Title XIX (Medicaid) Funds and Federal Financial Participation (FFP) :

*How to Utilize these Funds and the FFP Funding Mechanism to Enhance
Oral Health Activities at the Maternal, Child and Adolescent Local
Programs*

**Prepared by the**

**Maternal and Child Health Branch**

**California Department of Health Services**

**And**

**Office of Dental Health**

**Alameda County Public Health Department**

**May 1, 2004**

## 

C:FFP.April, 2004

**[Table of Contents:]{.underline}**

### **I. Introduction**

### 

### **Steps to Take to Obtain FFP Funding to enhance your Oral Health Program**

**III. Examples of Key Materials and Documents: (not included)**

A.  **Scope of Work**

B.  **Job descriptions**

C.  **Budget**

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VI. **Possible Sources of Qualifying Matching Funds**

### **Partial List of Professionals who can be funded** 

V.  **Codes, Functions and Examples of [Enhanced Matchable Activities.
    Examples are related to oral health activities ]{.underline}**

VI. **Codes, Functions of [Non-Enhanced Activities ]{.underline}**

VII. **Appendices**

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A.  **Purpose of FFP**

B.  **Time Studies**

C.  **Medi-Cal factor**

D.  **Options for establishing the Medi-Cal Factor**

E.  **FFP Program Requirements**

F.  **Additional contact**

G.  **References**

H.  **Resources on Oral Health**

**I.** **[Introduction]{.underline}**

In California, the local Maternal and Child Health (MCH) allocation
funding is a combination of federal Title V, Title XIX (Medicaid), State
General Funds, Prop 99, and local funds. In addition, local program may
utilize agency general funds, First 5 and private funds to additionally
support their MCH local activities.

Federal Financial Participation (FFP) is the funding mechanism under
which Title XIX (Medi-Cal) dollars are accessed (via matching) to
reimburse agencies for certain Medi-Cal administrative activities,
including oral health. However, before assessing these funds, it is
important to create a partnership and collaboration with your local MCAH
program staff and provide them with an assessment of the local oral
health needs of your MCAH community.

This document is developed to provide Maternal, Child and Adolescent
Health (MCAH) staff and other interested local oral health professionals
with a basic understanding of FFP and how to utilize Title XIX funds to
enhance oral health activities within local MACH programs.

II. **[Steps to Take to obtain FFP Funding to Enhance your Oral Health
    Programs]{.underline}**

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1.  Determine the oral health needs of your MCAH population. Following
    are some suggestions regarding data sources:

    i.  CHDP (CA EPSDT) PM 160 form data

    ii. Denti-Cal data

    iii. Local focus groups with organizations, community leaders,
         consumers, clients, etc

    iv. Oral health screening data (utilize the Association of State and
        Dental Directors (ASTDD) *Seven-Step Needs Assessment*)

    v.  Local oral health needs assessment (utilize the ASTDD *Basic
        Screening Survey: An Approach to Monitoring Community Oral
        Health*)

2.  Develop oral health objectives in your MCH Scope of Work

3.  Determine what resources (existing and new) are necessary to
    implement the program:

> Funds available -- matching dollars
>
> Staff (professional, clerical, etc.) -- develop job description
>
> Facilities
>
> Utilities
>
> Equipment, supplies

4.  Develop proposed budget

5.  Request a budget/budget revision to the California Department of
    Health Services (DHS), MCH Branch

    i.  Send budget revision to state contract managers and program
        consultants

6.  Wait for letter of approval from the MCH Branch

7.  Implement program/oral health activities

8.  Maintain time studies and provide secondary documentation when
    needed

9.  Submit necessary documentation to MCH Branch

10. Receive FFP funds and continue your oral health activities

# [Examples of Key Materials and Documents]{.underline}

**Scope of Work (not included)**

### **Job description (not included)**

**Budget (not included)**

# [IV. Possible sources of qualified matching funds]{.underline}

-   General Funds

-   Local revenue

-   Local tax dollars

-   Tobacco (Prop 99) funds

-   Attorney General's tobacco settlement dollars

-   Children's Dental Disease Prevention Program (DDPP or SB 111) if
    Grant Requirements are being met.

-   Realignment dollars (e.g., state sales tax, vehicle registration-fee
    derived)

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-   First 5

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-   Philanthropic or private funds donated to the County. (If funding is
    from Foundations, have to assure foundation is not using any federal
    funds they have received)

# [CAN NOT match Title XIX with federal funds or funds originated as federal funds]{.underline}

# [V. Partial List of Professionals who can be funded:]{.underline} 

Examples of SPMP -- Skilled Professional Medical Personnel:

-   **Dentist**

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-   **Dental Hygienist**

-   Health Educator (Master's in Public or Community Education and
    graduated from an accredited institution).

-   Nutritionist

-   Others

> Examples of Non-SPMP:

-   Community Health Outreach Worker

-   Clerical Staff

-   Epidemiologist

-   Clerical support staff --(Must have a county Civil Service
    classification)

Clerical support staff is not a SPMP; therefore matching is for
non-enhanced (50%). However, if the clerical support staff provides
direct support to SPMP on an enhanced activity and they are directly
supervised by a SPMP, they can also claim the 75%.

***Note***: An administrative classification must also require the
health professional credentials for 3:1 claiming (e.g., if an RDH is
hired into a position as an administrator and the job classification
does not require her/him to use SPMP skills, she/he can not claim the
3:1).

Note: Sub-contractors can never claim the enhanced (3:1) match unless
the are a government agency

For a complete list of qualified SPMP professional categories, please
refer to page 59 of the FY 2000-01 MCH Branch Policy and Procedures
manual.

# [VI. Codes, Functions and Examples of Enhanced Matchable Activities. Examples are related to oral health activities:]{.underline}

**Code 2** **SPMP Administrative Case Management**

######## **Functions** Assess the necessity for medical/dental care, i.e., provide rationale 

> for facilitating each client's timely referral to medical/dental
> services
>
> Provide technical assistance on clinical protocols, health
> assessments, and medical and dental benefits

Case coordination activities, e.g., client consultation and follow-up
also using medical expertise, case find among existing public health
programs; enrolled clients and refer for CHDP/EPSDT services.

> **Example** Review findings of screenings or oral health assessment,
> refer children to dental health preventive or restorative treatment
> and any other linkages to oral health care.

######### **Code 3** **SPMP Intra/Interagency Coordination, Collaboration and Administration**

### **Functions** Oversight, organization and implementation of preventive programs in oral health such as sealants in all its aspects, short of delivering the clinical services.

Develop dental referral resources such as referral directories with a
list of dentists who accept Denti-Cal and Healthy Families. In addition,
list of community clinics that provide dental services, dental schools,
rural health facilities and dentists that provide free dental services,
if applicable.

> Assess the inter-agency coordination in assisting clients to access
> oral health care services.
>
> **Example** Collaborate with schools, healthy start grantees, and with
> other units of the health department (WIC, nutrition, CMS, etc,) to
> assure the capacity of the provider resources for referral, as well as
> to participate in the oral health screening, oral health examination
> and or delivery of dental preventive services such as topical
> fluoride, fluoride varnishes, and dental sealants.
>
> Participate in meetings and discussions, workshops, action planning
> groups on how to provide better oral health services to the eligible
> population and on assessing the effectiveness in assisting clients to
> access oral health care services.

**Code 6 SPMP Training**

> **Functions** Training related to SPMP's performance of SPMP
> administrative, not clinical activities.
>
> **Example** Training on starting a dental sealant program,
> data-collection issues, continuing education workshops related to the
> SPMP activities.
>
> **Code 8 SPMP Program Planning and Policy Development**
>
> **Functions** SPMP tasks must officially involve program planning and
> resource development. Job description/duty statement must include
> planning and policy tasks.
>
> Provide SPMP knowledge and expertise to liaison with public and
> private schools related to the delivery of health assessment services.

Develop medical strategies needed to incorporate CHDP preventive
services into on going medical and dental care.

> Organize dental round tables and dental advisory committee groups to
> assist in the implementation of oral health programs.
>
> **Example** Planning, implementation and evaluation of dental health
> services that are covered under Denti-cal such as sealants and other
> appropriate preventive and treatment services.
>
> **Code 9 SPMP Quality management by skilled professional medical
> personnel**
>
> **Functions** Monitor process of authorization for dental services
>
> Ongoing program assessment/evaluation
>
> Development of program standards and protocols
>
> Using SPMP expertise, conduct data analysis to determine need for
> quality of children's oral health services.
>
> Strategic planning, implementation and evaluation of services related
> to Denti-Cal programs
>
> **Example** Ongoing and evaluation of dental public health programs.
> Development and update dental program standards and protocols for the
> delivery of oral health services.
>
> Functions Inform individuals, agencies and community groups about oral
> health programs (e.g., parent workshops, teacher training, etc).

#### VII. Codes, Functions of Non-Enhanced Activities 

> **Code 1 Outreach**
>
> **Code 4 Intra/Inter Agency Collaboration and Coordination**
>
> **Code 5 Program Specific Administration**
>
> **Cede 7 Non-SPMP Training**
>
> Training in organizing and coordinating a campaign on educating
> professionals and interested parties on fluoridation activities.
>
> **Code 10 Non-Program Specific General Administration**

**Code 11 Other Activities**

# 

# [VIII. Appendices:]{.underline}

# 

A.  **[Purpose of FFP]{.underline}**

-   Assist individuals eligible for Medi-Cal to enroll in that program

-   Assist individuals on Medi-Cal to access Medi-Cal services

There are two components to FFP. Time studies and the Medi-Cal Factor.
These respectively measure the percentage qualifying FFP activities and
the percentage of the population that is Medi-Cal.

#### B. Time Studies

The Primary Care and Family Health Division's time study provides the
basic documentation required by the Federal Health Care Financing
Administration (HCFA) to support claiming for the costs of
administrative support activities, which qualify for specific Federal
Financial Participation (FFP) under the Medicaid Program (Title XIX).

The Social Security Act provides for variable federal matching rates for
the administrative functions of the Medicaid program including:

-   a FFP rate of 50% ("non-enhanced") for the majority of expenses
    necessary for the proper and efficient operation of the program, and

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-   a FFP rate of 75% ("enhanced") for expenses of "skilled professional
    medical personnel" (SPMP) and their direct clerical support staff
    necessary for the development and administration of a medically
    sound program.

***Note***: SPMP includes only *licensed* professionals in the medical
and dental fields.

#### C. Medi-Cal Factor

-   To determine the estimated proportion of the target population that
    is Medi-Cal eligible

-   In conjunction with the time-study it is used to calculate the
    amount of staff time that can be matched with Title XIX funds

#### D. Options for Establishing the Medi-Cal Factor

-   Actual enrollee counts -- Medi-Cal beneficiary status verification

-   Population statistics

-   Medi-Cal birth rate per county (MCH Branch has an Excel file)

-   This is the rate that is applied to the activities being claimed for
    match.

> Example: If the rate for a certain county is 33%, and a nurse spends
> 100 hours on matchable activities, 33% of the cost of the nurse can be
> claimed for match, but only if 100% of her activities are claimable
> under FFP.

-   ***Note***: If the Agency targets services to areas that have a
    higher Medi-

> Cal rate than the county average Medi-Cal birthrate (e.g., Dental
> Disease Prevention Program (SB 111) schools that target high AFDC %
> schools), the higher rate could be used, however, it must be
> justified, documented, and approved by the MCH Branch.

#### E. FFP Program Requirements

-   No direct clinical services can be provided, such as:

-   Placing sealants

-   Performing dental prophylaxis

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-   Professional application of topical fluoride, such as gels and
    varnishes

-   Conducting an oral health screenings

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-   Time studies and other documentation need to be provided

-   Civil service employees

-   Licensed personnel only or support staff

-   Matching only available to a government entity that contracts
    directly with the MCH Branch or a subcontractor of a government
    agency that is also a government entity. (Joe, please clarify, we
    would like to be as specific as possible)

-   Examples of contracting agencies:

-   Local county health departments

-   Local county office of education

-   Community Based Organizations

#### F. Additional Contact

### California Department of Health Services

### Maternal and Child Health Branch web site [www.mch.dhs.ca.gov/programs/ohp](http://www.mch.dhs.ca.gov/programs/ohp)

MCH Branch 1-866-241-0395

### Jared I. Fine, DDS, MPH 510-208-5911 Jared.Fine@acgov.org

### Director, Office of Dental Health 

### Alameda County Public Health Department

#### G. References

For a complete and more comprehensive description of FFP, please refer
to the:

####### Maternal and Child Health Branch: fiscal year 2000-01 - Agency Allocation Policies and Procedures from pages 43 to 61.

1.  MCH-AFLP Time study workshop for Local Government Agencies Binder.

2.  Federal Financial Participation -- FFP User's Guide -- produced by
    the Maternal and Child Health Branch, California Department of
    Health Services.

#### H. Resources on Oral Health

1.  Seal America -- The prevention invention. American Association of
    Community Dental Programs. July, 1995.

> This binder includes a step-by-step description of all that is
> necessary to establish a school-based sealant program including
> funding, staff, targeting children, etc.

2\. MCH Program Interchange. [www.ncemch.org](http://www.ncemch.org/)

> It describes a variety of publications, educational materials, policy
> documents and manuals in the area of oral health. It describes the
> materials, cost (if applicable), and contact information to the
> various oral health materials and documents.

3.  Association of State and Territorial Dental Directors for Basic
    Screening Survey: An Approach to Monitoring Oral Health Manual

> Screening Training Project (STP) - Manual and video
>
> And Seven-Step Needs Assessment -
> [www.astdd.org](http://www.astdd.org/)

4.  US Department of Health and Human Services. Oral Health in America:
    A Report of the Surgeon General. *Executive Summary*. Rockville, MD:
    US Department of Health and Human Services, National Institute of
    Dental and Craniofacial Research, National Institutes of
    Health, 2000.
    [www.nidcr.nih.gov/srg/srg.htm](http://www.nidcr.nih.gov/srg/srg.htm)

5.  Denti-cal web site
    http://intranet.dhs.ca.gov/org/mcs/psd/omds/index.htm

6.  California Dental Association -- [www.cda.org](http://www.cda.org/)

7.  American Dental Association -- [www.ada.org](http://www.ada.org/)

8.  American Academy of Pediatric Dentistry --
    [www.acpd.org](http://www.acpd.org/)

### 10. California Children and Family Commission - First 5 --[www.ccfc.ca.gov](http://www.ccfc.ca.gov/)