Support Day Care Purchased Services Foster Care Adoption/PCA Relative Caregiver Community-based Care

NOTE: Amounts for fiscal year 2018 are estimated.

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SLIDE 14

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 14

Foster Car are Payments an and Community-based Car are Str trategy Expendit itures, FY FY 20 2009 09-2018 2018

37.2% 37.1% 39.3% 42.8% 43.2% 49.3% 40.8% 41.9% 43.9% 45.3% 62.8% 62.9% 60.7% 57.2% 56.8% 50.7% 59.2% 58.1% 56.1% 54.7%

$354.2 $376.8 $383.2 $375.2 $366.8 $399.3 $403.4 $422.6 $440.5 $510.3 $0 $100 $200 $300 $400 $500 $600 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Millions

General Revenue Non-GR

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SLIDE 15

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 15

Average Nu Number of

  • f Child

ildren (F (FTE) Se Served in in FP FPS-Paid id Foster Car are per r Mon

  • nth, FY

FY 20 2009 09-2018 2018

  • 2,000

4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

NOTE: Amounts for fiscal year 2018 are estimated.

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SLIDE 16

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 16

Paid Caseworkers and Caseload Per Worker by Type Fiscal Years 2009 to 2018

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 500 1,000 1,500 2,000 2,500 3,000 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 Caseload per Worker Paid Caseworkers

Conservatorship Foster/Adoptive Home Dev. Family Based Safety Services Kinship Investigations Conservatorship Foster/Adoptive Home Dev. Family Based Safety Services Kinship Investigations

Paid Caseworkers Caseload per Worker NOTE: Amounts for fiscal year 2018 are estimated.

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SLIDE 17

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 17

Overview of

  • f Temporary

ry Ass ssistance for

  • r Ne

Needy Famil ilie ies (T (TANF)

  • TANF is a block grant that provides assistance to needy families with children to care for

children in their homes or the homes of relatives; promotes job preparation, work, and marriage; strives to reduce and prevent out-of-wedlock pregnancies; and encourages the formation and maintenance of two-parent families.

  • One component of the program, TANF cash assistance, provides monthly cash payments

for eligible families with children under age 18 and includes certain obligations on the part of the parents or relative caretaker of children, including training for or looking for work and making sure the child attends school. The cash payments are intended to help these families pay for basic living needs such as food, clothing, housing, utilities, medical supplies not paid for by Medicaid, and other basic needs.

  • One-time annual TANF assistance is also available for families in crisis to help them

afford basic living needs and to certain grandparents caring for a child who gets TANF.

  • TANF appropriations include federal funds and state maintenance of effort funds.
  • Flexibility provided by the federal government allows the Legislature to appropriate

TANF funds on other allowable program areas in addition to TANF cash assistance.

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SLIDE 18

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 18

TANF Ca Cash Ass ssis istance St Strategy Exp xpendit itures, , FY 2009- 2018

64.0% 52.4% 56.2% 68.7% 77.5% 88.1% 20.9% 85.3% 86.5% 92.6% 36.0% 47.6% 43.8% 31.3% 22.5% 11.9% 79.1% 14.7% 13.5% 7.4%

$106.8 $129.4 $116.9 $96.3 $85.7 $74.8 $65.1 $59.2 $58.4 $54.3 $0 $20 $40 $60 $80 $100 $120 $140 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Millions

General Revenue Related Non-GR

NOTE: Amounts for fiscal year 2018 are estimated.

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SLIDE 19

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 19

TANF Ca Caselo loads by Eli ligib ibil ilit ity Ca Category ry, FY 2009-2018

  • 20,000

40,000 60,000 80,000 100,000 120,000 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 (Est)

TANF Caseloads

Basic State Program One-Time Payments One-Time Payments for Children One-Time Payments for Grandparents

NOTE: Amounts for fiscal year 2018 are estimated.

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SLIDE 20

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 20

House Bill ill 1, , All ll Funds by y Artic icle

Article 2018–19 Base 2020–21 HB 1 $ Change % Change 1 – General Government $7,503.3 $6,729.5 ($773.8) (10.3%) 2 – Health/Human Services $83,584.2 $84,826.1 $1,241.9 1.5% 3 – Public Education $60,492.7 $70,615.3 $10,122.6 16.7% 3 – Higher Education $20,736.3 $21,072.1 $335.8 1.6% 4 – Judiciary $857.1 $875.4 $18.4 2.1% 5 – Public Safety/Criminal Justice $18,378.5 $15,407.6 ($2,970.9) (16.2%) 6 – Natural Resources $6,566.0 $8,905.4 $2,339.4 35.6% 7 – Business/Econ Development $36,587.5 $37,770.0 $1,182.5 3.2% 8 – Regulatory $671.7 $633.7 ($38.0) (5.7%) 10 - Legislature $392.8 $392.0 ($0.8) (0.2%) TOTAL, ALL ARTICLES $235,770.2 $247,227.3 $11,457.1 4.9%

All Funds, in millions

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SLIDE 21

February 11, 2019 LEGISLATIVE BUDGET BOARD ID: 5654 21

House Bill ill 1, , GR by y Artic icle

Article 2018–19 Base 2020–21 HB 1 $ Change % Change 1 – General Government $3,406.9 $3,709.0 $302.2 8.9% 2 – Health/Human Services $34,716.3 $33,611.2 ($1,105.1) (3.2%) 3 – Public Education $41,548.7 $48,677.4 $7,128.7 17.2% 3 – Higher Education $14,909.7 $15,148.1 $238.4 1.6% 4 – Judiciary $490.8 $541.9 $51.1 10.4% 5 – Public Safety/Criminal Justice $11,322.1 $11,414.9 $92.7 0.8% 6 – Natural Resources $910.6 $786.5 ($124.1) (13.6%) 7 – Business/Econ Development $496.5 $815.4 $318.9 64.2% 8 – Regulatory $345.3 $350.4 $5.1 1.5% 10 - Legislature $392.7 $391.8 ($0.9) (0.2%) TOTAL, ALL ARTICLES $108,539.7 $115,446.6 $6,906.9 6.4%

General Revenue, in millions

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SLIDE 22

House Bill ill 1 Medicaid id

  • $67.6 billion in All Funds and $25.2 billion in General Revenue.
  • This is an increase of $2.0 billion in All Funds and a decrease of $1.4 billion in

General Revenue.

  • More favorable Federal Medical Assistance Percentages (FMAP) result in a higher

proportion of the program being funded with Federal Funds.

  • Funding is provided for:
  • Projected caseload growth
  • Maintaining fiscal year 2019 average costs for most services
  • Cost growth associated with average costs established by the federal

government

February 11, 2019 22 LEGISLATIVE BUDGET BOARD ID: 5654

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SLIDE 23

House Bill ill 1 Child ild Protective Servic ices (CPS)

  • $3.7 billion in All Funds and $2.1 billion in General Revenue.
  • This is an increase of $141.7 million in All Funds and $45.1 million in General

Revenue:

  • Foster Care Payments:
  • $1.0 billion in All Funds and $470.4 million in General Revenue
  • Includes Community-based Care
  • Includes projected caseload growth
  • CPS Direct Delivery Staff:
  • $1.5 billion in All Funds
  • Includes increased funding and additional full-time-equivalent (FTE)

positions to maintain caseload per worker

  • Includes increased funding and a decrease in FTE positions for

Community-based Care expansion that occurred during fiscal year 2019

February 11, 2019 23 LEGISLATIVE BUDGET BOARD ID: 5654

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SLIDE 24

Contact the LBB

Legislative Budget Board www.lbb.state.tx.us 512.463.1200

February 11, 2019 24 LEGISLATIVE BUDGET BOARD ID: 5654