# Cash and Non-Cash Benefits for Persons with Limited Income: Eligibility Rules, Recipient and Expenditure Data, FY1981-83 > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/crs%3A84-99EPW ## Record - **Collection:** Congressional research report - **Document type:** CRS Report - **Published:** June 18, 1984 - **Citation:** 84-99EPW ## Text LC ~ 4 . :a8~-99 EPJJ R e p o r t No. 84-99 EPW CASH AND NON-CASH BENEFITS FOR PERSONS WI7lti LIMITED INCOME: ELIGIBILITY RULES, RECIPIENT AND EXPENDITURE DATA, FY 1981-83 Compiled by Vee Burke Specialist i n Social Legislation Education and Public Welfare Division Updated J u n e 1 8 , 1984 The Congressional Research Service works exclusively for the Congress, conducting research, analyzing legislation, and providing information at the request of committees, Members, and their staffs. The Service makes such research available, without partisan bias, in many forms including studies, reports, compilations, digests, and background briefings. Upon request, CRS assists committees in analyzing legislative proposals and issues, and in assessing the possible effects of these proposals and their alternatives. The Service's senior specialists and subject analysts are also available for personal consultations in their respective fields of expertise. ABSTRACT T h i s r e p o r t summarizes b a s i c e l i g i b i l i t y r u l e s , a s o f May 1984, f o r more t h a n 70 c a s h and non-cash p e r s o n s o f l i m i t e d income. programs t h a t b e n e f i t p r i m a r i l y It a l s o g i v e s funding formulas, b e n e f i t l e v e l s , a n d , f o r f i s c a l y e a r s 1981-1983, r e c i p i e n t numbers and expen- d i t u r e d a t a f o r e a c h program. Update o f 83-110 EPW Cash and Non-Cash B e n e f i t s f o r P e r s o n s w i t h L i m i t e d Income : E l i g i b i l i t y R u l e s , R e c i p i e n t and E x p e n d i t u r e D a t a , FY 1981-83 82-113 EPW Cash and Non-Cash B e n e f i t s f o r P e r s o n s w i t h L i m i t e d Income: E l i g i b i l i t y R u l e s , R e c i p i e n t and E x p e n d i t u r e D a t a , FY 1978-80 81-44 EPW Cash and Non-Cash B e n e f i t s f o r P e r s o n s w i t h L i m i t e d Income: E l i g i b i l i t y R u l e s , R e c i p i e n t and E x p e n d i t u r e D a t a , FY 1977-79 79-216 EPW Cash and Non-Cash B e n e f i t s f o r P e r s o n s w i t h L i m i t e d Income: E l i g i b i l i t y R u l e s , R e c i p i e n t and E x p e n d i t u r e D a t a , FY 1976-78 Income S e c u r i t y f o r P e r s o n s w i t h L i m i t e d Income: Program Summaries, R e c i p i e n t and E x p e n d i t u r e D a t a , 76-5 ED F e d e r a l and S t a t e - L o c a l E x p e n d i t u r e s f o r Income T r a n s f e r s t o P e r s o n s w i t h L i m i t e d Income. FY 1975-76 CONTRIBUTORS The f o l l o w i n g CRS a n a l y s t s and s p e c i a l i s t s c o n t r i b u t e d program d a t a and r u l e s t o t h i s r e p o r t . Unless o t h e r w i s e i d e n t i f i e d each i s a member of t h e Education and P u b l i c Welfare D i v i s i o n of CRS. Boren, Susan Guaranteed s t u d e n t l o a n s National d i r e c t student loans Burke, Vee Aid t o f a m i l i e s w i t h dependent c h i l d r e n (AFDc) Earned income t a x c r e d i t (EITC) Emergency a s s i s t a n c e Emergency food d i s t r i b u t i o n and s h e l t e r General a s s i s t a n c e (medical c a r e and non-medical c a r e components) General a s s i s t a n c e t o I n d i a n s Supplemental s e c u r i t y income (SSI) C a h i l l , Kenneth Low-income energy a s s i s t a n c e I r w i n , Paul V o c a t i o n a l e d u c a t i o n work-study program Jones, Jean C h i l d c a r e food program. School b r e a k £ a s t program School l u n c h program S p e c i a l m i l k program S p e c i a l supplemental food program f o r women, i n f a n t s , and c h i l d r e n (WIG) Summer food s e r v i c e program f o r children Klebe, Edward Community h e a l t h c e n t e r s Crippled c h i l d r e n ' s s e r v i c e s Health professions student loans and s c h o l a r s h i p s Indian health services M a t e r n a l and c h i l d h e a l t h s e r v i c e s Migrant h e a l t h c e n t e r s Nursing s t u d e n t l o a n s and s c h o l a r s h i p s Lyke, Bob Chapter 1 m i g r a n t e d u c a t i o n program Migrant h i g h s c h o o l e q u i v a l e n c y program (HEP C o l l e g e a s s i s t a n c e m i g r a n t program (CAMP) McClure, Barbara Dependency and indemnity compensation for parents of veterans Medical care for veterans with a nonservice-connected disability Pensions for needy veterans, their dependents and survivors Milgram, Grace* Low-rent public housing Section 8 Lower-income housing assistance O'Shaughnessy, Carol Nutrition program for the elderly Foster grandparents Senior community service employment program for older Americans Senior companions Osmon, David Special programs for students from disadvantaged backgrounds (TRIO) programs Supplemental educational opportunity grants O'Sullivan, Jennifer Medicaid Richardson, Joe Food distribution program for needy families Food stamps Spar, Karen Comprehensive employment and training services (CETA Titles 11-B and 11-C) Job corps (CETA Title IV-B) Public service employment (CETA Titles 11-D and VI) Summer youth employment program Title IV-C) Youth employment demonstration programs (CETA Title IV-A) Legal services Title XX Social services Work incentive program (WIN) Stephan, Sharon Adoption assistance Foster care Headstart Stevens, Anne Follow through Ellender fellowships Tager, Evelyn Weatherization assistance Vanhorenbeck, Susan * I n d i a n housing improvement g r a n t s Sec. 101 r e n t supplements Sec. 235 homeownership a s s i s t a n c e Sec. 236 i n t e r e s t r e d u c t i o n payments Sec. 502 r u r a l h o u s i n g l o a n s Sec. 504 r u r a l h o u s i n g r e p a i r l o a n s and g r a n t s Sec. 514 farm l a b o r housing l o a n s and Sec. 516 farm l a b o r h o u s i n g g r a n t s Sec. 515 r u r a l r e n t a l h o u s i n g loans Sec. 523 r u r a l s e l f - h e l p housing technical assistance grants Joyce, V i a l e t A s s i s t a n c e t o c e r t a i n Cuban r e f u g e e s (cash) A s s i s t a n c e t o r e f u g e e s and cuban/ Haitian e n t r a n t s (cash) Medical a s s i s t a n c e t o c e r t a i n Cuban refugees Medical a s s i s t a n c e t o r e f u g e e s and ~uban/Haitianrefugees S o c i a l s e r v i c e s f o r r e f u g e e s and cuban/ Haitian entrants Wolfe, Mark C o l l e g e work-study program F e l l o w s h i p s f o r g r a d u a t e and professional study P e l 1 g r a n t s ( f o r m e r l y b a s i c educat i o n a l opportunity grants) Deborah Johnson typed t h e r e p o r t , w i t h p a t i e n c e and s k i l l . Mary P i l o t e prepared t h e g r a p h s . * Member o f t h e Economics D i v i s i o n CONTENTS ............................................ A . N a t u r e o f P r o g r a m s .................................. B . B i l l i o n - D o l l a r P r o g r a m s i n FY 1 9 8 1 .................. C . G r o w t h i n S p e n d i n g .................................. 1. S h a r e of G r o s s N a t i o n a l P r o d u c t ................ 2 . S h a r e o f F e d e r a l B u d g e t ........................ 3 . S h a r e of W e l f a r e O u t l a y s P a i d by F e d e r a l F u n d s . D . C o m p o s i t i o n o f B e n e f i t s ............................. INCOME TESTS O F THE BENEFIT PROGRAMS .................... INTRODUCTION POVERTY THRESHOLDS AND OTHER MEASURES OF NEED ................................................ CATALOGUE OF PROGRAMS OFFERING CASH AND NON-CASH BENEFITS TO PERSONS O F L I M I T E D INCOME .................. MEDICAL A I D ........................................... .............................. ........ ........................... ............................. ........................... .......................................... ............................ ....... ............................... MEDICAID MEDICAL CARE FOR VETERANS WITH A NON-SERVICECONNECTED D I S A B I L I T Y GENERAL ASSISTANCE (MEDICAL CARE COMPONENT) MATERNAL AND CHILD HEALTH SERVICES. T I T L E V O F THE SOCIAL SECURITY ACT INDIAN HEALTH SERVICES COMMUNITY HEALTH CENTERS MEDICAL ASSISTANCE TO REFUGEES AND CUBAN/HAITIAN ENTRANTS MIGRANT HEALTH CENTERS MEDICAL ASSISTANCE TO CERTAIN CUBAN REFUGEES CRIPPLED CHILDREN'S SERVICES, T I T L E V O F THE SOCIAL SECURITY ACT CASH A I D ..... ................. ..................................... AID TO F A M I L I E S WITH DEPENDENT CHILDREN (AFDC) SUPPLEMENTAL SECURITY INCOME (SSI) PENSIONS FOR NEEDY VETERANS. T H E I R DEPENDENTS. AND SURVIVORS .... 64 .................... 68 ........................................ 7 0 ......................... 7 1 ..................................... 7 3 ....................................... 7 5 ...................... 7 7 ................................ 80 ........................................ 81 GENERAL A S S I S T A N C E (NON-MEDICAL CARE COMPONENT) EARNED INCOME TAX C R E D I T (EITC) F O S T E R CARE A S S I S T A N C E TO REFUGEES AND CUBANIHAITIAN ENTRANTS (CASH COMPONENT) EMERGENCY A S S I S T A N C E TO NEEDY F A M I L I E S WITH CHILDREN (EA) DEPENDENCY AND INDEMNITY COMPENSATION F O R PARENTS OF VETERANS GENERAL A S S I S T A N C E TO I N D I A N S ADOPTION A S S I S T A N C E A S S I S T A N C E TO CERTAIN CUBAN REFUGEES (CASH COMPONENT) FOOD A I D ........................................ 8 2 ................................... 8 7 ....................... 90 ............................. 92 .................. 93 ........................................ 95 ............................ 9 7 ........... 99 ....... 99 ................ 101 FOOD STAMPS SCHOOL LUNCH PROGRAM ( F R E E AND REDUCEDP R I C E SEGMENTS) S P E C I A L SUPPLEMENTAL FOOD PROGRAM FOR WOMEN. INFANTS. AND CHILDREN ( W I C ) S P E C I A L FOOD DONATIONS N U T R I T I O N PROGRAM FOR THE ELDERLY SCHOOL BREAKFAST PROGRAM ( F R E E AND REDUCED-PRICE SEGMENTS) C H I L D CARE FOOD PROGRAM SUMMER FOOD S E R V I C E PROGRAM FOR CHILDREN FOOD D I S T R I B U T I O N PROGRAM FOR NEEDY F A M I L I E S S P E C I A L M I L K PROGRAM (FREE SEGMENT) HOUSING AND A I D .......... 103 ............................ 106 .................... 109 ............. 111 ............ 113 ........................... 116 ....................... 119 ........................................ 1 2 2 ............... 123 .................. 1 2 4 ........................................ 1 2 5 S E C T I O N 8 LOWER-INCOME HOUSING A S S I S T A N C E LOW-RENT P U B L I C HOUSING S E C T I O N 502 RURAL HOUSING LOANS SECTION 515 RURAL RENTAL HOUSING LOANS S E C T I O N 2 3 6 I N T E R E S T REDUCTION PAYMENTS S E C T I O N 2 3 5 HOMEOWNERSHIP A S S I S T A N C E F O R LOW-INCOME F A M I L I E S S E C T I O N 101 RENT SUPPLEMENTS S E C T I O N 504 RURAL HOUSING R E P A I R LOANS AND GRANTS S E C T I O N 514 FARM LABOR HOUSING LOANS AND S E C T I O N 516 FARM HOUSING GRANTS I N D I A N HOUSING IMPROVEMENT GRANTS S E C T I O N 523 RURAL SELF-HELP TECHNICAL ASSISTANCE EDUCATION A I D ........................... 1 2 6 ............................... 1 2 9 .......................................... 1 3 2 ......................... 134 ......... 135 ................ 136 ...................... 138 ....................... 139 ..................................... 1 4 2 ............ 143 .... 144 ... 146 ...... 1 4 7 ............................... 149 .......... 150 ............. 151 GUARANTEED STUDENT LOANS PELL GRANTS ( F o r m e r l y B a s i c E d u c a t i o n a l Opportunity Grants) HEADSTART COLLEGE WORK-STUDY PROGRAM SUPPLEMENTAL EDUCATIONAL OPPORTUNITY GRANT CXAPTER 1 MIGRANT EDUCATION PROGRAM NATIONAL DIRECT STUDENT LOANS SPECIAL PROGRAMS FOR STUDENTS FROM DISADVANTAGED BACKGROUNDS (TRIO PROGRILYS) FOLLOW THROUGH VOCATIONAL EDUCATION WORK-STUDY PROGRAM FELLOWSHIPS FOR GRADUATE AND PROFESSIONAL STUDY HEALTH PROFESSIONS STUDENT LOANS AND SCHOLARSHIPS MIGRANT HIGH SCHOOL EQUIVALENCY PROGRAM (HEP) ELLENDER FELLOWSHIPS COLLEGE ASSISTANCE MIGRANT PROGRAM (CAMP) NURSING STUDENT LOANS AND SCHOLARSHIPS J O B S AND TRAINING A I D COMPREHENSIVE EMPLOYMENT AND TRAINING SERVICES (CETA T I T L E S 1 1 - B AND 11-C) SUMMER YOUTH EMPLOYMENT PROGRAM (CETA T I T L E IV-C) J O B CORPS (CETA T I T L E IV-B) SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM WORK INCENTIVE PROGRAM YOUTH EMPLOYMENT DEMONSTRATION PROGRAMS (CETA T I T L E IV-A) FOSTER GRANDPARENTS PUBLIC SERVICE EMPLOYMENT (CETA T I T L E S 11-D AND I V ) SENIOR COMPANIONS ....................... 153 .. 155 ........................ 1 5 7 ........ 159 ............................. 161 ................................. 1 6 2 ................................ 164 ............................... 165 .................................. 166 OTHER SERVICES 69 70 71 72 .. LEGAL T I T L E XX SOCIAL SERVICES ........................... 1 6 7 SERVICES ..................................... 169 . EMERGENCY FOOD DISTRIBUTION AND SHELTER PROGRAM .... 1 7 1 . SOCIAL SERVICES FOR REFUGEES AND cUBAN/BAITIAN ENTRANTS ........................................ 1 7 3 ENERGY A I D 73 74 . LOW-INCOME ENERGY ASSISTANCE ....................... 1 7 5 . WEATHERIZATION ASSISTANCE .......................... 1 7 8 LIST OF TABLES Expenditures of Major Needs-Tested Benefit Programs. FY 1981-83 ................................ Total Expenditures for Income-Tested Benefits ........ Recent Trends by Form of Benefit. FY 1981-1983 ...... 2 8 9 Share of Federal Budget Used for Need-Tested Benefits ............................................ 10 Composition of Need-Tested Benefits ................. 14 Income Eligibility Tests Used by Benefit Programs ........................................ 16 Bureau of the Census Poverty Thresholds in 1983 ..... 22 1984 Federal Poverty Income Guidelines .............. 23 Eligibility Levels for Free and Reduced-Price Meals for the Period July 1. 1984-June 30. 1985 ........... 24 Sununary of Annual Budgets for a Four-Person Family at Three Levels of Living. Urban United States. Autumn 1981 (U.S. Department of Labor. Bureau of of Labor Statistics.. issued April 16. 1982 .......... 25 Sumnary of Annual Budgets for a Retired Couple at Three Levels of Living. Urban United States. Autumn 1981 (u.s. Department of Labor. Bureau of Labor Statistics.. issued July 30. 1982 .................... 26 Need-Based Benefits: Expenditure and Enrollment Data. by Program and Form of Benefit. FY 1980-83 .... 181 . .MEDICAL BENEFITS ................................. 182 . .CASH BENEFITS .................................... 183 . .FOOD BENEFITS .................................... 184 . .HOUSING BENEFITS ................................. 185 . .EDUCATION AID .................................... 186 . .JOBS AND TRAINING ................................ 187 . .SERVICES ......................................... 188 . .ENERGY AID ....................................... 189 LIST OF CHARTS . Total Expenditures for Income-Tested Benefits ....... 3 2 . Composition of Need-Based Benefit Dollar. FY68 ...... 12 1 3 . Composition of Need-Based Benefit Dollar. FY83 ...... 13 INTRODUCTION More t h a n 70 b e n e f i t programs 11 p r o v i d e c a s h and non-cash a i d t h a t i s d i r e c t e d p r i m a r i l y t o p e r s o n s w i t h l i m i t e d income. These b e n e f i t programs c o s t $127.3 b i l l i o n i n f i s c a l y e a r (FYI 1983, up 7.3 p e r c e n t from FY 1982, and e q u a l t o 3.9 p e r c e n t o f t h e g r o s s n a t i o n a l p r o d u c t . F e d e r a l f u n d s p r o v i d e d 75 p e r c e n t o f t h e t o t a l . A f t e r a d j u s t m e n t f o r p r i c e i n f l a t i o n , 1983 w e l f a r e s p e n d i n g was up 3 p e r c e n t from 1982, b u t down 3 p e r c e n t from t h e peak l e v e l o f 1981. Measured i n c o n s t a n t v a l u e d o l l a r s , 1983 o u t l a y s w e r e t h e second s m a l l e s t s i n c e 1980. C o l l e c t i v e l y , t h e s e b e n e f i t programs c o n s t i t u t e t h e p u b l i c "welfare" system, i f w e l f a r e i s d e f i n e d a s income-tested o r need-based b e n e f i t s . Most o f t h e programs b a s e e l i g i b i l i t y on i n d i v i d u a l , h o u s e h o l d , o r f a m i l y income, b u t some u s e g r o u p o r a r e a income t e s t s ; and a few o f f e r h e l p on t h e b a s i s o f presumed need. T h i s r e p o r t c o n s i s t s o f a c a t a l o g u e o f 74 need-based programs. F o r e a c h i t p r o v i d e s t h e f u n d i n g f o r m u l a , e l i g i b i l i t y r e q u i r e m e n t s , and b e n e f i t l e v e l s . A t t h e back o f t h e r e p o r t a t a b l e g i v e s e x p e n d i t u r e and r e c i p i e n t d a t a f o r FY 1981-1983 by program. Of FY 1983 w e l f a r e d o l l a r s , 61.5 p e r c e n t were s p e n t on m e d i c a l a i d and c a s h r e l i e f ( 3 4 and 27 p e r c e n t , r e s p e c t i v e l y ) . Food b e n e f i t s a c c o u n t e d f o r 14 p e r c e n t o f t h e t o t a l , and 1 5 p e r c e n t was i n t h e form o f h o u s i n g b e n e f i t s , j o b s - t r a i n i n g , and e n e r g y a i d . The r e m a i n i n g 9 p e r c e n t went f o r e d u c a t i o n a i d and o t h e r s e r v i c e s . ( S e e t a b l e 1 f o r FY 1981-1983 summary, page 2 . ) 11 The l i s t o f 74 programs i n t h e t a b l e o f c o n t e n t s i n c l u d e s one ( P u b l i c S e r v i c e ~ m p l o y m e n)t t h a t ended on September 30, 1981, and a n o t h e r ( ~ m e r g e n c yFood D i s t r i b u t i o n and S h e l t e r program) t h a t was s c h e d u l e d t o end i n 1984. The number o f programs i s somewhat a r b i t r a r y . For example, G e n e r a l A s s i s t a n c e , l i s t e d u n d e r b o t h c a s h and m e d i c a l a i d , c o u l d b e r e g a r d e d i n s t e a d a s a s i n g l e program. 15,600.0 Food b e n e f i t s 7,516.3 3,324.1 2,008.9 Jobs & t r a i n i n g Services Energy a i d NOTE: Program d a t a on which t h i s t a b l e i s b a s e d a r e found i n t a b l e 1 2 . - 4,710.2 Education Housing b e n e f i t s 10,455.5 21,566.2 $22,091.7 Cash a i d Medical c a r e S e e page 181. Chart 1 Total Expenditures for Income-Tested Benefits ...................... Ed Current Dollars ............................................. Constant 1972 Dollars Fiscal Year A. N a t u r e o f Programs Most of t h e s e programs p r o v i d e income " t r a n s f e r s . " T h a t i s , t h e y t r a n s f e r income, i n t h e form o f c a s h , goods, o r s e r v i c e s , t o p e r s o n s who make no payment and r e n d e r no s e r v i c e i n r e t u r n . However, i n t h e c a s e o f t h e j o b and t r a i n i n g programs and some e d u c a t i o n a l b e n e f i t s , r e c i p i e n t s must work o r s t u d y f o r wages, t r a i n i n g a l l o w a n c e s , s t i p e n d s , g r a n t s , o r loans. T h i s r e p o r t e x c l u d e s income m a i n t e n a n c e programs t h a t a r e n o t income t e s t e d , i n c l u d i n g s o c i a l i n s u r a n c e , many v e t e r a n s ' b e n e f i t s , and a l l b u t one t a x t r a n s f e r program. Thus, i t e x c l u d e s s o c i a l s e c u r i t y c a s h b e n e f i t s , unemployment i n s u r a n c e , and Medicare. The f i r s t o f t h e s e programs i n FY 1983 p a i d o u t 34 p e r c e n t more t h a n a l l i n c o m e - t e s t e d programs, o r a t o t a l o f $170.7 b i l l i o n , f i n a n c e d from p a y r o l l t a x c o l l e c t i o n s . The r e p o r t a l s o e x c l u d e s payments, even though f i n a n c e d w i t h g e n e r a l r e v e n u e s , t h a t may be r e g a r d e d a s " d e f e r r e d compensat i o n , " s u c h a s v e t e r a n s ' e d u c a t i o n a l b e n e f i t s ($1.7 b i l l i o n i n 1 9 8 3 ) , v e t e r a n s ' h o u s i n g b e n e f i t s , and m e d i c a l c a r e f o r v e t e r a n s with a service-connected d i s a b i l i t y . The r e p o r t i n c l u d e s one t a x - t r a n s f e r program, t h e r e b a t a b l e e a r n e d income c r e d i t f o r low-income w o r k e r s w i t h c h i l d r e n . T h i s program r e d u c e s t h e t a x e s o f working f a m i l i e s w i t h g r o s s income below $10,000 and makes d i r e c t payments t o t h o s e whose income i s below t h e income t a x t h r e s h o l d . O t h e r t a x t r a n s f e r s a r e e x c l u d e d b e c a u s e t h e y a r e n o t income t e s t e d . Tax t r a n s f e r s ( a l s o known a s t a x e x p e n d i t u r e s ) i n c r e a s e f a m i l i e s ' d i s p o s a b l e income by r e d u c i n g t h e i r t a x l i a b i l i t y . Examples a r e t h e d e d u c t i b i l i t y o f mortgage i n t e r e s t and p r o p e r t y t a x e s on owner-occupied p r o p e r t y ($20.8 b i l l i o n and $8 b i l l i o n r e s p e c t i v e l y , i n 1983) and t h e p a r e n t a l p e r s o n a l exemption f o r s t u d e n t s aged 19 and o v e r ($1.0 b i l l i o n i n 1 9 8 3 ) . B i l l i o n - D o l l a r Programs i n FY 1983 I n FY 1983 a t o t a l o f 20 income-tested programs s p e n t more t h a n $1 b i l l i o n e a c h i n F e d e r a l , S t a t e , and l o c a l f u n d s . The l i s t was l e d by M e d i c a i d , which c o s t more t h a n t h e sum o f t h e n e x t two programs, Aid t o F a m i l i e s w i t h Dependent C h i l d r e n (AFDc) and food s t a m p s . H e r e a r e t h e 20 programs and t h e i r FY 1983 e x p e n d i t u r e s . B i 11i o n s Percent I n c r e a s e From FY 1981 - Medicaid $34.96 AFDC 15.39 Food s t a m p s 13.27 SS I 10.10 S e c t i o n 8 lower income 4.99 housing a s s i s t a n c e Medical c a r e f o r v e t e r a n s w i t h a non-service4.41 connected d i s a b i l i t y 3.89 Veterans' pensions Low-rent pub1 i c h o u s i n g 3.21 3.10 Guaranteed s t u d e n t l o a n s Pel1 grants (formerly B a s i c E d u c a t i o n a l Oppor2.86 t u n i t y Grants) General a s s i s t a n c e 2.44 ( m e d i c a l c a r e component) S c h o o l l u n c h ( f r e e and 2.41 reduced-price segments) 2.40 b / T i t l e XX s o c i a l s e r v i c e s S e c t i o n 502 r u r a l hous2.33 ing loans General a s s i s t a n c e (cash and non-medical c a r e v e n d o r 2.11 payments ) Low-income e n e r g y a s s i s t a n c e 1.90 Earned income t a x c r e d i t 1.80 Comprehensive employment and t r a i n i n g s e r v i c e s (CETA T i t l e s 1 1 - B and 11-C 1.76 S p e c i a l s u p p l e m e n t a l food program f o r women, i n f a n t s 1.16 and c h i l d r e n (WIG) Heads t a r t 1.13 - -. -a / Not a p p l i c a b l e . b/ F e d e r a l d o l l a r s o n l y . o u t l a y s a f t e r 1981. D a t a a r e u n a v a i l a b l e on S t a t e t o t a l c / S t a t e d a t a a r e u n a v a i l a b l e t o c a l c u l a t e percentage change i n t o t a l spending. C. T r e n d s i n Spending T o t a l e x p e n d i t u r e s on c a s h and non-cash w e l f a r e programs w e r e e i g h t t i m e s g r e a t e r i n 1983 t h a n i n 1968. Even a f t e r a l l o w a n c e f o r p r i c e i n f l a t i o n , s p e n d i n g more t h a n t r i p l e d d u r i n g t h e 1 3 y e a r s . Measured i n c o n s t a n t 1972 d o l l a r s , i t c l i m b e d from $19.9 b i l l i o n i n FY 1968 t o a peak of $61.3 b i l l i o n i n FY 1981, a p e r i o d when t h e U.S. p o p u l a t i o n grew by 15 percent. P e r c a p i t a w e l f a r e s p e n d i n g grew i n r e a l t e r m s ( c o n s t a n t 1972 d o l l a r s ) from $100 i n FY 1968 t o $266 i n FY 1981, an i n c r e a s e o f 166 p e r c e n t , However, i n FY 1982, w e l f a r e s p e n d i n g f a i l e d t o k e e p pace w i t h i n f l a t i o n f o r t h e f i r s t t i m e s i n c e 1973. 21 I n r e a l t e r m s w e l f a r e o u t l a y s f e l l 5 . 5 p e r c e n t ($3.4 b i l l i z n i n 1972 d o l l a r s ) . Only s l i g h t l y more t h a n h a l f o f t h i s was r e s t o r e d by i n c r e a s e d s p e n d i n g i n 1983. C h a r t 1 and t a b l e 2 show t h e c o u r s e o f w e l f a r e s p e n d i n g i n b o t h c u r r e n t and c o n s t a n t d o l l a r s . During 1968-1978, Congress l i b e r a l i z e d some o l d w e l f a r e programs and e s t a b l i s h e d new o n e s . Some o f t h e m a j o r e x p a n s i o n s follow: e f f e c t i v e i n 1969 Congress g a v e a work i n c e n t i v e bonus t o a l l m o t h e r s who r e c e i v e d AFDC c h e c k s ; t h e bonus, v i r t u a l l y r e p e a l e d i n l a t e 1981, was t h e r i g h t t o a w e l f a r e supplement even a f t e r t h e i r e a r n i n g s r o s e above t h e S t a t e s t a n d a r d o f need. I n 1969, minimum r e n t s f o r p u b l i c h o u s i n g were a b o l i s h e d ( r e i n s t i t u t e d , a t a low l e v e l , i n 1 9 7 4 ) . By 1970 amendment, t h e food stamp program was c o n v e r t e d i n t o a F e d e r a l income g u a r a n t e e i n participating counties. By 1972 amendment, b a s i c e d u c a t i o n a l o p p o r t u n i t y g r a n t s were a d o p t e d f o r a l l needy c o l l e g e s t u d e n t s ( e x t e n d e d t o "middle-income" s t u d e n t s by 1978 l a w ) . I n 1972, e f f e c t i v e i n 1974, a F e d e r a l c a s h income g u a r a n t e e ( S S I ) was e n a c t e d f o r t h e a g e d , b l i n d , and d i s a b l e d . E f f e c t i v e i n 1974, food stamps were e x t e n d e d t o a l l c o u n t i e s , p r o v i d i n g a n a t i o n a l I n 1975, a r e b a t income g u a r a n t e e i n t h e form o f food stamps. a b l e t a x c r e d i t was a d o p t e d f o r low-income w o r k e r s w i t h c h i ld ren . I n 1981, however, Congress moved t o r e s t r i c t e l i g i b i l i t y f o r some programs and t o l o w e r some b e n e f i t s . F o r example, i t imposed g r o s s income e l i g i b i l i t y l i m i t s f o r AFDC and food s t a m p s , reduced AFDC and food stamp b e n e f i t s f o r f a m i l i e s ante / F e d e r a l o u t l a y s f o r s i x m a j o r income and m e d i c a l a s s i s t -2programs ( a n d program g r o u p s ) f o r low income p e r s o n s , a s mesured i n c o n s t a n t d o l l a r s , d e c l i n e d 3 p e r c e n t from FY 1972 t o FY 1973. I n a l l o t h e r y e a r s , from FY 1964 t o FY 1981, s u c h o u t lays rose. The programs: m e d i c a i d , s u b s i d i z e d h o u s i n g payments, food stamp program, c a s h a s s i s t a n c e , and v e t e r a n s ' p e n s i o n s . J.S. L i b r a r y o f Congress. Congressional Research Service. 1985 budget p e r s p e c t i v e s : F e d e r a l s p e n d i n g f o r t h e human r e s o u r c e [ b y ] R i c h a r d Rimkunas and Gene F a l k [ w a s h i n g t o n ] 1984. programs. CRS R e p o r t 84-35 EPW. p. 159. w i t h e a r n i n g s , r a i s e d p u b l i c h o u s i n g r e n t s , and reduced subs i d i e s f o r s c h o o l l u n c h e s . E f f e c t i v e i n FY 1983, i t tempora r i l y reduced t h e food stamp g u a r a n t e e . As t a b l e 2 shows, t h e a n n u a l r a t e o f growth i n t o t a l exp e n d i t u r e s f o r need-based b e n e f i t s d e c l i n e d i n t h e l a t t e r p a r t of t h i s p e r i o d . Measured i n c o n s t a n t d o l l a r s , t h e i n c r e a s e i n s u c c e s s i v e 5-year p e r i o d s was: 1968-73, 81 p e r c e n t ; 1973-1978, 54 p e r c e n t ; 1978-1983, 7 p e r c e n t . F u r t h e r , as mentioned b e f o r e , r e a l s p e n d i n g d e c l i n e d i n 1982. TABLE 2. Fiscal year T o t a l E x p e n d i t u r e s f o r Income-Tested Benefits --I------- - Current d o l l a r s a T ( b i l l i o n s ) -- C o n s t a n t 1972 d o l l a r s b/ ( b i l l i o n s ) -- ---- a / FY 1968 and FY 1973 d a t a a r e from "Income S e c u r i t y f o r ~ m e r i c a n :s Recommendations o f t h e P u b l i c W e l f a r e S t u d y R e p o r t o f t h e Subcommittee on F i s c a l P o l i c y of t h e J o i n t Economic Committee. December 5 , 1974. T a b l e 4 , page 28. D a t a f o r o t h e r years: -- FY 1975 d a t a , CRS m u l t i l i t h 77-152 ED, p. 1. From t h e t o t a l , t h e n e t sum o f $441 m i l l i o n h a s b e e n s u b t r a c t e d - $297 m i l l i o n was added t o c o r r e c t an e r r o r i n h o u s i n g o u t l a y s , and $738 m i l l i o n was d e d u c t e d b e c a u s e o f a r e v i s e d e s t i m a t e of medical b e n e f i t s f o r v e t e r a n s witho u t a service-connected d i s a b i l i t y . -- FY 1976 d a t a , CRS r e p o r t 79-216 EPW, p. 2. From t h e t o t a l , t h e n e t sum o f $950 m i l l i o n h a s been subtracted--$I336 m i l l i o n and $142 m i l l i o n i n lower e s t i m a t e s o f m e d i c a l spending f o r v e t e r a n s without a service-connected d i s a b i l i t y and f o r G e n e r a l A s s i s t a n c e (GA) m e d i c a l a i d , r e s p e c t i v e l y , o f f s e t i n p a r t by t h e a d d i t i o n o f $28 m i l l i o n , t h e sum s p e n t on w e a t h e r i z a t i o n . -- FY 1977 d a t a , CRS r e p o r t 51-44 EPW, p. 2 . From t h e t o t a l , t h e sum o f $1.3 b i l l i o n h a s been s u b t r a c t e d - - $ 1 , 0 5 0 and $250 m i l l i o n i n lower e s t i m a t e s of m e d i c a l s p e n d i n g f o r v e t e r a n s w i t h o u t a s e r v i c e - c o n n e c t e d d i s a b i l i t y and f o r GA m e d i c a l a i d , r e s p e c t i v e l y . -- FY 1978 d a t a , CRS r e p o r t 82-113 EPW, p. 2. -- FY 1979-80 d a t a , CKS r e p o r t 83-110 EPW, p. 2 . From t h e 1979 and 1980 t o t a l s , $57 m i l l i o n and $76.1 m i l l i o n , r e s p e c t i v e l y , h a v e been d e d u c t e d t o c o r r e c t a n e r r o r i n reported outlays for n u t r i t i o n for the elderly. -- FY 1981-83 d a t a , p. 2 o f t h i s r e p o r t . b/ C u r r e n t d o l l a r s have been t r a n s l a t e d i n t o 1972 cons t a n t - v a l u e d o l l a r s by u s e o f t h e i m p l i c i t p r i c e d e f l a t o r s f o r t h e g r o s s n a t i o n a l p r o d u c t : f i s c a l y e a r s 1968, 0.80675; 1973, 1.0232; 1975, 1.2217; 1975, 1.3066; 1977, 1.3951; 1978, 1.4904; 1979, 1.5964, 1980, 1.7329, 1981, 1.9143; 1982, 2.0469; and 1983, 2.1346. ." The 1982 w e l f a r e c u t b a c k s a r e r e f l e c t e d i n t a b l e 3 , which p r e s e n t s 1981-83 s p e n d i n g t o t a l s i n c o n s t a n t d o l l a r s , by form o f b e n e f i t . A s t h i s t a b l e shows, s p e n d i n g d e c l i n e d i n r e a l t e r m s i n 1982 f o r m e d i c a l a i d , c a s h a i d , f o o d b e n e f i t s , j o b s and t r a i n i n g , s e r v i c e s , and e n e r g y a i d . Growth resumed i n 1983 f o r m e d i c a l a i d , food b e n e f i t s , and e n e r g y a i d , b u t c o n t i n u e d t o d e c l i n e f o r c a s h a i d , j o b s and t r a i n i n g , and s e r v i c e s . I n c o n s t a n t d o l l a r s , spending increased during both y e a r s f o r e d u c a t i o n a i d and h o u s i n g b e n e f i t s . TABLE 3. - Recent T r e n d s by Form o f B e n e f i t , FY 1981-1983 a / FY 1982 FY 1 9 8 3 FY 1 9 8 3 a s FY 1981 outlays outlays percentage of outlays ( b i l l i o n s o f c o n s t a n t 1972 d o l l a r s ) 1981 M e d i c a l Aid Cash Food B e n e f i t s Housing Education Jobs-Training Services Energy Aid -a / D a t a s o u r c e s a r e t h e same a s f o r t a b l e 2. b/ The r i s e i n e d u c a t i o n ' s s h a r e o f n e e d - t e s t e d b e n e f i t s from i 9 8 1 t o 1983 i s d u e i n p a r t t o t h e FY 1982 r e s t o r a t i o n o f a n income t e s t f o r t h e G u a r a n t e e d S t u d e n t Loan Program (GSLP). As a r e s u l t , t h e program was r e t u r n e d t o t h i s r e p o r t ' s i n v e n t o r y a f t e r a n a b s e n c e i n 1979-81, when i t had n o income t e s t . Share of Gross National Product A s a percentage of g r o s s n a t i o n a l product (GNP), w e l f a r e o u t l a y s more t h a n d o u b l e d from 1968 t o 1976, t h e n w e r e r e l a t i v e l y s t e a d y . I n 1981 t h e s h a r e r o s e t o a peak o f 4.07 p e r c e n t . The s h a r e o f GNP u s e d f o r i n c o m e - t e s t e d b e n e f i t programs was a s follows: 2. S h a r e o f F e d e r a l Budget The s h a r e o f t h e F e d e r a l b u d g e t u s e d f o r b e n e f i t programs f o r t h e needy more t h a n doubled from 1968 t o 1976 and peaked i n 1978-1979 a t 14.1 p e r c e n t . However, i t began d r o p p i n g i n 1980 and i n 1983 f e l l t o 12 p e r c e n t , l o w e s t s i n c e 1973. T a b l e 4 summarizes t h i s . TABLE 4. S h a r e o f F e d e r a l Budget Used f o r Need-Tested B e n e f i t s Federal spending Total Federal f or need-tested b e n e f i t s a / outlays ( b i l l i o n s o f currTnt d o l l a r s ) Share of Federal budget f o r need-tested b e n e f i t s (percent) -a / D a t a s o u r c e s a r e t h e same a s f o r t a b l e 2, p. 6. 3. S h a r e o f Welfare O u t l a y s P a i d by F e d e r a l Funds The F e d e r a l Government's s h a r e of o u t l a y s f o r n e e d - t e s t e d programs climbed 9 p e r c e n t from 1968 t o 1979 and t h e n d e c l i n e d somewhat, a s f o l l o w s : D. Composition of B e n e f i t s The l a r g e s t i n c r e a s e s d u r i n g 1968-83 i n need-based b e n e f i t e x p e n d i t u r e s were i n forms o t h e r t h a n c a s h . The r e s u l t i s a d r a m a t i c change i n t h e composition of t h e b e n e f i t d o l l a r . A t t h e s t a r t o f t h e p e r i o d 46.9 c e n t s p e r b e n e f i t d o l l a r were g i v e n a s c a s h , but by 1983 t h e c a s h s h a r e had f a l l e n t o 27.1 c e n t s , a d r o p of 20 c e n t s p e r d o l l a r (42 p e r c e n t ) . The s h a r e o f a i d provided a s food and h o u s i n g more t h a n doubled d u r i n g t h e p e r i o d , r i s i n g from 10.1 c e n t s p e r b e n e f i t d o l l a r t o 24.5 c e n t s . The s h a r e g i v e n a s medical a i d r o s e 3.5 c e n t s ( 1 5 p e r c e n t ) , b u t t h e s h a r e provided a s j o b s and t r a i n i n g and o t h e r s e r v i c e s d e c l i n e d 2.3 c e n t s (29 p e r c e n t ) . This i s summarized i n C h a r t s 2 and 3. T a b l e 5 shows, f u r t h e r , t h a t i n t h e 4 y e a r s , 1979-83, t h e r e was a s i g n i f i c a n t s h i f t toward a i d i n t h e form o f medical b e n e f i t s , food, educat i o n , and energy a s s i s t a n c e . I n t h i s p e r i o d t h e s h a r e o f a i d g i v e n a s j o b s - t r a i n i n g plunged 7.1 c e n t s p e r b e n e f i t d o l l a r (78 p e r c e n t ) . Chart 2 Composition of Need-Based Benefit Dollar Fiscal Year 1968 Services 7 Is7 Education 5.4% Housing , 4.9% Jobs - Training 4.7% - Percentages do not sum to 100% due to rounding. Chart 3 Composition of Needs-Based Benefit Dollar Fiscal Year 1983 Energy 1.6% Education 6.8% Percentages do not sum to 100% due to rounding. TABLE 5. Form o f aid Composition of Need-Tested Benefits a/ FY 1968 FY 1979 FY 1980 FY 1981 FY 1982 (percentage share of total aid) Medical Aid Cash Food Benefits Housing Education Aid Jobs-Training Services Energy Aid -a/ Data sources are the same as for table 2. -b/ Total does not add because of rounding. F Y 1983 INCOME TESTS OF THE BENEFIT PROGRAMS Almost 90 p e r c e n t o f t h e p r o g r a m s i n t h i s r e p o r t h a v e a n e x p l i c i t t e s t o f i n c o m e . The o t h e r s b a s e e l i g i b i l i t y o n a r e a o f r e s i d e n c e , e n r o l l m e n t i n a n o t h e r w e l f a r e program, o r o t h e r f a c t o r s t h a t presume n e e d . The e x p l i c i t income t e s t s a r e o f f i v e k i n d s : 1 . Income c e i l i n g r e l a t e d t o o n e o f t h e F e d e r a l Governm e n t ' s o f f i c i a l p o v e r t y measures ( c e n s u s Bureau p o v e r t y t h r e s h o l d s o r F e d e r a l p o v e r t y income g u i d e l i n e s ) . 2. tics' Income l i m i t r e l a t e d t o S t a t e o r a r e a m e d i a n income. 3 . Income l i m i t r e l a t e d t o t h e B u r e a u o f L a b o r S t a t i s lower-level budgets. 4. Income b e l o w a b s o l u t e d o l l a r s t a n d a r d . 5. Income l e v e l deemed t o i n d i c a t e "need." - T a b l e 6 c l a s s i f i e s t h e 74 programs 3 / i n t h i s r e p o r t by t y p e o f income t e s t . I t shows t h a t f o u r F e d e r a l c a s h b e n e f i t p r o g r a m s u s e an a b s o l u t e F e d e r a l d o l l a r c e i l i n g . The o t h e r s , i n c l u d i n g Aid t o F a m i l i e s w i t h Dependent C h i l d r e n ( l a r g e s t c a s h program), b a s e e l i g i b i l i t y on S t a t e d e c i s i o n s a b o u t income n e e d , a s d o e s M e d i c a i d , t h e l a r g e s t w e l f a r e p r o g r a m o f a l l . Most f o o d b e n e f i t p r o g r a m s t i e e l i g i b i l i t y t o t h e F e d e r a l p o v e r t y income guidelines. Many h o u s i n g p r o g r a m s b a s e e l i g i b i l i t y on a r e a m e d i a n income. J o b programs, on t h e o t h e r hand, t e n d t o u s e o f f i c i a l p o v e r t y m e a s u r e s o r BLS income s t a n d a r d s , w h i c h e v e r a r e higher. The b e n e f i t p r o g r a m s u s e income t e s t s t o d e c i d e e l i g i b i l i t y a n d , i n some c a s e s , t o d e c i d e w h e t h e r t o g i v e f r e e s e r v i c e o r t o charge a fee. Some p r o g r a m s a d m i t a l i m i t e d p e r c e n t a g e o f r e c i p i e n t s w i t h income a b o v e t h e i r c u s t o m a r y limits. An e x a m p l e i s H e a d s t a r t . 3/ The t o t a l number o f c l a s s i f i c a t i o n s i n t a b l e 6 e x c e e d s 7 4 b e c a u s e many p r o g r a m s h a v e a l t e r n a t i v e income t e s t s . TABLE 6. Income E l i g i b i l i t y T e s t s Used by B e n e f i t P r o g r a m s Limit related to: Official poverty BLS measure b u d g e t s Program 11 State1 area median income Dollar amount Income deemed "needy" Area Enrollment of i n other r e s i d e n c e program Other MEDICAL BENEFITS 1. Medicaid 2. 3. 4. 5. 6. 7. 8. 9. 10. .......................................................... X 2 1 -------------- X ................................................................. X ...................................... X 21 Medical c a r e f o r v e t e r a n s with non-service disability General a s s i s t a n c e( m e d i c a l ) M a t e r n a l and c h i l d h e a l t h ....................... X 41 ...................................................... -------- x y ..................................... services I n d i a n h e a l t h services Community h e a l t h c e n t e r s Medical a i d f o r refugees and C u b a n / H a i t i a n e n t r a n t s M i g r a n t h e a l t h c e n t e r s ---------Medical a i d f o r c e r t a i n Cuban r e f u g e e s C r i p p l e d c h i l d r e n ' s s e r v i c e s ---- ........................................ X .............................................................. ...................................................... pensions x y x 21 51 ........................................................................ X 41 CASH AID 1 1 . AFDC 1 2 . SSI 1 3 . veterans' X x 2/ x I1 X xy X x y TABLE 6 . Income E l i g i b i l i t y T e s t s Used b y B e n e f i t Programs (Cont'd) Limit r e l a t e d t o : Program 1 1 Official poverty BLS measure budget State1 area median income Dollar amount Incomr deemed "needy" HOUSING BENEFITS 33. S e c . 8 lower-income h o u s i n g 41. Farm l a b o r h o u s i n g l o a n s X Area Enral lment of in other r e s i d e n c e pragram Other TABLE 6 . Income E l i g i b i l i t y T e s t s Used by B e n e f i t P r o g r a m s ( C o n t ' d ) Limit related to: Official BLS poverty measure budgets Program I-/ State/ area median income Dollar mount Income deemed "needy" Area of residence JOBS AND TRAINING 6 0 . Comprehensive e m ~ l o v m e n t . . g/------------.................... and t r a i n i n g s e r v i c e s Summer y o u t h employment 201 Job corps 2 0 1 S e n i o r comumn i t y s e r v i c e employment Work i n c e n t i v e p r o g r a m (WIN) Youth employment D e m o n s t r a t i o n p r o g r a m s 2 2 / ---------------F o s t r r g r a n d p a r e n t s -------------P u b l i c s e r v i c e employment 261 S e n i o r companions ....................... ------ - ---- ---------------- SERVICES 6 9 . T i t l e XX s o c i a l s e r v i c e s 2 5 / 7 0 . ~~~~l s e r v i c e s 71. Emergency f o o d d i s t r i b u t i o n and s h e l t e r - ....................................... x 21 ------------------X ..................................................................................... ENERGY AID Enrollment in other program Other 11 S h o r t t i t l e s and a b b r e v i a t i o n s a r e u s e d i n t h i s t a b l e . contezts for f u l l t i t l e s . See t a b l e o f -21 Need i s d e c i d e d by S t a t e ( o r l o c a l i t y ) . -3 / V e t e r a n must s w e a r t h a t h e c a n n o t pay f o r c a r e . 41 The s t a t e d p u r p o s e o f t h e M a t e r n a l and C h i l d H e a l t h (MCH) S e r v i c e s lock- rant law i s t o e n a b l e S t a t e s t o a s s u r e a c c e s s t o q u a l i t y MCH s e r v i c e s t o m o t h e r s and c h i l d r e n , p a r t i c u l a r l y t h o s e w i t h low income ( 9 r l i m i t e d a v a i l a b i l i t y o f h e a l t h s e r v i c e s ) . The law d e f i n e s low income i n t e r m s o f t h e F e d e r a l T h i s b l o c k g r a n t which t o o k e f f e c t i n FY 1981, i n c l u d e s poverty guidelines. funding f o r c r i p p l e d c h i l d r e n ' s s e r v i c e s . -51 The law l i m i t s f r e e c a r e t o t h o s e below p o v e r t y . -6 1 A l l r e s i d e n t s o f t h e a r e a s e r v e d a r e e l i g i b l e , b u t f e e s must b e c h a r g e d t h e non-poor. -71 For b a s i c SSI payment from t h e U.S. -8 1 S t a t e s d e c i d e need f o r a n o p t i o n a l S t a t e supplement t o SSI. 91 - For a b l i n d o r d i s a b l e d c h i l d . 101 Food stamp e l i g i b i l i t y i s a c c e p t e d a s d o c u m e n t a t i o n o f e l i g i b i l i t y f o r t h e f r e e s c h o o l l u n c h and f r e e s c h o o l b r e a k f a s t programs. 111 R e g u l a t i o n s p r o v i d e t h a t income l i m i t s s h a l l n o t b e lower t h a n t h o s e f o r f r e e o r r e d u c e d - p r i c e h e a l t h c a r e , p r o v i d e d t h e s e l i m i t s a r e between 100 and 185 percent of poverty. 121 need7 The law r e q u i r e s p r e f e r e n c e f o r t h o s e w i t h g r e a t e s t economic o r s o c i a l 131 Need i s d e c i d e d by a n e e d s a n a l y s i s s y s t e m a u t h o r i z e d by t h e H i g h e r ~ d u c x i o nAct and u p d a t e d a n n u a l l y by t h e S e c r e t a r y o f E d u c a t i o n . 141 Need i s d e c i d e d by t h e e d u c a t i o n a l i n s t i t u t i o n , by u s e o f a n e e d s a n a l F i s s y s t e m approved by t h e S e c r e t a r y of E d u c a t i o n . 151 There i s no income t e s t . t o beneedy. 16/ - M i g r a t o r y c h i l d r e n and s t u d e n t s a r e presumed Need i s d e c i d e d by t h e e d u c a t i o n a l i n s t i t u t i o n . 1 7 1 F o r f o r g i v e n e s s o f l o a n s made t o needy s t u d e n t s who f a i l t o c o m p l e t e studzs. 181 Need f o r l o a n s i s d e c i d e d by t h e e d u c a t i o n a l i n s t i t u t i o n , by u s e o f a n e e d F a n a l y s i s s y s tem approved by t h e S e c r e t a r y of E d u c a t i o n " i n c o m b i n a t i o n w i t h o t h e r i n f o r m a t i o n " a b o u t t h e s t u d e n t ' s f i n a n c e s . For a l l h e a l t h p r o f e s s i o n a l s c h o l a r s h i p s and f o r l o a n s t o s t u d e n t s o f m e d i c i n e and o s t e o p a t h y , F e d e r a l r e g u l a t i o n s d e f i n e t h e r e q u i r e d " e x c e p t i o n a l f i n a n c i a l need." 1 9 1 Law makes e l i g i b l e s e c o n d a r y s t u d e n t s who a r e "economically d i s a d v a z a g e d , " b u t d o e s n o t d e f i n e t h e t e r m . T h e r e a r e no r e g u l a t i o n s . 20/ C h a r t shows p r a c t i c e s u n d e r t h e Comprehensive Employment and ~ r a i x A n c~t (CETA), which was r e p l a c e d by t h e J o b T r a i n i n g P a r t n e r s h i p Act (JTPA), e f f e c t i v e i n FY 1984. The new law u s e s s i m i l a r e l i g i b i l i t y r u l e s f o r t h e s e programs. 211 F e d e r a l p o v e r t y g u i d e l i n e s a r e u s e d i f h i g h e r t h a n BLS income st a n z r d . 221 C h a r t shows p r a c t i c e s u n d e r CETA. grant e f f e c t i v e i n FY 1983. Program was r e p l a c e d by a b l o c k 231 I n S t a t e s t h a t p r o v i d e SSI s u p p l e m e n t s , income l i m i t s c a n exceed 125 p e r c e n t o f p o v e r t y . 24/ T h i s program was e n d e d , e f f e c t i v e FY 1982. C h a r t shows p r a c t i c e i n 1981. 251 B e f o r e P.L. 97-35, F e d e r a l law s e t a n o u t e r e l i g i b i l i t y l i m i t r e l a t e d t o ~ c t median e income and r e q u i r e d o n e - h a l f o f F e d e r a l m a t c h i n g f u n d s t o b e used f o r w e l f a r e r e c i p i e n t s . 261 Need was d e c i d e d by v o l u n t a r y a g e n c i e s a d m i n i s t e r i n g t h e b e n e f i t s . 271 S t a t e s h a v e t h e o p t i o n o f s e t t i n g l i m i t s below o u t e r F e d e r a l c e i l i n g s i n t z s category . POVERTY THRESHOLDS AND OTHER MEASUKES OF NEED On t h e n e x t pages a r e found: E s t i m a t e d w e i g h t e d a v e r a g e p o v e r t y t h r e s h o l d s i n 1983, i s s u e d by t h e Census Bureau i n J a n u a r y 1984. F e d e r a l p o v e r t y income g u i d e l i n e s f o r 1984, i s s u e d by t h e Department of H e a l t h and Human S e r v i c e s i n F e b r u a r y 1984. 1/ - Income e l i g i b i l i t y l e v e l s f o r f r e e and reduced p r i c e m e a l s f o r t h e p e r i o d J u l y 1, 1984-June 30, 1985 (130 p e r c e n t and 185 p e r c e n t , r e s p e c t i v e l y , o f 1984 F e d e r a l p o v e r t y income g u i d e l i n e s ) . Annual b u d g e t s f o r a f o u r - p e r s o n u r b a n f a m i l y , a t t h r e e l e v e l s o f l i v i n g , autumn 1981, i s s u e d by t h e Bureau o f Labor S t a t i s t i c s i n A p r i l 1982. Annual b u d g e t s f o r a r e t i r e d u r b a n c o u p l e , a t t h r e e l e v e l s o f l i v i n g , autumn 1981, i s s u e d by t h e Bureau o f Labor S t a t i s t i c s i n J u l y 1982. 1/ P u b l i c Law 97-35 r e q u i r e s t h e S e c r e t a r y o f H e a l t h and ~ u m a n - s e r v i c e s (HHS) t o r e v i s e a t l e a s t a n n u a l l y " t h e o f f i c i a l p o v e r t y l i n e ( a s d e f i n e d by t h e O f f i c e o f Management and The u p d a t i n g methodology was d e v e l o p e d by t h e Budget). O f f i c e o f Economic and O p p o r t u n i t y , c o n t i n u e d by t h e O f f i c e o f Management and Budget, a n d , s i n c e e n a c t m e n t o f P.L. 97-35, h a s been u s e d by t h e HHS S e c r e t a r y . . ." TABLE 7 . Bureau o f t h e Census P o v e r t y T h r e s h o l d s i n 1983 Estimated weighted average t h r e s h o l d : 1983 a / - ..................... ............. .......... 2 p e r s o n s .................... 1 person Under 65 y e a r s 65 y e a r s and o v e r Householder under 65 y e a r s . . H o u s e h o l d e r 65 y e a r s and o l d e r .................... .................... .................... .................... .................... .................... ............ 3 persons 4 persons 5 persons 6 persons 7 persons 8 persons 9 p e r s o n s o r more ---- - - - - - - - - - _ _ ^ 4 F a c t o r u s e d t o u p d a t e 1982 t h r e s h o l d s : -a / 1 _ - 1 _ _ I . - - 1.03217 Census Bureau p r e s s r e l e - a s e , J a n u a r y , 25, 1984. - 1 - TABLE 8. - 1984 Federal Poverty Income Guidelines a/ Poverty Guidelines for All States Except Alaska and Hawaii Guideline $ 4,980 6,720 8,460 10,200 11,940 13,680 15,420 17,160 Size of Family Unit 1 2 3 4 5 6 7 8 For family units with more than 8 members, add $1,740 for each additional member. Size of Familv Unit Guideline $ 6,240 8,410 10,580 12,750 14,920 17,090 19,260 21,430 For family units with more than 8 members, add $2,170 for each additional member. Poverty Guidelines for Hawaii Size of Family Unit 1 Nonfarm Family Guideline $ 5,730 For family units with more than 8 members, add $2,000 for each additional member. -a/ Source: 49 Federal Register. No. 39. Feb. 27, 1984, p. 7152. . TABLE 9 Eligibility Levels for Free and Reduced-Price Meals for the Period July 1. 1984-June 30. 1985 Maximum income levels for free and reduced-price meals Family size 1983 Federal poverty income Free meals guidelines 130% Reduced-price meals 185% 48 States. District of Columbia. Territories excluding Guam .................. .................. .................. 4 .................. 5 .................. 6 .................. 7 .................. 8 .................. Each additional family member ....... 1 2 3 $ 4.980 6. 720 8.460 10. 200 11.940 13. 680 15.420 17. 160 +1. 740 Alaska .................. $ 6.240 .................. 8.410 .................. 10.580 4 .................. 12. 750 5 .................. 14. 920 6 .................. 17.090 19. 260 7 .................. 8 .................. 21. 430 Each additional + 2 . 170 family member ...... 1 2 3 Hawaii and Guam .................. ....... 8 Each additional family member a/ 49 Federal Register . No . 77. April 18.1984 . p . 15590. TABLE 10. Summary of Annual Budgets f o r a Four-Person Family a t Three L e v e l s of L i v i n g , Urban United S t a t e s , Autumn 1981 a / (U.S. Department of Labor Bureau o f Labor S t a t i s t i c s - i s s u e d A p r i l 16, 1982) - Intermediate budget Higher budget $25,407 $38,060 18,240 25,008 5,843 7,366 5,546 8,423 2,372 3,075 1,333 1,947 508 719 1,443 1,505 1,196 1,972 62 1 1,021 1,718 1,036 1,703 1,993 1,596 4,443 9,340 Lower budget ...................... $15,323 T o t a l f a m i l y consumption ........ 12,069 Food ......................... 4,545 Housing ....................... 2,817 1,311 T r a n s p o r t a t i o n ................ 93 7 C l o t h i n g ...................... P e r s o n a l c a r e ................. 397 Medical c a r e .................. 1,436 644 Other f a m i l y consumption ...... T o t a l budget O t h e r items...................... .. P e r s o n a l income t a x e s ........... ----S o c i a l s e c u r i t y and d i s a b i l i t y ---- --- NOTE: Because o f rounding, sums o f i n d i v i d u a l items may n o t equal t o t a l s . a / L a s t r e l e a s e of 4-person f a m i l y budget d a t a . The Labor ~ e ~ a r t m e ne lti m i n a t e d t h e program a f t e r Congress passed t h e Omnibus Budget R e c o n c i l i a t i o n Act of 1981. I t s a i d funds were n o t a v a i l a b l e t o make changes r e q u i r e d t o c o n t i n u e t h e program. TABLE 11. Summary of Annual Budgets f o r a R e t i r e d Couple a t Three L e v e l s of L i v i n g , Urban United S t a t e s , Autumn 1 9 8 1 5 1 (u.s. Department o f Labor, Bureau o f Labor S t a t i s t i c s i s s u e d J u l y 30, 1982) Lower budget --- - - Intermediate budget Higher budget - -b/ ................... $7,226 T o t a l f a m i l y consumption ......... 6,914 Food ........................... 2,183 Housing ........................ 2,377 T r a n s p o r t a t i o n ................. 553 C l o t h i n g ....................... 244 198 P e r s o n a l c a r e .................. Medical c a r e c / ................ 1,085 O t h e r f a m i l y consumptions ...... 27 5 311 Other i t e m s ...................... T o t a l budget - NOTE: Because o f rounding, sums o f i n d i v i d u a l i t e m s may n o t equal t o t a l . a / L a s t r e l e a s e o f r e t i r e d c o u p l e budget d a t a . The Labor ~e~artmen d its c o n t i n u e d t h e program a f t e r Congress passed t h e Omnibus Budget R e c o n c i l i a t i o n Act of 1981. The Department s a i d funds were n o t a v a i l a b l e t o make changes r e q u i r e d t o c o n t i n u e t h e program. b/ Beginning w i t h t h e autumn 1973 u p d a t i n g o f t h e budgets f o r t z e r e t i r e d c o u p l e , t h e t o t a l budget i s d e f i n e d a s t h e sum of " t o t a l f a m i l y consumption" and " o t h e r i t e m s . " Income t a x e s a r e n o t i n c l u d e d i n t h e t o t a l budgets. c / The e s t i m a t e s f o r m e d i c a l c a r e c o n t a i n a p r e l i m i n a r y e s t i m a t e f o r "out-of-pocket" c o s t s f o r Medicare. CATALOGUE OF PROGRAMS OFFERING CASH AND NON-CASH BENEFITS TO PERSONS OF LIMITED INCOME 1. MEDICAID* Funding Formula By law, t h e F e d e r a l Government h e l p s S t a t e s s h a r e i n t h e c o s t o f Medicaid s e r v i c e s by means o f a v a r i a b l e m a t c h i n g f o r m u l a t h a t i s a d j u s t e d b i e n n a l l y . The m a t c h i n g r a t e , which i s i n v e r s e l y r e l a t e d t o a S t a t e ' s p e r c a p i t a income, r a n g e s from 50 t o 77.63 p e r c e n t i n F i s c a l Y e a r s (FYs) 1984-85. F o r FY 1983 t h e r a t e a v e r a g e d s l i g h t l y more t h a n 5 4 p e r c e n t f o r t h e N a t i o n a s a whole. The F e d e r a l s h a r e o f a d m i n i s t r a t i v e c o s t s g e n e r a l l y i s 50 p e r c e n t b u t a s h i g h a s 9 0 p e r c e n t f o r c e r t a i n i t e m s . P.L. 97-35, t h e Omnibus Budget R e c o n c i l i a t i o n Act o f 1981, p r o v i d e d f o r a r e d u c t i o n i n t o t a l F e d e r a l f u n d s t o which a S t a t e i s o t h e r w i s e e n t i t l e d i n FY82-FY84 u n l e s s c e r t a i n c o n d i t i o n s a r e met. i. F e d e r a l Medical A s s i s t a n c e P e r c e n t a g e (FMAP) The F e d e r a l s h a r e o f a S t a t e ' s m e d i c a l v e n d o r payments i s c a l l e d t h e F e d e r a l m e d i c a l a s s i s t a n c e p e r c e n t a g e (FMAP). The FMAP i s h i g h e r f o r S t a t e s w i t h l o w e r p e r c a p i t a incomes and lower f o r S t a t e s w i t h h i g h e r p e r c a p i t a incomes. I f a s t a t e ' s p e r c a p i t a income w e r e e q u a l t o t h e n a t i o n a l a v e r a g e p e r c a p i t a income, i t s FMAP would b e 55 p e r c e n t . The law e s t a b l i s h e s a minimum FMAP o f 50 p e r c e n t 11 and a maximum o f 8 3 p e r c e n t ( t h o u g h t h e h i g h e s t r a t e i n ~ y 8 4 - 8 5 i s 77.63 p e r c e n t f o r Mississippi). 11 F o r FY84 and FY85, 1 3 S t a t e s and t h e D i s t r i c t o f Columbia t h e maximum S t a t e s h a r e o f 50 p e r c e n t b e c a u s e t h e i r p e r c a p i t a must income i n t h e b a s e p e r i o d exceeded t h e n a t i o n a l a v e r a g e by more t h a n 5.4093 p e r c e n t . The S t a t e s a r e : A l a s k a , C a l i f o r n i a , C o l o r a d o , Conn e c t i c u t , Delaware, H a w a i i , I l l i n o i s , Maryland, Nevada, New J e r s e y , New York, Washington, and Wyoming. pay * R e g u l a t i o n s g o v e r n i n g Medicaid a r e found i n 42 C.F.R. 430-456. - The s t a t u t o r y f o r m u l a f o r d e t e r m i n i n g t h e FMAP f o l l o w s : 21 FMAP = 100% - S t a t e s h a r e ( w i t h a minimum o f 50% and a maximum o f 8 3 % ) ( S t a t e p e r c a p i t a income) State share = 2 x 45% ( N a t i o n a l p e r c a p i t a income) By law, between O c t o b e r 1 and November 30 of e a c h even-numbered y e a r , t h e S e c r e t a r y o f HHS p r o m u l g a t e s t h e p e r c e n t a g e t h a t w i l l b e i n e f f e c t f o r t h e 2-year p e r i o d b e g i n n i n g t h e f o l l o w i n g O c t o b e r . The p e r c e n t a g e s a r e b a s e d on t h e a v e r a g e p e r c a p i t a income o f e a c h S t a t e and t h e U n i t e d S t a t e s f o r t h e 3 most r e c e n t c a l e n d a r y e a r s f o r which s a t i s f a c t o r y d a t a a r e a v a i l a b l e from t h e Department o f Commerce. 31 - The law p r o v i d e s one e x c e p t i o n t o t h e FMAP. Family p l a n n i n g s e r v i c e s a r e f e d e r a l l y matched a t a 90 p e r c e n t r a t e . ii. A d m i n i s t r a t i v e Matching R a t e The law s p e c i f i e s a F e d e r a l m a t c h i n g r a t e o f 50 p e r c e n t f o r a d m i n i s t r a t i v e c o s t s w i t h t h e f o l l o w i n g e x c e p t i o n s : automated c l a i m s p r o c e s s i n g s y s t e m s ( 9 0 p e r c e n t f o r development, 75 p e r c e n t f o r o p e r a t i o n ) , p r o f e s s i o n a l m e d i c a l p e r s o n n e l used i n program a d m i n i s t r a t i o n ( 7 5 p e r c e n t ) , e s t a b l i s h m e n t and o p e r a t i o n o f S t a t e f r a u d and a b u s e c o n t r o l u n i t s (90 p e r c e n t f o r t h e f i r s t 3 y e a r s , 75 p e r c e n t t h e r e a f t e r ) , and u t i l i z a t i o n r e v i e w a c t i v i t i e s c o n d u c t e d by p r o f e s s i o n a l s t a n d a r d s r e v i e w o r g a n i z a t i o n s on u t i l i z a t i o n and q u a l i t y c o n t r o l peer review o r g a n i z a t i o n s under c o n t r a c t (75 p e r c e n t ) . 21 P.L. 97-35 r e q u i r e d t h e C o m p t r o l l e r G e n e r a l t o c o n d u c t a s t u d y o f t h e FMAP and r e p o r t t h e r e s u l t s t o Congress by O c t o b e r 1, 1982. The s t u d y was t o examine t h e f e a s i b i l i t y and c o n s e q u e n c e s o f r e v i s i n g t h e f o r m u l a t o t a k e i n t o a c c o u n t : ( 1 ) t h e r e l a t i v e economic p o s i t i o n s and n e e d s o f t h e d i f f e r e n t S t a t e s ; ( 2 ) t h e d i f f e r e n t amounts o f w e l f a r e payments; ( 3 ) t h e r e l a t i v e c o s t o f l i v i n g and unemployment r a t e s ; ( 4 ) t h e r e l a t i v e t a x a b l e w e a l t h and amount o f t a x e s r a i s e d p e r c a p i t a ; and ( 5 ) o t h e r r e l e v a n t f a c t o r s b e a r i n g on an e q u i t a b l e d i s t r i b u t i o n o f F e d e r a l f u n d s . The r e p o r t was i s s u e d on March 9 , 1983. 31 I n t h e FY84-FY85 p e r i o d t h e S t a t e s and t h e D i s t r i c t o f ~ o l u m F i a f a l l i n t o r o u g h l y t h r e e g r o u p s u n d e r t h e Medicaid f o r m u l a : F e d e r a l s h a r e between 50 and 55 p e r c e n t , 19 S t a t e s ; 55-65 p e r c e n t , 1 7 S t a t e s ; 65-77.63 p e r c e n t , 1 5 S t a t e s . The r a t e f o r American Samoa, Guam, P u e r t o R i c o , t h e V i r g i n I s l a n d s , and t h e N o r t h e r n M a r i a n a I s l a n d s i s s e t by law a t 50 p e r c e n t . However, t h e law e s t a b l i s h e s a n n u a l l i m i t s on F e d e r a l e x p e n d i t u r e s i n t h e s e o u t l y i n g a r e a s . iii. R e d u c t i o n s i n Payments-. t o S t a t e s P.L. 97-35, t h e Omnibus Budget R e c o n c i l i a t i o n Act o f 1981, prov i d e s f o r r e d u c t i o n s i n F e d e r a l Medicaid payments t o S t a t e s i n t h e FY82-FY84 p e r i o d . S t a t e s can l o w e r t h e r e d u c t i o n s o t h e r w i s e a p p l i c a b l e by m e e t i n g c e r t a i n c r i t e r i a a n d / o r by s p e n d i n g l e s s t h a n a s p e c i f i e d t a r g e t amount. The amount o f F e d e r a l m a t c h i n g payments t o which a S t a t e i s o t h e r w i s e e n t i t l e d i s t o b e r e d u c e d by 3 p e r c e n t i n FY82, 4 p e r c e n t i n FY83, and 4 . 5 p e r c e n t i n FY84. A S t a t e c a n l o w e r t h e amount o f i t s r e d u c t i o n by 1 p e r c e n t a g e p o i n t f o r e a c h o f t h e f o l l o w i n g : ( 1 ) o p e r a t i n g a q u a l i f i e d h o s p i t a l c o s t r e v i e w program; 41 ( 2 ) s u s t a i n i n g a n unemployment r a t e e x c e e d i n g 150 p e r c e n t o f t h z n a t i o n a l a v e r a g e ; and ( 3 ) d e m o n s t r a t i n g r e c o v e r i e s from f r a u d and a b u s e a c t i v i t i e s , and w i t h r e s p e c t t o FY82, t h i r d - p a r t y r e c o v e r i e s e q u a l t o 1 p e r c e n t o f F e d e r a l payments. A S t a t e i s e n t i t l e d t o a d o l l a r - f o r - d o l l a r o f f s e t i n i t s reduct i o n s i f t o t a l F e d e r a l Medicaid e x p e n d i t u r e s i n a y e a r f a l l below a s p e c i f i e d t a r g e t amount. I n no c a s e can t h e amount r e c o v e r e d exceed t h e t o t a l amount o f r e d u c t i o n s . I n FY82, t h e t a r g e t amount was e q u a l t o 109 p e r c e n t o f t h e S t a t e ' s e s t i m a t e f o r FY81. The law s p e c i f i e s t h a t t h e FY83 and FY84 t a r g e t s s h a l l e q u a l t h e FY82 t a r g e t i n c r e a s e d o r d e c r e a s e d by t h e p e r c e n t a g e change i n t h e i n d e x o f t h e m e d i c a l c a r e component o f t h e consumer p r i c e i n d e x o v e r t h e same p e r i o d . The FY 1983 t a r g e t e q u a l l e d 107.5 p e r c e n t o f t h e FY 1982 amount, and t h e FY 1984 t a r g e t i s e s t i m a t e d a t 116.5 p e r c e n t o f t h e FY 1982 amount. A S t a t e e n t i t l e d t o an o f f s e t w i l l r e c e i v e payment f o r s u c h amount d u r i n g t h e f i r s t q u a r t e r o f t h e f o l l o w i n g f i s c a l y e a r . The law e x c l u d e s t h e f o l l o w i n g i t e m s from t h e d e t e r m i n a t i o n o f (1) w h e t h e r a S t a t e s p e n d s l e s s t h a n i t s t a r g e t amount f o r a y e a r : a d j u s t m e n t s w i t h r e s p e c t t o p r i o r y e a r c l a i m s ; ( 2 ) i n t e r e s t p a i d on d i s a l l o w a n c e s f o r p r i o r y e a r s ; ( 3 ) any o f f s e t payments t h e S t a t e h a s r e c e i v e d f o r s p e n d i n g l e s s t h a n i t s t a r g e t amount i n t h e p r e v i o u s y e a r , and ( 4 ) any o f t h e r e d u c t i o n s i n t h e F e d e r a l f u n d s a S t a t e r e c e i v e s t h a t a r e imposed u n d e r t h e new law. 4 1 A q u a l i f i e d h o s p i t a l c o s t r e v i e w program i s one t h a t h a s been e s t a b l i s h e d by s t a t u t e , i s o p e r a t e d d i r e c t l y by a S t a t e , a p p l i e s t o s u b s t a n t i a l l y a l l non-Federal h o s p i t a l s , and r e v i e w s a l l non-Medicare i n p a t i e n t r e v e n u e s o r e x p e n s e s o r a t l e a s t 75 p e r c e n t o f a l l r e v e n u e s o r e x p e n s e s i n c l u d i n g t h o s e a r i s i n g under Medicare. Q u a l i f y i n g programs must a s s u r e t h e S e c r e t a r y t h a t e a c h e n t i t y which pays f o r h o s p i t a l s e r v i c e s , employees, and p a t i e n t s ( i n c l u d i n g t h e M e d i c a r e and Medicaid programs) i s p r o v i d e d s u b s t a n t i a l l y e q u a l t r e a t m e n t . F o r a p p r o v a l o f i t s p l a n , moreover, a S t a t e must show t h a t t h e a n n u a l r a t e o f i n c r e a s e i n a g g r e g a t e h o s p i t a l i n p a t i e n t c o s t s p e r c a p i t a o r p e r a d m i s s i o n h a s r i s e n a t l e a s t 2 perc e n t a g e p o i n t s l e s s ( u s i n g a I-, 2-, o r 3-year b a s e ) t h a n t h e r a t e o f i n f l a t i o n i n a l l S t a t e s w i t h o u t q u a l i f y i n g programs. The r e d u c t i o n and o f f s e t p r o v i s i o n s d o n o t a p p l y t o t h e t e r r i t o r i e s . 5 1 They a l s o d o n o t a p p l y t o A r i z o n a , which d i d n o t h a v e a ~ e d i c a i d - p r o g r a m when t h e s p e n d i n g r e d u c t i o n p r o v i s i o n s were approved. 6-l B. E l i g i b i l i t y Requirements E l i g i b i l i t y f o r Medicaid i s l i n k e d t o a c t u a l o r p o t e n t i a l r e c e i p t o f c a s h a s s i s t a n c e u n d e r t h e programs of Aid t o F a m i l i e s w i t h Dependent . C h i l d r e n (AFDc) and S u p p l e m e n t a l S e c u r i t y Income ( S S I ) f o r t h e aged, b l i n d , and d i s a b l e d ; t h e r e a r e two c l a s s e s o f e l i g i b i l i t y u n d e r Medicaid: c a t e g o r i c a l l y needy and m e d i c a l l y needy. A l l S t a t e Medicaid programs c o v e r t h e " c a t e g o r i c a l l y needy." I n g e n e r a l , t h e s e a r e p e r s o n s r e c e i v i n g c a s h a i d from AFDC o r SSI. Each S t a t e h a s t h e o p t i o n o f r e s t r i c t i n g Medicaid c o v e r a g e o f SSI r e c i p i e n t s by r e q u i r i n g them t o meet any more s t r i n g e n t e l i g i b i l i t y r u l e t h a t t h e S t a t e a p p l i e d on J a n u a r y 1, 1972, t o Medicaid c o v e r a g e o f needy aged, b l i n d , o r d i s a b l e d a d u l t s i n programs t h a t preceded SSI. S t a t e s c h o o s i n g t h e more r e s t r i c t i v e c r i t e r i a must a l l o w a p p l i c a n t s t o d e d u c t m e d i c a l e x p e n s e s from income i n d e t e r m i n i n g e l i g i b i l i t y . 7 1 S t a t e s a l s o may c o v e r a d d i t i o n a l p e r s o n s a s c a t e g o r i c a l l y neTdy; t h e s e i n c l u d e p e r s o n s r e c e i v i n g S t a t e supplement SSI payments ( S S P ) , p e r s o n s who would b e e l i g i b l e f o r c a s h a s s i s t a n c e except t h a t they a r e r e s i d e n t s i n medical i n s t i t u t i o n s (such a s s k i l l e d n u r s i n g f a c i l i t i e s ) , o r c h i l d r e n between a g e s 18 and 20 o r any r e a s o n a b l e c l a s s i f i c a t i o n o f s u c h c h i l d r e n . S t a t e s may a l s o e x t e n d c o v e r a g e t o unemployed f a t h e r s and t h e i r f a m i l i e s o r c h i l d r e n o f unemployed f a t h e r s . S t a t e s must e x t e n d Medicaid e l i g i b i l i t y t o aged, b l i n d , and d i s a b l e d p e r s o n s who w e r e e l i g i b l e f o r Medicaid i n December 1973 ( b e f o r e t h e s t a r t o f SSI on J a n u a r y 1, 1974) a s l o n g a s t h e y meet t h e 1973 c r i t e r i a ; p e r s o n s r e c e i v i n g mandatory S t a t e s u p p l e m e n t a r y payments; 51 As n o t e d b e f o r e , a c e i l i n g i s imposed on F e d e r a l Medicaid f u n d i z g f o r t h e o u t l y i n g a r e a s ; w i t h i n t h e c e i l i n g , t h e i r F'MAP i s 50 p e r c e n t . 6 1 Beginning Oct. 1, 1982, A r i z o n a began i m p l e m e n t a t i o n o f a t h r e e x y e a r d e m o n s t r a t i o n p r o j e c t u n d e r which s p e c i f i e d s e r v i c e s a r e t o b e p r o v i d e d t o t h e i n d i g e n t on a p r e p a i d b a s i s . 71 As of Aug. 1, 1983, t h e f o l l o w i n g 14 S t a t e s employed more r e s t r T c t i v e c r i t e r i a t h a n SSI i n d e t e r m i n i n g Medicaid e l i g i b i l i t y : C o n n e c t i c u t , Hawaii, I l l i n o i s , I n d i a n a , M i n n e s o t a , M i s s o u r i , Nebraska, New Hampshire, North C a r o l i n a , N o r t h Dakota, Ohio, Oklahoma, Utah, and V i r g i n i a . p e r s o n s who would b e e l i g i b l e f o r c a s h a i d e x c e p t f o r a S t a t e b a r r i e r d i s a l l o w e d by Medicaid law; and p e r s o n s a c t u a l l y r e c e i v i n g SSI a n d / o r SSP payments who l o s e t h e i r e l i g i b i l i t y f o r SSI o r SSP s o l e l y because of a c o s t - o f - l i v i n g s o c i a l s e c u r i t y i n c r e a s e . Medicaid coverage a l s o must b e extended f o r 4 a d d i t i o n a l months t o c e r t a i n f a m i l i e s whose AFDC c a s h a s s i s t a n c e h a s been t e r m i n a t e d provided t h e y had r e c e i v e d AFDC f o r a t l e a s t 3 o f t h e p r e c e d i n g 6 months; t h i s e x t e n s i o n a p p l i e s only t o f a m i l i e s whose AFDC c o v e r a g e h a s been t e r m i n a t e d due t o i n c r e a s e d income from, o r i n c r e a s e d h o u r s o f , employment. S t a t e s a l s o may c o v e r t h e "medically needy" under t h e i r Medicaid programs. These a r e p e r s o n s whose income a n d / o r r e s o u r c e s ( a s counted under e l i g i b i l i t y r u l e s of t h e r e l e v a n t program o f c a s h a i d ) i s above t h e S t a t e s t a n d a r d f o r c a s h a s s i s t a n c e , 8/ provided t h a t : ( 1 ) t h e y a r e aged, b l i n d , d i s a b l e d , o r members of-families w i t h dependent c h i l d r e n , and ( 2 ) t h e i r income ( a f t e r d e d u c t i n g i n c u r r e d medical expenses) f a l l s below t h e S t a t e m e d i c a l l y needy s t a n d a r d . 9 / P r i o r t o enactment of P.L. 97-35, S t a t e s having m e d i c a l l y needy programs were r e q u i r e d t o o f f e r comparable c o v e r a g e t o a l l f o u r groups ( i . e . , aged, b l i n d , d i s a b l e d , and members of f a m i l i e s w i t h c h i l d r e n ) . P.L. 97-35 p r o v i d e s t h a t i f a S t a t e o f f e r s m e d i c a l l y needy c o v e r a g e t o any group, i t must p r o v i d e ambulatory s e r v i c e s t o c h i l d r e n and pren a t a l and d e l i v e r y s e r v i c e s f o r p r e g n a n t women. C. Benefits S t a t e Medicaid programs must o f f e r t h e f o l l o w i n g s e r v i c e s t o c a t e g o r i c a l l y needy r e c i p i e n t s : i n p a t i e n t and o u t p a t i e n t h o s p i t a l s e r v i c e s ; l a b o r a t o r y and X-ray s e r v i c e s ; s k i l l e d n u r s i n g f a c i l i t y (SNF) s e r v i c e s f o r t h o s e o v e r age 21; home h e a l t h s e r v i c e s f o r t h o s e e n t i t l e d t o SNF c a r e ; e a r l y and p e r i o d i c s c r e e n i n g , d i a g n o s i s , and t r e a t m e n t (EPSDT) f o r t h o s e under age 21; f a m i l y p l a n n i n g s e r v i c e s and s u p p l i e s ; and p h y s i c i a n s ' s e r v i c e s . They a l s o may p r o v i d e medical s e r v i c e s such a s d r u g s , i n t e r m e d i a t e c a r e f a c i l i t y ( I c F ) s e r a v i c e s , e y e g l a s s e s , i n p a t i e n t p s y c h i a t r i c c a r e f o r i n d i v i d u a l s under age 21 o r o v e r 65. S t a t e s a r e p e r m i t t e d t o e s t a b l i s h l i m i t a t i o n s 8/ P a r t i c i p a t i n g S t a t e s s e t t h e i r own m e d i c a l l y needy income s t a n d z r d s w i t h i n an o u t e r F e d e r a l l i m i t . By law, t h e l i m i t i s 133 1 / 3 p e r c e n t o f t h e maximum sum paid i n t h e AFDC program t o a u n i t o f t h e same s i z e . 9/ A s o f J a n u a r y 1984, t h e f o l l o w i n g 35 S t a t e s and j u r i s d i c tions-had m e d i c a l l y needy programs : Arkansas, C a l i f o r n i a , C o n n e c t i c u t , D i s t r i c t o f Columbia, Guam, Hawaii, I l l i n o i s , Kansas, Kentucky, L o u i s i a n a , Maine, Maryland, M a s s a c h u s e t t s , Michigan, Minnesota, Mont a n a , Nebraska, New Hampshire, New York, North C a r o l i n a , North Dakota, Northern Mariana I s l a n d s , Oklahoma, Oregon, Pennsylvania, P u e r t o Rico, Rhode I s l a n d , Tennessee, Utah, Vermont, V i r g i n I s l a n d s , V i r g i n i a , Washington, West V i r g i n i a , and Wisconsin. on t h e amount of c a r e p r o v i d e d u n d e r a s e r v i c e c a t e g o r y ( s u c h a s l i m i t i n g t h e number o f d a y s o f c o v e r e d h o s p i t a l c a r e o r number o f physicians' services). P r i o r t o e n a c t m e n t o f P.L. 97-35, S t a t e s h a v i n g m e d i c a l l y needy programs w e r e r e q u i r e d , a s a minimum, t o o f f e r t h i s p o p u l a t i o n g r o u p e i t h e r a l l o f t h e mandatory s e r v i c e s , o r a l t e r n a t i v e l y t h e c a r e and s e r v i c e s l i s t e d i n 7 o f t h e 17 p a r a g r a p h s i n t h e law d e f i n i n g c o v e r e d s e r v i c e s , p r o v i d e d t h e y met c e r t a i n c o n d i t i o n s ( i n c l u d i n g o f f e r i n g a mix o f i n s t i t u t i o n a l and n o n i n s t i t u t i o n a l s e r v i c e s ) . P.L. 97-35 s p e c i f i e s t h a t : ( 1 ) i f a S t a t e p r o v i d e s m e d i c a l l y needy c o v e r a g e t o any g r o u p , i t must p r o v i d e a m b u l a t o r y s e r v i c e s t o c h i l d r e n and pren a t a l and d e l i v e r y s e r v i c e s f o r p r e g n a n t women; ( 2 ) i f a S t a t e prov i d e s i n s t i t u t i o n a l s e r v i c e s f o r any m e d i c a l l y needy g r o u p , i t must a l s o p r o v i d e a m b u l a t o r y s e r v i c e s f o r t h i s p o p u l a t i o n g r o u p ; and ( 3 ) i f t h e S t a t e p r o v i d e s m e d i c a l l y needy c o v e r a g e f o r p e r s o n s i n i n t e r m e d i a t e c a r e f a c i l i t i e s f o r t h e m e n t a l l y r e t a r d e d (ICF/MRS), i t must o f f e r t o a l l g r o u p s c o v e r e d i n i t s m e d i c a l l y needy program t h e same mix o f i n s t i t u t i o n a l and n o n i n s t i t u t i o n a l s e r v i c e s a s r e q u i r e d u n d e r p r i o r law. F e d e r a l law, a s m o d i f i e d by P.L. 97-248, t h e Tax E q u i t y and F i s c a l R e s p o n s i b i l i t y Act o f 1982, p e r m i t s S t a t e s t o impose c o s t sharing charges f o r a l l persons f o r a l l services with t h e following exceptions: -- S t a t e s a r e b a r r e d from imposing s u c h c h a r g e s on a l l c a t e g o r i c a l l y and m e d i c a l l y needy c h i l d r e n u n d e r age 18; S t a t e s may p r o v i d e t h a t no copayments would b e imposed f o r c h i l d r e n aged 1 8 t o 21. -- S t a t e s a r e b a r r e d from imposing copayments on s e r v i c e s r e l a t e d t o pregnancy ( i n c l u d i n g p r e n a t a l , d e l i v e r y , and p o s t partum s e r v i c e s ) . S t a t e s may p r o v i d e t h a t no copayments would b e imposed f o r any s e r v i c e p r o v i d e d t o p r e g n a n t women. These l i m i t a t i o n s a p p l y b o t h t o t h e c a t e g o r i c a l l y needy and m e d i c a l l y needy. -- S t a t e s a r e b a r r e d from imposing copayments on s e r v i c e s p r o v i d e d t o c a t e g o r i c a l l y and m e d i c a l l y needy i n p a t i e n t s i n SNFs and ICFs who a r e r e q u i r e d t o spend a l l t h e i r income f o r m e d i c a l e x p e n s e s e x c e p t f o r t h e amount exempted f o r p e r s o n a l n e e d s . -- S t a t e s may n o t impose copayments on f a m i l y p l a n n i n g o r emergency s e r v i c e s f o r e i t h e r t h e c a t e g o r i c a l l y needy o r m e d i c a l l y needy. -- S t a t e s a r e p r e c l u d e d from imposing copayments on c a t e g o r i c a l l y needy HMO e n r o l l e e s . They may a l s o exempt t h e m e d i c a l l y needy from such c h a r g e s . A l l copayment c h a r g e s must b e "nominal" i n amount, w i t h o n e e x c e p t i o n . The S e c r e t a r y may waive t h e "nominal" r e q u i r e m e n t s i n t h e c a s e o f non-emergency s e r v i c e s p r o v i d e d i n emergency rooms where t h e S t a t e h a s e s t a b l i s h e d , s u b j e c t t o t h e s t a t i s f a c t i o n o f t h e S e c r e t a r y , t h a t a l t e r n a t i v e s o u r c e s o f nonemergency s e r v i c e s ate a c t u a l l y a v a i l a b l e and a c c e s s i b l e . I n s u c h c a s e s t h e S t a t e may impose a c h a r g e u p t o t w i c e t h e amount d e f i n e d a s nominal. I n FY 1382, e s t i m a t e d a v e r a g e a n n u a l Medicaid payments p e r r e c i p i e n t were as f o l l o w s : aged, $3,222; b l i n d , $2,048; d i s a b l e d , $3,702; c h i l d r e n , $369; and a d u l t s i n AFDC f a m i l i e s , $772. The e s t i m a t e d a v e r a g e a n n u a l payment f o r a l l g r o u p s was $1,343. FY 1983 program c o s t s t o t a l e d $35.0 b i l l i o n , an i n c r e a s e o f 7.7 p e r c e n t o v e r t h e $32.4 b i l l i o n r e c o r d e d i n FY 1982. 2. MEDICAL CARE FOR VETERANS WITH A NON-SERVICE-CONNECTED DISABILITY A. Funding Formula - T h i s program i s funded 100 p e r c e n t by t h e F e d e r a l Government. 1 / B. - E l i g i b i l i t y Requirements 2 / P o t e n t i a l l y , a b o u t 5 p e r c e n t o f t h e U.S. p o p u l a t i o n i s e l i g i b l e t o r e c e i v e f r e e V e t e r a n s A d m i n i s t r a t i o n (VA) m e d i c a l c a r e . V e t e r a n s w i t h a c c e s s t o m e d i c a l c a r e i n c l u d e f o u r sometimes o v e r - l a p p i n g groups: ( 1 ) v e t e r a n s with service-connected d i s a b i l i t i e s ; (2) r e c i p i e n t s o f v e t e r a n s ' p e n s i o n s ; ( 3 ) v e t e r a n s 65 y e a r s and o l d e r ; ( 4 ) v e t e r a n s o f any war, o r o f s e r v i c e a f t e r J a n u a r y 3 1 , 1955, w i t h nons e r v i c e - c o n n e c t e d d i s a b i l i t i e s f o r which t h e y swear t h a t t h e y c a n n o t d e f r a y m e d i c a l e x p e n s e s . ( I t s h o u l d b e n o t e d t h a t v e t e r a n s o v e r 65 y e a r s of age o r i n r e c e i p t of v e t e r a n s ' pension a r e n o t r e q u i r e d t o s t a t e under o a t h t h a t t h e y a r e unable t o d e f r a y t h e c o s t of such c a r e . ) Based on VA e s t i m a t e s f o r FY83, a p p r o x i m a t e l y 58 p e r c e n t o f m e d i c a l c a r e i s p r o v i d e d t o v e t e r a n s who meet a t e s t o f need, 3/ t h a t i s , v e t e r a n s who e i t h e r r e c e i v e a c a s h p e n s i o n o r a r e medically indigent. - C. Benefit Levels Benefits include prehospitalization, hospitalization, post h o s p i t a l i z a t i o n , p r o s t h e t i c d e v i c e s and n u r s i n g home c a r e , domic i l i a r y care, medical devices, outpatient care, prescribed drugs and m e d i c i n e , and t r a n s p o r a t i o n s e r v i c e s . FY83 o u t l a y s t o t a l l e d $4.4 b i l l i o n , up 25 p e r c e n t from t h e FY81 t o t a l o f $3.5 b i l l i o n . I n t h i s p e r i o d t h e e s t i m a t e d a v e r a g e m o n t h l y number o f r e c i p i e n t s ( n o t i n c l u d i n g o u t p a t i e n t s ) i n c r e a s e d by o n l y 7 p e r c e n t , from 63.5 t h o u s a n d t o 67.7 t h o u s a n d . 1/ However, t h r o u g h g r a n t s - i n - a i d , t h e VA a l s o a s s i s t s s t a t e s t h a t p r o v i d e c a r e i n S t a t e v e t e r a n homes. The VA makes p e r diem payments f o r t h e c a r e o f e l i g i b l e v e t e r a n s and p a r t i c i p a t e s i n t h e c o s t o f c o n s t r u c t i n g S t a t e home f a c i l i t i e s . 2/ E l i g i b i l i t y r u l e s o f t h i s program a r e found i n 3 8 C.F.R.5 17.46~17.48 (1982). 3/ Based on VA e s t i m a t e t h a t 58 p e r c e n t o f v e t e r a n s r e c e i v i n g VA m e x i c a l c a r e w e r e below t h e p o v e r t y l e v e l o f income. 3. GENERAL ASSISTANCE (MEDICAL CARE COMPONENTS) 1/ - A. Funding Formula No F e d e r a l f u n d s a r e a v a i l a b l e f o r t h i s program, which h e l p s p e r s o n s who d o n o t q u a l i f y f o r Medicaid. As o f l a t e 1982, m e d i c a l a s s i s t a n c e f o r c a s h r e c i p i e n t s o f G e n e r a l A s s i s t a n c e (GA) and f o r o t h e r p e r s o n s i n e l i g i b l e f o r Medicaid was f u l l y S t a t e funded i n 1 5 S t a t e s 2 / and t h e D i s t r i c t o f Columbia. Twenty-three S t a t e s p r o v i d e d no-funds f o r l o c a l m e d i c a l a i d programs. 31 E l e v e n S t a t e s g e n e r a l l y s h a r e d t h e c o s t o f GA m e d i c a l a s s i s t a n c e w i t h l o c a l i t i e s . 4 / F i n a l l y , A r i z o n a , which h a s n e v e r o p e r a t e d a t r a d i t i o n a l ~ e d T c a i dprogram, on O c t o b e r 1 , 1982, began a 3-year d e m o n s t r a t i o n p r o j e c t t h a t was judged t o be q u a l i f i e d f o r F e d e r a l Medicaid f u n d s . Thus, i t now h a s no GA m e d i c a l a s s i s t a n c e program. 1/ S t a t e d a t a r e p o r t e d h e r e a r e drawn from a s t u d y e n t i t l e d " C h a ~ a c t e r i s t i c s o f G e n e r a l A s s i s t a n c e Programs, 1982," p r e p a r e d by Urban Systems R e s e a r c h and E n g i n e e r i n g , l n c . , Cambridge, Massac h u s e t t s , f o r t h e U.S. Department o f H e a l t h and Human S e r v i c e s . C o n t r a c t No. HHS-100-82-0038. 2/ A l a s k a , H a w a i i , Kansas, L o u i s i a n a , Maryland, M a s s a c h u s e t t s , ~ i s s o y r i ,Oklahoma (which g i v e s a s s i s t a n c e i n t h e form o f l i m i t e d c a s h f o r m e d i c a l e m e r g e n c i e s ) , Oregon, P e n n s y l v a n i a , Rhode I s l a n d , Vermont, Washington, West V i r g i n i a , and Wyoming. 3/ S t a t e s w i t h v e r y l i m i t e d c o u n t y programs: Alabama, ~ r k a n s a s , G e o r g i a , Kentucky, M i s s i s s i p p i , New Mexico, North Carol i n a , North Dakota, S o u t h C a r o l i n a , T e n n e s s e e , and Texas. O t h e r S t a t e s w i t h county-funded a i d : Delaware, F l o r i d a , I d a h o , I n d i a n a , Iowa, Montana, Nebraska, Nevada, New Hampshire, S o u t h Dakota, Vermont, and Wisconsin. 41 I n t h i s g r o u p a r e I l l i n o i s , which p r o v i d e s 100 p e r c e n t s t a t e-funds f o r m e d i c a l a s s i s t a n c e i n Cook County ( C h i c a g o ) and s e v e r a l downstate townships, but r e q u i r e s l o c a l funding elsewhere; Michigan, which p r o v i d e s 100 p e r c e n t S t a t e f u n d s f o r o u t p a t i e n t c a r e , none f o r i n p a t i e n t c a r e ; and Maine, which p r o v i d e s 100 percent S t a t e funds f o r a i d i n unorganized m u n i c i p a l i t i e s , but r e q u i r e s o t h e r l o c a l i t i e s t o s h a r e funding. E l i g i b i l i t y Requirements To r e c e i v e GA m e d i c a l a s s i s t a n c e , a p e r s o n g e n e r a l l y must be deemed needy and must l i v e where s u c h a i d i s a v a i l a b l e . Many a r e a s u s e t h e same e l i g i b i l i t y r u l e s f o r GA m e d i c a l a s s i s t a n c e a s f o r GA c a s h a i d ( s e e program No. 1 4 ) . Some h a v e more l i b e r a l r u l e s , and w i l l a i d t h e m e d i c a l l y needy, whose incomes exceed l i m i t s f o r c a s h h e l p . When West V i r g i n i a s t o p p e d p a y i n g f o r GA c a s h a s s i s t a n c e i n 1980, i t c o n t i n u e d t o fund m e d i c a l a s s i s t a n c e u n d e r i t s program, G e n e r a l A s s i s t a n c e f o r D i s a b l e d Adults. Some c o u n t i e s o f f e r h e l p o n l y f o r m e d i c a l e m e r g e n c i e s . Benefit Levels The s c o p e o f m e d i c a l a s s i s t a n c e v a r i e s among S t a t e s a n d , o f t e n , w i t h i n them. I n c o u n t i e s w i t h v e r y l i m i t e d a i d , h e l p u s u a l l y t a k e s t h e form o f m e d i c a l c a r e by c o u n t y h o s p i t a l s . As o f l a t e 1982, t h r e e S t a t e s r e p o r t e d t h a t t h e i r programs o f GA m e d i c a l a s s i s t a n c e were more comprehensive t h a n Medicaid: A l a s k a , Rhode I s l a n d , and Wyoming. C o n n e c t i c u t s a i d i t s program was comparable t o t h a t o f M e d i c a i d . However, i n most a r e a s , GA m e d i c a l a s s i s t a n c e was more l i m i t e d t h a n Medicaid. For example, t h e Oklahoma program c o n s i s t e d o f a d d i n g up t o $70 f o r emergency m e d i c a l n e e d s t o a p e r s o n ' s c a s h r e l i e f g r a n t . S e v e r a l S t a t e s r e p o r t e d c u t b a c k s i n GA m e d i c a l a s s i s t a n c e . E f f e c t i v e i n J a n u a r y 1982, South C a r o l i n a e l i m i n a t e d m e d i c a l b e n e f i t s f o r GA c a s h r e c i p i e n t s . E f f e c t i v e i n September 1982, C a l i f o r n i a e l i m i n a t e d from S t a t e - o n l y Medical m e d i c a l l y i n d i g e n t a d u l t s ( a g e d 21-64) who were n o t l i n k e d t o F e d e r a l a s s i s t a n c e programs and gave b l o c k g r a n t s t o t h e c o u n t i e s t o e s t a b l i s h I n 1983 I l l i n o i s c o u n t y m e d i c a l programs t o a s s i s t s u c h p e r s o n s . suspended i t s program o f Aid t o t h e M e d i c a l l y I n d i g e n t , which had p r o v i d e d ongoing h o s p i t a l and p h y s i c i a n b e n e f i t s comparable t o Medicaid f o r p e r s o n s i n e l i g i b l e f o r Medicaid t h r o u g h t h e S t a t e . M i s s o u r i r e p o r t e d t h a t GA m e d i c a l s e r v i c e s had been " s i g n i f i c a n t l y r e s t r i c t e d " i n 1981-82. The U.S. Department of H e a l t h and Human S e r v i c e s e s t i m a t e d t h a t S t a t e - l o c a l o u t l a y s f o r GA m e d i c a l a s s i s t a n c e (which i t c a l l s " S t a t e - o n l y Medicaid") d e c l i n e d 1 8 p e r c e n t i n FY 1982., from t h e 1983 r e c o r d h i g h o f $3.2 b i l l i o n t o $2.6 b i l l i o n . I t s p r e l i m i n a r y e s t i m a t e o f 1983 o u t l a y s i s $2.4 b i l l i o n , down 8 p e r c e n t from 1982. 4. MATERNAL AND CHILD HEALTH SERVICES, TITLE V OF THE SOCIAL SECURITY ACT 1/ - A. Funding Formula 1. P r e v i o u s A u t h o r i t y . F o r FY 1981 and p r e v i o u s f i s c a l y e a r s , a b o u t 90 p e r c e n t o f t h e t i t l e V a p p r o p r i a t i o n had t o b e made a v a i l a b l e f o r m a t e r n a l and c h i l d h e a l t h (MCH) and c r i p p l e d c h i l d r e n s ( C C ) s e r v i c e s w i t h t h e r e m a i n d e r d e s i g n a t e d f o r r e s e a r c h and t r a i n i n g activities. The MCH a p p r o p r i a t i o n was d i v i d e d i n t o h a l v e s , c a l l e d Fund A and Fund B. Fund A was a p p o r t i o n e d among t h e S t a t e s by a f o r m u l a s p e c i f i e d i n t h e law and r e q u i r e d S t a t e m a t c h i n g , d o l l a r f o r d o l l a r . Each f i s c a l y e a r , a S t a t e r e c e i v e d from Fund A a g r a n t o f $70,000, p l u s t h a t p o r t i o n o f t h e r e m a i n d e r o f Fund A which equalled i t s p r o p o r t i o n a t e s h a r e of l i v e b i r t h s i n t h e United S t a t e s . No S t a t e m a t c h i n g was r e q u i r e d f o r Fund B. I n e a c h f i s c a l y e a r , $10 m i l l i o n was a l l o c a t e d from Fund B t o S t a t e s and i n s t i t u t i o n s o f h i g h e r l e a r n i n g f o r e s t a b l i s h m e n t o f proj e c t s t o s e r v e t h e m e n t a l l y r e t a r d e d . Of t h e r e m a i n d e r , a t l e a s t 75 p e r c e n t was a l l o c a t e d t o S t a t e s on t h e b a s i s o f S t a t e p e r c a p i t a income and t h e number o f l i v e b i r t h s , w i t h r u r a l b i r t h s g i v e n t w i c e t h e w e i g h t o f u r b a n b i r t h s . These f u n d s w e r e i n t e n d e d t o a s s i s t S t a t e s i n carrying out t h e i r S t a t e plans. The r e m a i n i n g 25 p e r c e n t o r l e s s , known g e n e r a l l y a s "Reserve B" o r "RB" f u n d s , was r e t a i n e d a t the Federal level f o r discretionary grants f o r special projects of regional o r national significance. 1/ P.L. 97-35, t h e Omnibus Budget R e c o n c i l i a t i o n Act of 1981, c o n s o i i d a t e d t h e MCH and CC programs i n t o an MCH b l o c k g r a n t w i t h t h e f o l l o w i n g o t h e r F e d e r a l g r a n t programs: services for disabled c h i l d r e n e n r o l l e d i n t h e S u p p l e m e n t a l S e c u r i t y Income program, l e a d b a s e d p a i n t p o i s o n i n g p r e v e n t i o n , g e n e t i c d i s e a s e s , sudden i n f a n t d e a t h syndrome, h e m o p h i l i a t r e a t m e n t c e n t e r s , and t h e a d o l e s c e n t pregnancy program. E f f e c t i v e O c t . 1 , 1981, S t a t e s c o u l d b e g i n a d m i n i s t e r i n g MCH b l o c k g r a n t s . P.L. 97-35 p r o v i d e d t h a t t h e S e c r e t a r y o f H e a l t h and Human S e r v i c e s would c o n t i n u e m a t c h i n g g r a n t s u n d e r e x i s t i n g programs u n t i l a S t a t e assumed a u t h o r i t y f o r t h e MCH b l o c k g r a n t , b u t s t i p u l a t e d t h a t S t a t e s must d o s o b e f o r e O c t . 1, 1982. As o f August 1982, e v e r y S t a t e and t e r r i t o r y had begun implementing t h e b l o c k g r a n t . 2. Current Authoritv F i f t e e n p e r c e n t o f t h e MCH b l o c k g r a n t a p p r o p r i a t i o n i n FY 1982, and between 10 and 15 p e r c e n t i n FY 1983 and FY 1984, i s r e t a i n e d a t t h e F e d e r a l l e v e l t o fund s p e c i a l p r o j e c t s , r e s e a r c h , t r a i n i n g and g e n e t i c d i s e a s e and h e m o p h i l i a programs. The r e m a i n d e r o f t h e a p p r o p r i a t i o n i s d i s t r i b u t e d among S t a t e s t o p r o v i d e s e r v i c e s . Each S t a t e r e c e i v e s a s h a r e o f funds equal t o t h e proportion i t received i n FY 1981 f o r t h e c o n s o l i d a t e d programs, e x c l u d i n g t h o s e i n t h e set-aside. S t a t e s must spend t h r e e S t a t e d o l l a r s f o r e v e r y f o u r Federal d o l l a r s received through t h e block g r a n t . Between 10 and 15 p e r c e n t o f t h e b l o c k g r a n t a p p r o p r i a t i o n i s r e s e r v e d f o r MCH p r o j e c t s o f r e g i o n a l and n a t i o n a l s i g n i f i c a n c e , r e s e a r c h and t r a i n i n g , and g e n e t i c d i s e a s e and h e m o p h i l i a programs. These programs a r e f e d e r a l l y a d m i n i s t e r e d . B. E l i g i b i l i t y Requirements 1. P r e v i o u s A u t h o r i t y . For FY 1981 and p r e v i o u s f i s c a l y e a r s , t i t l e V o f t h e S o c i a l S e c u r i t y Act a u t h o r i z e d S t a t e s t o u s e F e d e r a l f u n d s t o e x t e n d and improve h e a l t h s e r v i c e s f o r m o t h e r s and c h i l d r e n , " e s p e c i a l l y i n r u r a l a r e a s and i n a r e a s s u f f e r i n g from s e v e r e economic d i s t r e s s . ' ' N e i t h e r i n t h e law n o r i n F e d e r a l r e g u l a t i o n was income d e f i n e d , and e a c h S t a t e d e t e r m i n e d who was e l i g i b l e f o r m a t e r n a l and c h i l d h e a l t h s e r v i c e s . F e d e r a l r e g u l a t i o n s s t a t e d t h a t income s t a n d a r d s u s e d by t h e S t a t e s i n d e t e r m i n i n g e l i g i b i l i t y f o r t r e a t m e n t and i n s e t t i n g f e e s c h e d u l e s must c o n s i d e r f a m i l y s i z e and t h e f a m i l y ' s o t h e r f i n a n c i a l r e s p o n s i b i l i t i e s . I n o r d e r t o b e e n t i t l e d t o i t s a l l o t m e n t o f MCH f u n d s , Under e a c h S t a t e was r e q u i r e d t o p r o v i d e a "program o f p r o j e c t s . " t h i s program, S t a t e s had t o implement a p r o j e c t i n e a c h o f f i v e a r e a s : m a t e r n i t y and i n f a n t c a r e , c h i l d r e n and y o u t h , f a m i l y plann i n g d e n t a l h e a l t h , and i n t e n s i v e i n f a n t c a r e . 2. C u r r e n t A u t h o r i t y . For FY 1982 and s u b s e q u e n t f i s c a l y e a r s , S t a t e s a r e t o u s e F e d e r a l f u n d s t o a s s u r e m o t h e r s and c h i l d r e n , - p a r t i c u l a r l y t h o s e w i t h low income o r l i m i t e d a v a i l a b i l i t y of h e a l t h s e r v i c e s , a c c e s s t o q u a l i t y MCH s e r v i c e s . Low-income p e r s o n s a r e d e f i n e d a s i n d i v i d u a l s o r f a m i l i e s w i t h a n income below 100 p e r c e n t of t h e p o v e r t y l e v e l . 21 2 1 The 1984 F e d e r a l p o v e r t y g u i d e l i n e s were i s s u e d i n ~ e b r u a rby~ t h e Department of H e a l t h and Human S e r v i c e s , u s i n g t h e methodology o f t h e O f f i c e o f Management and Budget (OMB). F o r a f a m i l y o f f o u r , t h e g u i d e l i n e i s $10,200 i n 1984. C. Benefit Levels 1. P r e v i o u s A u t h o r i t y . For FY 1981 and p r e v i o u s f i s c a l y e a r s , S t a t e s determined t h e l e v e l o f s e r v i c e s . R e g u l a t i o n s 3 / d e f i n e d m a t e r n a l and c h i l d h e a l t h s e r v i c e s a s ( 1 ) t h e p r o v i s i % of e d u c a t i o n a l , p r e v e n t i v e , d i a g n o s t i c and t r e a t m e n t s e r v i c e s ; ( 2 ) t h e development, s t r e n g t h e n i n g and improvement o f s t a n d a r d s and t e c h n i q u e s r e l a t i n g t o s u c h s e r v i c e s and c a r e ; ( 3 ) t h e t r a i n i n g o f p e r s o n n e l engaged i n t h e p r o v i s i o n , development, s t r e n g t h e n i n g , o r improvement o f such s e r v i c e s and c a r e ; and ( 4 ) a d m i n i s t r a t i v e s e r v i c e s i n c o n n e c t i o n w i t h such s e r v i c e s and c a r e . 2. C u r r e n t A u t h o r i t y . For FY 1982 and subsequent f i s c a l y e a r s , S t a t e s d e t e r m i n e t h e l e v e l o f s e r v i c e s . The law f o r b i d s S t a t e s t o c h a r g e f e e s f o r s e r v i c e s provided t o p e r s o n s whose income i s below t h e p o v e r t y g u i d e l i n e . -3/ 42 C.F.R. S 51a. 1 0 1 ( j ) (19811, 5. INDIAN HEALTH SERVICES A. Funding Formula T h i s program i s 100 p e r c e n t funded by t h e F e d e r a l Government. B. E l i g i b i l i t y Requirements - Persons e l i g i b l e under r e g u l a t i o n s o f t h e P u b l i c H e a l t h S e r v i c e I / a r e persons of Indian ( o r Alaskan Native) d e s c e n t belonging t o t h e I n d i a n , A l e u t , o r Eskimo community s e r v e d by t h e l o c a l h e a l t h f a c i l i t i e s and program and t h e non-Indian w i v e s o f s u c h p e r s o n s . I n a d d i t i o n , a p e r s o n may be r e g a r d e d e l i g i b l e i f he i s r e g a r d e d a s an I n d i a n by t h e community i n which h e l i v e s . The program s e r v e s F e d e r a l r e s e r v a t i o n s , I n d i a n communities i n Oklahoma and C a l i f o r n i a , and I n d i a n , Eskimo, and A l e u t communities i n A l a s k a . I n a d d i t i o n , u n d e r t h e I n d i a n H e a l t h Care Improvement Act o f 1976, P.L. 94-437, t h e I n d i a n H e a l t h S e r v i c e c o n t r a c t s w i t h 37 u r b a n I n d i a n o r g a n i z a t i o n s t o make h e a l t h s e r v i c e s more a c c e s s i b l e t o t h e u r b a n I n d i a n p o p u l a t i o n . C. Benefit Levels The I n d i a n H e a l t h S e r v i c e o f t h e P u b l i c H e a l t h S e r v i c e p r o v i d e s h o s p i t a l , m e d i c a l , and d e n t a l c a r e . I n c l u d e d a r e o u t p a t i e n t s e r v i c e s and t h e s e r v i c e s o f m o b i l e c l i n i c s and p u b l i c h e a l t h n u r s e s , a s w e l l a s p r e v e n t i v e c a r e , i n c l u d i n g i m m u n i z a t i o n s and h e a l t h e x a m i n a t i o n s o f s p e c i a l g r o u p s , s u c h a s s c h o o l c h i l d r e n . A l l s e r v i c e s a r e provided f r e e of charge t o beneficiaries. B e n e f i t s i n c l u d e i n p a t i e n t and o u t p a t i e n t h e a l t h s e r v i c e s t h r o u g h 47 h o s p i t a l s and t h e i r o u t p a t i e n t d e p a r t m e n t s , 8 4 h e a l t h c e n t e r s ( i n c l u d i n g s c h o o l h e a l t h c e n t e r s ) , and 300 s m a l l h e a l t h s t a t i o n s and s a t e l l i t e c l i n i c s ; c o n t r a c t s w i t h non-Federal h o s p i t a l s , c l i n i c s , p r i v a t e p h y s i c i a n s and d e n t i s t s ; and c o n t r a c t u a l a r r a n g e m e n t s w i t h S t a t e and l o c a l h e a l t h o r g a n i z a t i o n s . FY83 program e x p e n d i t u r e s t o t a l l e d $679.2 m i l l i o n , up 12 perc e n t from t h e FY83 t o t a l o f $606.3 m i l l i o n . The a n n u a l number o f r e c i p i e n t s r o s e 10 p e r c e n t d u r i n g t h i s same t i m e , from a p p r o x i m a t e l y 750,000 t o a n e s t i m a t e d 883,000. A -1/ 42 C.F.R. § 36.12 (1983). 6. COMMUNITY HEALTH CENTERS A. Funding Formula Under s e c t i o n 330 o f t h e P u b l i c H e a l t h S e r v i c e (PHS) A c t , c e n t e r s a r e funded and a d m i n i s t e r e d by t h e F e d e r a l Government. S t a r t i n g i n FY 1983, S t a t e s have had t h e o p t i o n , u n d e r t h e author i t y o f t h e P r i m a r y C a r e Block G r a n t c r e a t e d by P.L. 97-35, t o a d m i n i s t e r t h e community h e a l t h c e n t e r s program t h e m s e l v e s . 11 Under t h i s o p t i o n , S t a t e s r e c e i v e b l o c k g r a n t a l l o t m e n t s basTd on t h e p r o p o r t i o n o f f u n d s awarded t o community h e a l t h c e n t e r s i n t h e S t a t e i n FY 1982. I n o r d e r t o b e e l i g i b l e f o r g r a n t s u n d e r t h i s b l o c k g r a n t , S t a t e s a r e r e q u i r e d t o match F e d e r a l f u n d s . F o r FY 1983, t h e m a t c h i n g r a t e i s 20 p e r c e n t o f a S t a t e ' s a l l o t m e n t ; f o r FY 1984 i t i s 33-113 p e r c e n t . I n S t a t e s which d o n o t c h o o s e t o a d m i n i s t e r t h i s b l o c k g r a n t t h e m s e l v e s , t h e F e d e r a l Government c o n t i n u e s t o a d m i n i s t e r t h e community h e a l t h c e n t e r s u n d e r t h e a u t h o r i t y o f s e c t i o n 330 o f t h e PHs Act. E l i g i b i l i t y Requirements S e c t i o n 330 o f t h e PHs Act p r o v i d e s s u p p o r t f o r t h e community h e a l t h c e n t e r s , a term t h a t i n c l u d e s family h e a l t h c e n t e r s , comuni t y h e a l t h n e t w o r k s , neighborhood h e a l t h c e n t e r s , and o t h e r s i m i l a r p r o j e c t s p r e v i o u s l y funded u n d e r t h e Economic O p p o r t u n i t y Act and o t h e r l a w s . The law makes e l i g i b l e f o r s e r v i c e a l l r e s i d e n t s o f an a r e a s e r v e d by a community h e a l t h c e n t e r , b u t r e g u l a t i o n s l i m i t f r e e s e r v i c e t o t h o s e w i t h f a m i l y income below CSA p o v e r t y guidelines. The law s a y s t h a t c e n t e r s s h o u l d b e l o c a t e d i n " m e d i c a l l y unders e r v e d " a r e a s , t o be d e s i g n a t e d by t h e s e c r e t a r y o f H e a l t h and Human S e r v i c e s (HHS). By r e g u l a t i o n , m e d i c a l l y u n d e r s e r v e d a r e a s a r e d e s i g n a t e d by t a k i n g i n t o c o n s i d e r a t i o n s u c h f a c t o r s a s : (1) r a t i o of primary c a r e p h y s i c i a n s t o p o p u l a t i o n , ( 2 ) i n f a n t m o r t a l i t y r a t e , 11 tion West V i r g i n i a and t h e V i r g i n I s l a n d s assumed a d r n i n i s t r a - of t h e b l o c k g r a n t i n FY 1983. ( 3 ) p e r c e n t a g e of p o p u l a t i o n aged 65 and o v e r , and ( 4 ) p e r c e n t a g e of p o p u l a t i o n w i t h f a m i l y income below t h e poverty l e v e l . 2/ - C, Benefit Levels PHS r e g u l a t i o n s 31 l i m i t f r e e s e r v i c e t o t h o s e w i t h f a m i l y income a t o r below t h e most r e c e n t CSA p o v e r t y income g u i d e l i n e s . The 1984 F e d e r a l p o v e r t y income g u i d e l i n e i s $10,200 f o r a f a m i l y of f o u r , p l u s o r minus $1,740 p e r person f o r b i g g e r o r s m a l l e r f a m i l y s i z e s ) . 41 Nominal f e e s may be c o l l e c t e d from such i n d i v i d u a l s and f a m i l i e s , under c e r t a i n c i r c u m s t a n c e s . I n d i v i d u a l s and f a m i l i e s w i t h annual incomes g r e a t e r than t h e p o v e r t y i n d e x b u t below 200 p e r c e n t of i t a r e r e q u i r e d t o pay f o r s e r v i c e s from a d i s c o u n t f e e s c h e d u l e adj u s t e d on t h e b a s i s of t h e p a t i e n t ' s a b i l i t y t o pay. F u l l payment, t o c o v e r r e a s o n a b l e c o s t s , i s r e q u i r e d from t h o s e w i t h income t h a t exceeds t w i c e t h e p o v e r t y l e v e l . - The c e n t e r s p r o v i d e a range o f primary h e a l t h s e r v i c e s on an ambul a t o r y b a s i s , i n c l u d i n g d i a g n o s t i c , t r e a t m e n t , p r e v e n t i v e , emergency, t r a n s p o r t a t i o n , and p r e v e n t i v e d e n t a l s e r v i c e s and can a r r a n g e and pay f o r h o s p i t a l and o t h e r supplemental s e r v i c e s i n c e r t a i n c i r c u m s t a n c e s i f approved by t h e S e c r e t a r y . FY83 c o s t s t o t a l l e d $360 m i l l i o n , up 11 p e r c e n t from t h e FY81 t o t a l o f $323.6 m i l l i o n . The annual number of r e c i p i e n t s dropped 10 p e r c e n t i n t h i s p e r i o d , from 5 m i l l i o n t o 4.5 m i l l i o n . -21 42 C.F.R. -31 42 C.F.R. § 51c. 102(e) (1983). § 51c. 3 0 3 ( f ) (1983). 4 / The 1984 g u i d e l i n e s were i s s u e d i n February by t h e ~ e ~ a r & e n of t H e a l t h , Education, and Welfare, u s i n g t h e methodology o f t h e O f f i c e o f Management and Budget (OMB). 7. MEDICAL ASSISTANCE TO REFUGEES AND CUBAN/HAITIAN ENTRANTS A. F u n d i n e Formula The Refugee Act (P.L. 96-212) a u t h o r i z e s 100 p e r c e n t f e d e r a l l y funded m e d i c a l a s s i s t a n c e f o r needy r e f u g e e s d u r i n g t h e i r f i r s t 3 y e a r s i n t h e U n i t e d S t a t e s . T i t l e V o f t h e Refugee E d u c a t i o n A s s i s t a n c e Act (P.L. 96-4221, p o p u l a r l y r e f e r r e d t o a s t h e F a s c e l l - S t o n e amendment, a u t h o r i z e s s i m i l a r a s s i s t a n c e f o r c e r t a i n Cubans and H a i t i a n s who h a v e r e c e n t l y e n t e r e d t h e U n i t e d S t a t e s . The F e d e r a l r e f u g e e a s s i s t a n c e program r e i m b u r s e s S t a t e s 100 p e r c e n t f o r t h e nonF e d e r a l s h a r e o f Medicaid payments t o r e f u g e e s and e n t r a n t s who q u a l i f y f o r t h a t program. I t a l s o p r o v i d e s " r e f u g e e m e d i c a l a s s i s t a n c e " t o needy r e f u g e e s and e n t r a n t s who a r e n o t c a t e g o r i c a l l y e l i g i b l e f o r Medicaid. M e d i c a l a s s i s t a n c e t o r e f u g e e s and e n t r a n t s i s a u t h o r i z e d t h r o u g h FY 1984. B. E l i g i b i l i t y Requirements -11 A p e r s o n must ( a ) h a v e b e e n a d m i t t e d t o t h e U.S. a s a r e f u g e e under p r o v i s i o n s o f t h e I m m i g r a t i o n and N a t i o n a l i t y A c t , o r ( b ) be a Cuban o r H a i t i a n p a r o l e d i n t o t h e U n i t e d S t a t e s between A p r i l 10 and O c t o b e r 1 0 , 1980, and d e s i g n a t e d " C u b a n l H a i t i a n e n t r a n t , " o r ( c ) b e a Cuban o r H a i t i a n n a t i o n a l who a r r i v e d i n t h e U.S. a f t e r O c t o b e r 1 0 , 1980, who h a s an a p p l i c a t i o n f o r asylum pending o r i s s u b j e c t t o e x c l u s i o n o r d e p o r t a t i o n and a g a i n s t whom a f i n a l o r d e r o f d e p o r t a t i o n h a s n o t been i s s u e d . I f a needy r e f u g e e o r e n t r a n t i s e l i g i b l e f o r M e d i c a i d , h e may r e c e i v e a s s i s t a n c e u n d e r t h a t program. I f a r e f u g e e o r e n t r a n t m e e t s t h e income and a s s e t s t e s t s p r e s c r i b e d by h i s S t a t e o f r e s i dence f o r medicaid e l i g i b i l i t y b u t does not otherwise q u a l i f y f o r t h a t program b e c a u s e o f i t s c a t e g o r i c a l r e q u i r e m e n t s , t h e r e f u g e e o r e n t r a n t i s e l i g i b l e f o r "refugee medical assistance." E f f e c t i v e A p r i l 1, 1981, o n l y r e f u g e e s o r e n t r a n t s i n t h e U.S. 3 years o r l e s s q u a l i f y f o r fully-reimbursed medical a s s i s t a n c e . E f f e c t i v e A p r i l 1, 1982, t h e s p e c i a l " r e f u g e e m e d i c a l a s s i s t a n c e " made a v a i l a b l e t o t h o s e r e f u g e e s and e n t r a n t s c a t e g o r i c a l l y i n e l i g i b l e f o r m e d i c a i d e n d s 18 months a f t e r t h e r e f u g e e o r e n t r a n t ' s e n t r y 11 R e g u l a t i o n s g o v e r n i n g t h i s program a r e found i n 45 C.F.R: 400-401. i n t o t h e U.S. F o r t h e n e x t 18 months S t a t e s c a n b e r e i m b u r s e d f o r any m e d i c a l a s s i s t a n c e p r o v i d e d t o a r e f u g e e o r e n t r a n t u n d e r a S t a t e o r l o c a l g e n e r a l a s s i s t a n c e program. Income l i m i t s f o r GA a r e g e n e r a l l y lower t h a n f o r m e d i c a i d and s e r v i c e s may b e l e s s extensive. C. Benefit Levels Medical b e n e f i t s c o n s i s t o f payments made on b e h a l f o f needy r e f u g e e s t o d o c t o r s , h o s p i t a l s , and p h a r m a c i s t s . F e d e r a l law r e q u i r e s S t a t e Medicaid programs t o o f f e r c e r t a i n b a s i c s e r v i c e s , b u t a u t h o r i z e s S t a t e s t o d e t e r m i n e t h e s c o p e o f s e r v i c e s and reimbursement r a t e s , e x c e p t f o r h o s p i t a l c a r e . 8. MIGRANT HEALTH CENTERS A. Funding Formula The c e n t e r s a r e funded 100 p e r c e n t by t h e F e d e r a l Government. B. E l i g i b i l i t y Requirements S e c t i o n 329 of t h e PHs Act a u t h o r i z e s g r a n t s t o s u p p o r t migrant h e a l t h c e n t e r s . E l i g i b l e f o r s e r v i c e s a r e b ~ t hm i g r a t o r y farm workers and t h e i r f a m i l i e s (and former m i g r a t o r y a g r i c u l t u r a l workers who a r e aged o r d i s a b l e d ) and s e a s o n a l farm workers. The law d e f i n e s "migrat o r y farm worker1' a s a person whose p r i n c i p a l employment i s i n a g r i c u l t u r e on a s e a s o n a l b a s i s , who h a s been s o employed w i t h i n t h e l a s t 2 y e a r s , and who e s t a b l i s h e s a temporary abode f o r t h e purpose of t h i s work. "Seasonal farm worker" i s d e f i n e d a s a person whose p r i n c i p a l employment i s i n a g r i c u l t u r e on a s e a s o n a l b a s i s and who i s n o t a m i g r a t o r y a g r i c u l t u r e worker. C e n t e r s a r e t a r g e t e d t o s e r v i c e ''high migrant impact1' a r e a s , which a r e c o u n t i e s o r o t h e r p o l i t i c a l s u b d i v i s i o n s o f a S t a t e i n which a t l e a s t 4,000 m i g r a t o r y farm workers and members of t h e i r f a m i l i e s and/ o r s e a s o n a l workers and t h e i r f a m i l i e s l i v e f o r more than 2 months i n a c a l e n d a r y e a r . I n f i s c a l y e a r 1981 m i g r a n t h e a l t h c e n t e r s s e r v e d 557,000 persons, o f whom 368,000 were m i g r a n t s and 189,000 were seas o n a l farm workers. C. Benefit Levels PHs r e g u l a t i o n s 1 1 l i m i t f r e e s e r v i c e t o t h o s e w i t h f a m i l y income a t o r below t h e most r e c e n t Community S e r v i c e A d m i n i s t r a t i o n (CSA) poverty income g u i d e l i n e s . 2/ The 1984 F e d e r a l p o v e r t y income g u i l d e l i n e i s $9,900 f o r a f a m i l y o £ f o u r , p l u s o r minus $1,740 p e r person f o r b i g g e r o r s m a l l e r f a m i l y s i z e s . Nominal f e e s may be c o l l e c t e d from such i n d i v i d u a l s and f a m i l i e s . I n d i v i d u a l s and famil i e s w i t h annual incomes g r e a t e r t h a n t h e p o v e r t y i n d e x b u t below 200 p e r c e n t o f i t a r e r e q u i r e d t o pay f o r s e r v i c e s from a d i s c o u n t f e e -1/ 42 C.F.R. S 56.303(£)(1983). 2/ The 1984 F e d e r a l poverty g u i d e l i n e s were i s s u e d i n ~ e b r u ' ; ; r ~by t h e Department of H e a l t h and Human S e r v i c e s , u s i n g t h e methodology of t h e O f f i c e of Management and Budget (OMB). s c h e d u l e a d j u s t e d on t h e b a s i s o f t h e p a t i e n t ' s a b i l i t y t o pay. F u l l payment, t d c o v e r r e a s o n a b l e c o s t s , i s r e q u i r e d from t h o s e w i t h i n come t h a t e x c e e d s t w i c e t h e p o v e r t y l e v e l . The c e n t e r s p r o v i d e p r i m a r y h e a l t h c a r e s e r v i c e s , i n c l u d i n g d i a g n o s t i c , t h e r a p e u t i c , p r e v e n t i v e , and emergency s e r v i c e s . The law s t i p u l a t e s t h a t p r e v e n t i v e c a r e i n c l u d e s c h i l d r e n ' s e y e and e a r examinat i o n s and d e n t a l c a r e f o r a l l g r o u p s . The c e n t e r s h a v e a l s o d e v e l o p e d " l i n k a g e s " w i t h o t h e r programs, s u c h a s t h e Department o f A g r i c u l t u r e ' s Women, I n f a n t and C h i l d r e n (WIG) n u t r i t i o n program and A l c o h o l , Drug Abuse, and Mental H e a l t h A d m i n i s t r a t i o n p r o j e c t s . F i s c a l y e a r 1983 c o s t s t o t a l l e d $38.1 m i l l i o n , down 11.8 perc e n t from t h e f i s c a l y e a r 1981 t o t a l o f $43.2 m i l l i o n . I n f i s c a l y e a r 1983, a n n u a l r e c i p i e n t s t o t a l l e d 394,000. 9. MEDICAL ASSISTANCE TO CERTAIN CUBAN REFUGEES A. Funding Formula The Migration and Refugee A s s i s t a n c e Act of 1962 a u t h o r i z e d F e d e r a l reimbursement f o r t h e c o s t s o f p r o v i d i n g m e d i c a l a s s i s t a n c e t o needy Cuban r e f u g e e s . The Refugee Act o f 1980 r e p e a l e d t h i s a u t h o r i t y and phased o u t F e d e r a l c o s t s h a r i n g by s t a g e s , e n d i n g on September 30, 1981. However, t h e Refugee Act a u t h o r i z e d t h e i n d e f i n i t e c o n t i n u a t i o n o f 100 p e r c e n t F e d e r a l reimbursement f o r t h e non-Federal s h a r e o f t h e c o s t s of Medicaid f o r aged, b l i n d , o r d i s a b l e d Cuban r e f u g e e s whose Medicaid e n t i t l e m e n t i s a r e s u l t o f t h e i r e n r o l l m e n t i n t h e Supplemental S e c u r i t y Income (SSI) program. The phased-out reimbursements were f o r t h e non-Federal s h a r e o f Medicaid b e n e f i t s t o Cuban r e f u g e e s r e c e i v i n g c a s h a s s i s t a n c e o t h e r than SSI under t h e Cuban r e f u g e e program, and f o r S t a t e a d m i n i s t r a t i v e c o s t s . The r a t e s of F e d e r a l reimbursements f o r t h o s e c o s t s were a s f o l l o w s : FY 1979, 85 p e r c e n t ; FY 1980, 75 p e r c e n t ; FY 1981, 60 p e r c e n t . B. E l i g i b i l i t y Requirements C u r r e n t l y , o n l y t h o s e Cuban r e f u g e e s who r e c e i v e d SSI payments a s of September 30, 1978 and c o n t i n u e t o r e c e i v e t h e s e benef i t s a r e e l i g i b l e . Before FY 1982, Cuban r e f u g e e s who were rec e i v i n g o t h e r c a s h a i d under t h e Cuban r e f u g e e program b e f o r e October 1 , 1978, were a l s o e l i g i b l e . C. Benefit Levels Medical b e n e f i t s c o n s i s t o f payments made on b e h a l f o f needy ref u g e e s t o d o c t o r s , h o s p i t a l s , and p h a r m a c i s t s . F e d e r a l law r e q u i r e s S t a t e Medicaid programs t o o f f e r c e r t a i n b a s i c s e r v i c e s , b u t author i z e s S t a t e s t o d e t e r m i n e t h e scope o f s e r v i c e s and reimbursement r a t e s , except f o r h o s p i t a l care. 10. CRIPPLED CHILDREN'S SECURITY ACT 11 A. SERVICES, TITLE v OF THE SOCIAT, Funding Formula 1. P r e v i o u s A u t h o r i t y . F o r FY 1981 and p r e v i o u s f i s c a l y e a r s , a b o u t 90 p e r c e n t o f t h e t i t l e V a p p r o p r i a t i o n was r e q u i r e d t o b e made a v a i l a b l e f o r MCH and CC s e r v i c e s , w i t h t h e r e m a i n d e r d e s i g n a t e d f o r r e s e a r c h and t r a i n i n g a c t i v i t i e s . G r a n t f u n d s f o r CC s e r v i c e s were d i v i d e d i n t o two h a l v e s , c a l l e d Fund A and Fund B. Fund A was a p p o r t i o n e d among t h e S t a t e s i n a c c o r d a n c e w i t h c r i t e r i a i n t h e l a w and r e q u i r e d S t a t e m a t c h i n g , d o l l a r f o r d o l l a r . Each f i s c a l y e a r a S t a t e r e c e i v e d from Fund A a g r a n t o f $70,000, p l u s t h a t p o r t i o n o f t h e r e m a i n d e r o f Fund A which e q u a l l e d i t s proport i o n a t e s h a r e o f t h e number o f c h i l d r e n u n d e r 21 i n t h e U n i t e d S t a t e s . No S t a t e m a t c h i n g was r e q u i r e d f o r Fund B. I n each f i s c a l y e a r , $10 m i l l i o n was a l l o c a t e d from Fund B t o S t a t e s and i n s t i t u t i o n s o f h i g h e r l e a r n i n g f o r e s t a b l i s h m e n t o f p r o j e c t s t o s e r v e ment a l l y r e t a r d e d c r i p p l e d c h i l d r e n . Of t h e r e m a i n d e r , a t l e a s t 75 p e r c e n t was a l l o c a t e d t o S t a t e s on t h e b a s i s o f S t a t e p e r c a p i t a income and t h e number o f c h i l d r e n u n d e r 21, w i t h r u r a l c h i l d r e n g i v e n t w i c e t h e w e i g h t o f u r b a n c h i l d r e n . These f u n d s were i n t e n d e d t o a s s i s t S t a t e s i n c a r r y i n g o u t t h e i r S t a t e p l a n s . The r e m a i n i n g 25 p e r c e n t o r l e s s , known g e n e r a l l y a s "Reserve B" o r "RB" f u n d s , were r e t a i n e d a t t h e F e d e r a l l e v e l f o r d i s c r e t i o n a r y g r a n t s f o r special projects of regional o r national significance. 2. Current Authority For FY 1982 and l a t e r y e a r s between 85 and 90 p e r c e n t o f t h e MCH b l o c k g r a n t a p p r o p r i a t i o n i s a l l o t t e d among S t a t e s b a s e d on 1/ P.L. 97-35, t h e Omnibus Budget R e c o n c i l i a t i o n Act o f 1981, c o n s o i i d a t e d t h e MCH and CC programs i n t o an HCM b l o c k g r a n t w i t h t h e f o l l o w i n g o t h e r c a t e g o r i c a l programs: s e r v i c e s f o r d i s a b l e d c h i l d r e n e n r o l l e d i n t h e Supplemental S e c u r i t y Income program, lead-based p a i n t p o i s o n i n g p r e v e n t i o n , g e n e t i c d i s e a s e s , s u d d e n t i n f a n t d e a t h syndrome, h e m o p h i l i a t r e a t m e n t c e n t e r s , and t h e a d o l e s c e n t pregnancy program. E f f e c t i v e O c t . 1, 1981, S t a t e s c o u l d b e g i n a d m i n i s t e r i n g MCH b l o c k g r a n t s . P.L. 97-35 a l s o p r o v i d e d t h a t t h e S e c r e t a r y o f H e a l t h and Human S e r v i c e s would c o n t i n u e m a t c h i n g g r a n t s u n d e r e x i s t i n g programs u n t i l a S t a t e assumed a u t h o r i t y f o r t h e MCH b l o c k g r a n t , b u t s t i p u l a t e d t h a t S t a t e s must d o s o b e f o r e Oct. 1, 1982. A s o f August 1982, e v e r y S t a t e and t e r r i t o r y had begun implementing t h e b l o c k g r a n t . t h e S t a t e ' s p r o p o r t i o n o f t o t a l funds a l l o t t e d t o a l l S t a t e s i n FY 1981 under c e r t a i n c a t e g o r i c a l programs now i n c l u d e d i n t h e b l o c k . These c a t e g o r i c a l programs i n c l u d e m a t e r n a l and c h i l d h e a l t h and c r i p p l e d c h i l d r e n ' s s e r v i c e s , s u p p l e m e n t a l s e c u r i t y income s e r v i c e s f o r d i s a b l e d c h i l d r e n , lead-based p a i n t p o i s o n i n g p r e v e n t i o n programs, g e n e t i c d i s e a s e , sudden i n f a n t d e a t h syndrone, hemophilia t r e a t m e n t c e n t e r s , and a d o l e s c e n t pregnancy. S t a t e s must spend t h r e e S t a t e d o l l a r s f o r e v e r y f o u r F e d e r a l d o l l a r s r e c e i v e d through t h e b l o c k g r a n t . Between 10 and 15 p e r c e n t o f t h e b l o c k g r a n t a p p r o p r i a t i o n i s r e s e r v e d f o r MCH p r o j e c t s o f r e g i o n a l and n a t i o n a l s i g n i f i c a n c e , r e s e a r c h and t r a i n i n g , and g e n e t i c d i s e a s e and h e m o p h i l l a programs. These programs a r e a d m i n i s t e r e d a t t h e F e d e r a a l l e v e l . B. E l i g i b i l i t y Requirements 1. P r e v i o u s A u t h o r i t y . For FY 1981 and p r e v i o u s f i s c a l y e a r s , t i t l e V of t h e S o c i a l S e c u r i t y Act a u t h o r i z e d S t a t e s t o u s e F e d e r a l funds t o e x t e n d and improve s e r v i c e s t o c r i p p l e d c h i l d r e n " e s p e c i a l l y i n r u r a l a r e a s and i n a r e a s s u f f e r i n g from s e v e r e economic d i s t r e s s . " Regulations defined a c r i p p l e d c h i l d a s one under 21 y e a r s o f age, "who h a s an o r g a n i c d i s e a s e , d e f e c t , o r c o n d i t i o n 21 which may h i n d e r t h e achievement of normal growth o r development. l1 D i a g n o s t i c s e r v i c e s had t o b e provided w i t h o u t any e l i g i b i l i t y r e q u i r e m e n t s . S t a t e s determined who r e c e i v e d a i d . 2. C u r r e n t A u t h o r i t y . For FY 1981 and subsequent f i s c a l y e a r s , S t a t e s a r e t o u s e F e d e r a l funds t o a s s y r e mothers and c h i l d r e n , p a r t i c u l a r l y t h o s e w i t h low income o r l i m i t e d a v a i l a b i l i t y of h e a l t h s e r v i c e s , a c c e s s t o q u a l i t y MCH s e r v i c e s . The Act d e f i n e s low income p e r s o n s a s i n d i v i d u a l s o r f a m i l i e s w i t h an income below 100 p e r c e n t o f t h e p o v e r t y l e v e l . 3 C. Benefit Levels 1. P r e v i o u s A u t h o r i t y . F e d e r a l law and DHHS r e g u l a t i o n s d e s c r i b e d t y p e s o f s e r v i c e s t h a t c o u l d b e provided. G r a n t s were used f o r l o c a t i n g c r i p p l e d c h i l d r e n and p r o v i d i n g m e d i c a l , s u r g i c n l , c o r r e c t i v e , and o t h e r s e r v i c e s f o r d i a g n o s i s , h o s p i t a l i z a t i o n , and -21 42 C.F.R. 8 51a. 1 0 1 ( f ) (1981). 3/ The 1984 F e d e r a l p o v e r t y g u i d e l i n e s were i s s u e d i n ~ e b r u % by ~ t h e Department of H e a l t h and Human S e r v i c e s , u s i n g t h e methodology o f t h e O f f i c e of Management and Budget (OMB). F o r a f a m i l y o f f o u r , t h e g u i d e l i n e i s $10,200 i n 1984. a f t e r c a r e f o r such c h i l d r e n . S t a t e s d e c i d e d t h e l e v e l o f s e r v i c e s . R e g u l a t i o n s d e f i n e d c r i p p l e d c h i l d r e n s e r v i c e s a s : (1) t h e e a r l y l o c a t i o n o f c r i p p l e d c h i l d r e n ; ( 2 ) t h e p r o v i s i o n f o r such c h i l d r e n of p r e v e n t i v e , d i a g n o s t i c and t r e a t m e n t s e r v i c e s ; ( 3 ) t h e development, s t r e n g t h e n i n g and improvement o f s t a n d a r d s and t e c h n i q u e s r e l a t i n g t o such c a r e and s e r v i c e s ; ( 4 ) t h e t r a i n i n g o f p e r s o n n e l engaged i n t h e p r o v i s i o n , development, s t r e n g t h e n i n g , o r improvement o f such c a r e and s e r v i c e s ; and ( 5 ) a d m i n i s t r a t i v e s e r v i c e s i n conn e c t i o n w i t h such c a r e and s e r v i c e s . 51 2. Current Authority. S t a t e s determine t h e l e v e l of s e r v i c e s . The law f o r b i d s S t a t e t o c h a r g e f e e s f o r s e r v i c e s provided t o p e r s o n s whose income i s below [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3A84-99EPW. Public record. Not legal advice.