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Entitlements

Federal Funding Primer: Entitlements

Entitlements are a mechanism of federal funding provided based on the needs of eligible individuals, generally in the form of reimbursement to states, territories, tribes, and localities, with no cap on the total amount that can be spent.

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Medicaid

Department: U.S. Department of Health and Human Services (HHS)
Agency: Centers for Medicare & Medicaid Services (CMS)

Overview

Medicaid is a joint federal-state program that provides health coverage to individuals and families with low incomes, including children, pregnant individuals, older adults, and individuals with disabilities. It serves as the primary source of coverage for health, dental, and behavioral health services for children in the foster care system. Kin caregivers who are caring for children outside of the foster care system may also qualify for Medicaid based on their income, or the children they care for may be eligible independently.

Beyond covering traditional health care services, Medicaid offers opportunities for community-based organizations to develop and expand supportive services that address the broader needs of families, particularly kin caregivers. Community-based organizations can leverage Medicaid funds to provide preventive and supportive services that help stabilize families, improve child well-being, and reduce the need for more intensive interventions.

Eligible Services

Under the Medicaid program, there are a number of mandatory services that must be covered, including in- and out-patient hospitalizations, physicians, lab and x-ray services, home health, and nursing facilities. Children under 21 must also be provided Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) programs. EPSDT covers a wide range of preventative, diagnostic, and treatment services, including developmental assessments; vision, dental, and hearing services; and any other services deemed medically necessary.

Additionally, states can choose to offer a range of optional medical and specialized health care services, including psychological and behavioral health services, case management, personal care services, and non-emergency medical transportation to and from Medicaid-covered services. 

States also have several options for providing additional services that are not typically covered under the standard Medicaid program, including the use of Medicaid waivers and “in lieu of services” (ILOS), which offer greater flexibility to address the specific needs of their populations.

Medicaid Waivers

Through waivers, states can offer a broader range of home- and community-based services (HCBS) and implement innovative practices. Under the Section 1915(c) Home and Community-Based Services Waiver, states can provide services such as personal care, respite care, case management, and home modifications to individuals with disabilities or chronic conditions. Similarly, Section 1115 waivers give the option to test new practices in Medicaid that can include innovative services or coverage expansions. These waivers are essential tools for tailoring Medicaid services to support family caregivers, including kin caregivers, and to enhance the overall effectiveness of Medicaid in promoting health and well-being.

In Lieu of Services

States that operate through a managed care model (see below) can cover certain non-traditional services as a substitute for standard Medicaid services if the alternative services are expected to achieve the same or better outcomes at a lower cost. These services, called “in lieu of services” (ILOS), are particularly important for addressing social determinants of health and providing holistic, community-based support that goes beyond traditional medical care. ILOS can include non-standard services like housing support, transportation, nutrition assistance, and peer support that are approved by the state Medicaid agency. For example, instead of covering only hospital stays for chronic conditions, a managed care organization might fund home visits or health education classes that prevent hospitalizations.

For community-based organizations, the ILOS option presents an opportunity to deliver innovative, non-medical services that address the underlying causes of poor health. By establishing effective partnerships, organizations can play a key role in delivering these services, potentially reducing health care costs while improving outcomes for Medicaid beneficiaries.

All services must be provided by Medicaid-enrolled providers.

How Funds are Distributed

Medicaid funding is provided through a federal-state partnership, with the federal government reimbursing states for a portion of their Medicaid expenditures. While the program is administered federally, it is implemented by state Medicaid agencies, which are responsible for determining eligibility, processing claims, and overseeing service delivery within their respective states.

States submit state plans and plan amendments to the federal Centers for Medicare & Medicaid Services (CMS) for approval, detailing how they will administer their Medicaid programs. State Medicaid systems fall under one of two finance and delivery methods or a combination of both.

Fee-for-service (FFS) programs are directly administered by the state, which contracts directly with providers and pays them for covered services. States reimburse providers based on predetermined rates for each individual service they deliver. In most circumstances, any provider that is licensed by the state can form an agreement with the state Medicaid agency to provide services.

When a provider delivers a Medicaid-approved service under the FFS model, they submit a claim directly to the state Medicaid agency. The state reviews and pays the provider based on predetermined rates for each service rendered. After payment, the state submits a claim to CMS for federal reimbursement, which is provided based on the Federal Medical Assistance Percentage (FMAP).

Managed care programs operate through state contracts with managed care organizations (MCOs) to deliver services. MCOs can be geographically based or focused on specific population. Services are delivered by a closed network of providers and organizations that contract directly with the MCO. Payments are provided on a per-person basis over a given period of time for a defined scope of benefits, rather than on a per-service basis. MCOs have greater flexibility in how they deliver care, including innovative approaches like care coordination and integration of social services with health care.

Under an MCO model, a contracted provider submits a claim to the MCO, which pays the provider according to the terms of their contract. The state reimburses the MCO through a fixed, per-member-per-month payment and submits a claim to CMS for federal reimbursement based on the FMAP for the payments made to the MCO.

The FMAP varies by state and is based on a formula that considers per capita income levels. Under statute the FMAP rate ranges from 50-83%.

There is no fixed federal funding limit, as Medicaid operates as an entitlement program, meaning the amount of federal investment increases along with state spending. However, states must meet certain federal requirements to receive matching funds. States must contribute a portion of the funding and may blend or braid Medicaid funds with other funding streams to provide comprehensive services. Medicaid operates differently in every state, with variations in covered services, eligible beneficiaries, and provider networks. Organizations interested in providing services should work to understand their state’s systems.

Where to Find More Information

Note

Kinship service providers can contract with state Medicaid offices to provide covered mental and behavioral health care, case management, or non-emergency medical transportation services. In a managed care system, kinship service providers can work with Medicaid agencies to provide a wider range of ILOS programs and services.

A major limitation for entities seeking to access Medicaid funds to provide services to kinship families is the complexity of Medicaid reimbursement requirements. One service provider spoken to during the development of this primer noted that while their organization was approved to bill Medicaid, not having dedicated staff for billing meant they needed to forgo Medicaid reimbursement.

Example

In North Carolina, therapeutic foster care, including kinship therapeutic foster care, is a covered behavioral health service under Medicaid. Private child welfare placement agencies can bill Medicaid for these services, through their local Managed Care Organization.

SNAP Outreach

Department: U.S. Department of Agriculture (USDA)
Agency: Food and Nutrition Service (FNS)

Overview

The Supplemental Nutrition Assistance Program (SNAP) outreach program is a federal initiative designed to increase awareness of and participation in SNAP, particularly among underserved and eligible populations who may not be currently enrolled. The program provides funding to state agencies and their local government and nonprofit partners to conduct outreach activities. These activities aim to educate the public about SNAP benefits, eligibility criteria, and the application process, thereby reducing barriers to access and ensuring that more individuals and families receive the nutritional support they need.

The Food and Nutrition Service has explicitly named kinship families as a priority area for SNAP outreach in both FY2024 and FY2025.

Eligible Services

Funds from SNAP outreach can be used to support activities aimed at increasing SNAP participation. These services may include:

  • Education: Implementing targeted outreach programs to educate underserved households, particularly those in groups with low participation, about SNAP benefits, eligibility, and the application process
  • Application Assistance: Providing direct support to individuals and families who need help completing the SNAP application, whether through in-person assistance, phone support, or online resources

Since the passage of the Agricultural Act of 2014, states and community-based providers have been prohibited from using SNAP outreach funds for activities to persuade individuals to apply for SNAP; for television, radio, or billboard advertising; or for agreements with foreign governments.

How Funds are Distributed

Funds for SNAP outreach are distributed through a cost-sharing model. To be eligible to receive SNAP outreach funds, state agencies must submit an outreach plan annually, detailing goals, action steps, timelines, and evaluation measures. States are required to name any community organizations they will partner with and the activities those organizations will undertake. Activities performed by organizations that are not included in the state’s SNAP outreach plan will not be eligible for outreach funds.

Following approval of a state SNAP outreach plan, the federal government will reimburse up to 50% of expenses for allowable activities. States and their local government and nonprofit partners use a variety of public and private funds to cover the remainder of the costs.

Where to Find More Information

For more information about SNAP outreach, interested individuals and entities should look to:

Example

Organizations that specialize in serving kinship families should contact their local SNAP offices to establish partnerships to educate and assist kinship families in accessing SNAP. The University of Minnesota Extension partners with its state Department of Children, Youth, and Families to spread the word about SNAP and offer healthy cooking and eating programs for families. Note how the Extension’s brochure about its SNAP services talks about “families,” rather than parents.  The of inclusive language is very important in reaching kin caregivers who often do not see themselves in the word “parent.”

Title IV-E Administrative

Department: U.S. Department of Health and Human Services (HHS)
Agency: Administration for Children and Families (ACF)

Overview

Title IV-E of the Social Security Act authorizes open-ended federal reimbursement for foster care, adoption assistance, kinship guardianship assistance, certain prevention activities, and qualified kinship navigator program activities. Although this funding stream primarily provides reimbursement for direct funding to families while in foster care and exiting to subsidized adoption and kinship guardianship, states, territories, and tribes can also claim title IV-E funds for allowable costs related to the effective running of their title IV-E programs. 

Eligible Services

The majority of the allowable costs that states, territories, and tribes can claim relate to case planning, referral, administration, data collection, overhead, and case management activities. However, ACF has made clear that certain services provided for children in foster care, children who are candidates for foster care, and their families and caregivers are also eligible for title IV-E administrative funds.

Certain allowable expenses that are considered necessary to effectively conduct the title IV-E program can be reimbursed, such as the provision of legal representation to all parties and kin caregivers, services to help families access the title IV-E prevention program, and fingerprinting services for the purpose of licensure.

Legal Representation

Title IV-E agencies have the option to claim reimbursement for administrative costs related to independent legal representation provided by an attorney who is representing:

  • A child in title IV-E foster care;
  • A child who is a candidate for title IV-E foster care;
  • The child’s parent(s);
  • The child’s relative caregiver(s); or
  • The child’s Indian custodian(s) [An “Indian custodian” is defined in statute as “any Indian person who has legal custody of an Indian child under tribal law or custom or under State law or to whom temporary physical care, custody, and control has been transferred by the parent of such child”].

These services can be provided for foster care and other civil legal proceedings that are deemed necessary for the operation of the title IV-E foster care program. ACF has declined to specify all civil legal proceedings that are eligible for title IV-E administrative reimbursement. However, it did enumerate several forms of civil legal representation that are eligible when necessary to support a child’s case plan, including preparing for or participating in legal services to:

  • Advocate with a housing authority to help a family or a youth aging out of foster care secure a housing voucher;
  • Appeal a denial of a housing voucher;
  • Sue a landlord whose housing has unsafe conditions;
  • Secure public benefits;
  • Help a victim of family violence obtain an order of protection against the abuser to maintain or secure custody of their child(ren);
  • Establish custody or guardianship; and
  • Enroll a child in school or access education records.

These services are only eligible in cases in which they are necessary to effectively administer the title IV-E foster care program.

Costs of legal representation include such costs as necessary to support an attorney in providing legal representation to prepare for and participate in legal proceedings, including wages for paralegals, investigators, peer partners, or social workers that support an attorney, as well as wages for office support staff and overhead expenses. ACF has declined to provide a list of all allowable legal activities, as it would not be possible to list all activities that can be claimed.

Title IV-E Prevention Program Administrative Costs

Title IV-E agencies can also claim administrative funds for costs related to the proper and efficient administration of the title IV-E prevention program. In addition to costs related to program management, data collection and reporting, evaluation, and policy development, the title IV-E agency may claim administrative costs for child-specific allowable activities necessary to ensure families can utilize title IV-E prevention services and programs, including:

  • Outreach to provide information, coordinate services, and connect families with resources;
  • Child care to facilitate a parent’s or kin caregiver’s participation in the provision of prevention services;
  • Transportation support, including bus passes, rideshares, gas cards, and community partner-provided transportation to services and related appointments; and
  • Peer navigation programs provided as part of case management to support participation in a title IV-E prevention program or service.

These costs must be claimed in accordance with a title IV-E prevention plan.

Fingerprinting

New guidance published in the Child Welfare Policy Manual in July 2024 clarified that title IV-E administrative funds can be used to pay for services related to fingerprinting families for the purposes of foster care licensure. Costs related to fingerprinting kin caregivers, including purchasing fingerprinting equipment, will be reimbursed at a 50% rate and training related to fingerprinting will be reimbursed at a 75% rate, allowing kin-serving organizations to receive funding for services to help kin caregivers become licensed. See Child Welfare Policy Manual, 8.1B  TITLE IV-E, Administrative Functions/Costs, Allowable Costs – Foster Care Maintenance Payments Program, Q/A #33.

How Funds are Distributed

Title IV-E administrative payments are claimed as part of the title IV-E entitlement. Eligible child welfare agencies make quarterly claims for federal reimbursement based on incurred expenditures. While legal representation and prevention programs and services are allowable expenses, they are optional, and not all title IV-E agencies will opt to undertake these activities.

Title IV-E agencies may contract with public and private entities, including other agencies, community-based organizations, and individuals to perform administrative functions of the title IV-E program.

The federal financial participation rate for title IV-E administrative costs is 50%.

Where to Find More Information

For more information about Title IV-E Administrative funding, interested individuals and entities should look to:

  • Administration for Children and Families (ACF): Detailed information and relevant guidance is available at acf.hhs.gov.
  • Implementing the Family First Prevention Services Act: A comprehensive question-and-answer guide to the Family First Prevention Services Act and the title IV-E kinship navigator program is available at grandfamilies.org/Portals/0/Documents/FFPSA/FFPSA%20Guide.pdf.
  • Child Welfare Policy Manual: Detailed questions and answers about federal child welfare policy, including title IV-E administrative costs, is available at acf.hhs.gov/cwpm.

Note

Flexibility to utilize title IV-E administrative funds for services to help families access prevention services was only clarified in July 2024. Organizations interested in providing these services may consider informing the local child welfare agency of these new flexibilities.

Title IV-E Kinship Navigator Program

Department: U.S. Department of Health and Human Services (HHS)
Agency: Administration for Children and Families (ACF)

Overview

The title IV-E kinship navigator program, established under the Family First Prevention Services Act (FFPSA), is a federal initiative designed to support kin caregivers—including caregivers formally involved in the child welfare system and those caring for children without that system’s involvement—in learning about and accessing resources and supports that are available in their communities. The program provides funding to title IV-E agencies in states, tribes, and territories for certain evidence-based kinship navigator programs. This funding is in addition to the jurisdiction’s existing title IV-E funding and will not take away from existing priorities.

Eligible Services

Title IV-E agencies can access title IV-E kinship navigator program funding to support kinship navigator programs that have been found by the Title IV-E Prevention Services Clearinghouse to have met their evidence-based standards. The programs must also adhere to requirements enumerated in the Social Security Act by:

  • Coordinating with other State or local agencies that promote service coordination or provide information and referral services, including the entities that provide 2–1–1 or 3–1–1 information systems, where available, to avoid duplication or fragmentation of services to kinship families
  • Planning and operating their services in consultation with kin caregivers and organizations representing them, youth raised by kin caregivers, relevant government agencies, and relevant community-based or faith-based organizations
  • Establishing information and referral systems that link (via toll-free access) kin caregivers, kinship support group facilitators, and kinship service providers to
    • Each other
    • Eligibility and enrollment information for Federal, State, and local benefits
    • Relevant training to assist kin caregivers in caregiving and in obtaining benefits and services
    • Relevant legal assistance and help in obtaining legal services
  • Providing outreach to kinship families, including by establishing, distributing, and updating a kinship care website, or other relevant guides or outreach materials
  • Promoting partnerships between public and private agencies, including schools, community-based or faith-based organizations, and relevant government agencies, to increase their knowledge of the needs of kinship families and other individuals who are willing and able to be foster parents for children in foster care under the responsibility of the State who are themselves parents to promote better services for those families

Additionally, kinship navigator programs may:

  • Establish and support a kinship care ombudsperson with authority to intervene and help kin caregivers access services
  • Support any other activities designed to assist kin caregivers in obtaining benefits and services to improve their caregiving

Kinship Navigator Programs Can Serve All Kinship Families

Title IV-E kinship navigator programs can serve all kinship families, regardless of child welfare system involvement. Families are eligible for title IV-E kinship navigator program services without regard to title IV-E eligibility or definitions of candidacy defined in the state, territory, or Tribe’s title IV-E prevention program plan. Child welfare agencies have discretion to determine the populations served by the program, including families of children formally in the custody of the child welfare system, those who have exited to guardianship or adoption, and those with no child welfare system involvement, so long as they meet the practice criteria of an approved program model. It is particularly important to serve those families with no child welfare involvement, as they typically do not have access to case management and services that are offered to families with open child welfare cases. 

How Funds are Distributed

Federal funds are distributed to a jurisdiction’s title IV-E agency that operates or contracts for the operation of an approved evidence-based kinship navigator program. For a nonprofit kinship navigator service provider, they must have a contract with the title IV-E agency to access those funds,

As of the publication of this primer, the Title IV-E Prevention Services Clearinghouse has awarded designations of “promising,” “supported,” or “well-supported” to six kinship navigator programs, and they can obtain ongoing federal funds once they complete administrative steps:

Other title IV-E agencies that want to follow one of these models with fidelity rather than evaluating their own program should follow the guidance in ACYF-CB-PI-18-11 to submit a Title IV-E Plan Pre-Print Attachment XII and revise their cost allocation plan. The attachment must specify the approved kinship navigator program that will be operated, the target population, how the program will be delivered (by the child welfare agency or a contracted provider), and how it will coordinate with other local agencies. It must also include assurances that the program has been and will be informed by kinship families, other agencies, and community-based organizations.

The attachment can be submitted at any time, and agencies can resubmit an updated attachment for any proposed adjustments or expansions of the approved plan.

Once the attachment has been approved and the jurisdiction’s cost allocation plan has been modified and approved, allowable program, administrative, and training expenditures for the title IV-E kinship navigator program are reimbursable at a 50% rate.

A kinship navigator program can be offered across the jurisdiction or operated in specific localities. A child welfare agency can also lead multiple kinship navigator programs across the jurisdiction to utilize approved evidence-based models to meet the needs of specific populations. ACF encourages child welfare agencies to offer kinship navigator services as broadly as possible.

Where to Find More Information

For more information about the title IV-E kinship navigator program, interested individuals and entities should look to:

  • Administration for Children and Families (ACF): Detailed information and relevant guidance is available at acf.hhs.gov.
  • Title IV-E Prevention Services Clearinghouse: Information on the specific evidence-based programs eligible for funding under the title IV-E kinship navigator program is available at preventionservices.acf.hhs.gov.
  • Implementing the Family First Prevention Services Act: A comprehensive question-and-answer guide to the Family First Prevention Services Act and the title IV-E kinship navigator program is available at https://www.grandfamilies.org/Portals/0/Documents/FFPSA/FFPSA%20Guide.pdf.

Example

Through a contract with its title IV-E agency, Children’s Service Society of Utah is obtaining title IV-E funds for following Nevada’s Foster Kinship navigator program model with fidelity. 

Title IV-E Prevention

Department: U.S. Department of Health and Human Services (HHS)
Agency: Administration for Children and Families (ACF)

Overview

The title IV-E prevention program, established under the Family First Prevention Services Act (FFPSA), is a federal initiative designed to prevent children from entering foster care by providing funding to states, tribes, and territories for services and programs aimed at stabilizing and strengthening families so children can safely remain home with their families. The program allows for certain time-limited, trauma-informed mental health, substance use, and parent skill programs that have been rated as sufficiently evidence-based. The title IV-E prevention program is the only source of federal entitlement funds for prevention of entry into foster care.

States, tribes, and territories are able to offer services to three categories of people:

  1. Children who are deemed “candidates for foster care,” meaning that they are at “imminent risk” of entering foster care—including those at risk of adoption or guardianship disruption/dissolution—but can remain safely at home or in a kinship placement if they receive title IV-E prevention services or programs
  2. Expectant and parenting youth in foster care
  3. Parents and/or kin caregivers of children or youth who are eligible for title IV-E prevention services under either of the other two categories.

States, territories, and tribes have flexibility to determine their definitions of “candidate for foster care” and “imminent risk.”

Eligible Services

The title IV-E prevention program provides entitlement funding to allow child welfare agencies to provide time-limited, trauma-informed programs and services for children or youth who are candidates for foster care, expectant and parenting youth in foster care, and the parents and kin caregivers of these children and youth. These services fall under three categories:

  • Mental Health Services
  • Substance Abuse Prevention and Treatment Services
  • In-Home Parent (Caregiver) Skill-Based Programs

Services and programs are only eligible for reimbursement under the title IV-E prevention program if they have met certain standards to be considered “evidence-based.” The Title IV-E Prevention Services Clearinghouse systematically reviews research on programs and rates them based on their level of evidence. Programs that receive a rating of “promising,” “supported,” or “well-supported” are eligible for reimbursement if they are included in the state, Tribe, or territory’s title IV-E prevention program plan and are delivered with fidelity to the approved model.

How Funds are Distributed

The title IV-E prevention program is optional for states, tribes, and territories. In order to participate, the child welfare agency must submit a five-year plan for prevention services to the Children’s Bureau for approval. The plan must include:

  • A description of the approved evidence-based services that will be offered, the target populations for the services, and information about oversight of the services;
  • An evaluation strategy for each service offered (or a waiver request for programs with a “well-supported” rating);
  • Descriptions of how the agency will continue to monitor the safety of children receiving prevention services;
  • Details of how the agency will coordinate with other state agencies;
  • Plans for training and support of the workforce;
  • Details of how the agency will manage the caseloads of prevention caseworkers; and
  • Assurance that the agency will provide information and data.

Once a five-year prevention plan has been approved, states, tribes, and territories can receive reimbursement for services and programs delivered in accordance with their plan. Services and programs can be offered to an individual for up to 12 months, though the child welfare agency can renew services for an additional 12-month period if it is determined that the child is still a candidate for foster care. This must be done on a case-by-case basis.

Child welfare agencies may provide services directly through their own staff or contract with public and private entities to provide services.

Through FY2026, the federal government provides 50% reimbursement for programs and services delivered through the title IV-E prevention program. Beginning in FY2027, this rate will change to the Federal Medicaid Assistance Percentage (FMAP) rate. Administrative and training costs for these programs will continue to be reimbursed at a 50% rate.

Where to Find More Information

For more information about the title IV-E prevention program, interested individuals and entities should look to:

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