8ase||ne Ana|ys|s of Ma|ne's

ub||c-We|fare System


A 8evlew SubmlLLed Lo Lhe
Commlssloner of PealLh
& Puman Servlces


llnal 8eporL
May 2014





1he A|exander Group, LLC
rovldence, 8.l.
hlladelphla, a.
WashlngLon, u.C.



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Ioreword


1he Alexander Croup (AC) ls pleased Lo respecLfully submlL Lhls basellne analysls Lo Lhe
Malne ueparLmenL of PealLh and Puman Servlces (uPPS). 1he reporL represenLs more Lhan
seven monLhs of work on behalf of AC wlLh Lhe close cooperaLlon of key uPPS personnel. A
pro[ecL of Lhls slze normally would have Laken a year or more Lo compleLe, buL Lhe exLenslve
experlence of Lhe AC Leam and Lhe lnpuL we recelved from Lhe sLaLe made lL posslble Lo
compleLe Lhe work wlLhln a compressed Llmeframe.

lndeed, AC Lurned Lhls reporL around ln an expedlLed manner because of Lhe
commlssloner's deslre Lo move forward wlLh reformlng Lhe sysLem as qulckly as posslble. lor
sLaLes ln general, Medlcald and welfare programs conLlnue Lo grow ln magnlLude and
proporLlon desplLe reform measures LhaL were enacLed and lmplemenLed Lhrough Lhe ersonal
8esponslblllLy and Work CpporLunlLy 8econclllaLlon AcL of 1996 (8WC8A). 1hls naLlonal
paLLern of dramaLlc growLh has noL bypassed Malne. AlLhough Lhe Leage admlnlsLraLlon has
succeeded ln moderaLlng and decllnlng LoLal expendlLures, Malne's welfare burden remalns
among Lhe hlghesL ln Lhe naLlon. AbsenL comprehenslve pollcy changes aL Lhe federal and sLaLe
levels, Lhe burden wlll noL be slgnlflcanLly lmproved.

ln laylng ouL a comprehenslve overvlew of Malne's welfare sysLem, Lhls reporL provldes
speclflc recommendaLlons Lo lmprove programs and lnlLlaLe more meanlngful reform lnLended
Lo lmprove ouLcomes for reclplenLs whlle enhanclng cosL effecLlveness across Lhe enLlre
enLerprlse. Whlle reporLs and sLudles LhaL explore ways Lo lmprove publlc-asslsLance programs
are plenLlful, none of whlch AC ls aware lnvolves Lhe breadLh and scope of Lhls analysls.
1ranslLlon reporLs Lo help new governors esLabllsh prlorlLles and pollcles may come close.
Powever, AC belleves LhaL Lhls reporL's level of quanLlLaLlve deLall, pollcy analysls Lo lmprove
program funcLlonallLy, and recommendaLlons for broader reform offer Malne an opporLunlLy Lo
acceleraLe Lhe pace of lmprovlng program ouLcomes aL more affordable cosLs.





l





1ab|e of Contents


Lxecut|ve Summary ............................................................................................................. v
ASl8L-1Anl ........................................................................................................................... v
SupplemenLal nuLrlLlon AsslsLance rogram (SnA) ............................................................ vll
Chlld Care ............................................................................................................................ vlll
Ceneral AsslsLance ................................................................................................................ lx
Welfare-1o-Work CoordlnaLlon ............................................................................................. xl
MalneCare ............................................................................................................................ xll

1. Introduct|on .................................................................................................................... 1
Cvervlew ................................................................................................................................. 1
8ackground Lo 8eporL ........................................................................................................... 23
ConLenLs and uaLa Sources .................................................................................................. 24
MeLhodology ........................................................................................................................ 23
Ak1 I: GLNLkAL U8LIC-WLLIAkL kCGkAMS ................................................................... 27
2. 1emporary Ass|stance for Needy Iam|||es (1ANI) .......................................................... 27
Crlglns of Lhe 1Anl Law ....................................................................................................... 29
Changes Lo 1Anl under Lhe ueflclL 8educLlon AcL ............................................................... 30
1Anl Work arLlclpaLlon 8equlremenLs ............................................................................... 31
Caseload-8educLlon and Lxcess-MCL CredlLs ...................................................................... 31
undersLandlng Lhe lmpacL of 1Anl-enalLy rovlslons ....................................................... 32
Work-Lllglble lndlvlduals and Work arLlclpaLlon 8equlremenLs ......................................... 38
LngagemenL of Work-Lllglble lndlvlduals ............................................................................. 38
Malne's 1Anl ollcy Cholces, 8elaLlve Lo oLher SLaLes ........................................................ 47
Malne's 1Anl Plgh-erformance Measures 8elaLlve Lo CLher SLaLes ................................. 30
8ecommendaLlons for Malne's 1Anl rogram .................................................................... 34
3. Supp|ementa| Nutr|t|on Ass|stance rogram (SNA) ...................................................... S9
Cvervlew ............................................................................................................................... 39
Changes ln Lhe SnA Caseload ............................................................................................. 39
Malne SnA erformance lndlcaLors ................................................................................... 60
Malne's SnA Lrror 8aLes uecllne ........................................................................................ 61
lraud lnvesLlgaLlons ............................................................................................................. 62
lood-SLamp 8eforms under Lhe 2014 larm 8lll ................................................................... 63
rogram lnLegrlLy ln SnA .................................................................................................... 64
SnA ollcy 8ecommendaLlons ............................................................................................ 63


ll
4. Ch||d Care Ass|stance rograms ..................................................................................... 67
SLrucLure of uPPS Chlld Care rograms ............................................................................... 69
CuallLy lnlLlaLlves ln Malne's Chlld Care rograms ............................................................... 74
Malne's CCul ollcy Cholces 8elaLlve Lo CLher SLaLes ......................................................... 76
arenL's Co-aymenL 8aLe .................................................................................................... 77
Chlld Care 8elmbursemenL 8aLes ......................................................................................... 78
8ecommendaLlons for Chlld Care rograms ......................................................................... 86
S. Ch||d-Support Lnforcement v|a DSLk ............................................................................. 89
8ackground ........................................................................................................................... 89
lnLegraLlon of Chlld-SupporL LnforcemenL wlLh CLher uPPS rograms .............................. 89
Chlld-SupporL LnforcemenL AcLlvlLles, 2012-13 .................................................................. 91
Malne's uSL8 SysLem 8anklngs ............................................................................................ 92
6. Genera| Ass|stance rogram .......................................................................................... 9S
Cvervlew ............................................................................................................................... 93
rogram CperaLlons ............................................................................................................. 93
Malne's CA rogram 8elaLlve Lo CLher SLaLes ..................................................................... 98
8ecommendaLlons/CpLlons for Ceneral AsslsLance ........................................................... 100
7. kefugee Cash Ass|stance ............................................................................................. 102
Cvervlew ............................................................................................................................. 102
8ecommendaLlons for 8CA ................................................................................................. 103
8. We|fare-to-Work Coord|nat|on .................................................................................... 104
CurrenL lnlLlaLlves ............................................................................................................... 104
Lxpandlng 8eforms of Lhe ASl8L-1Anl rogram .............................................................. 109
Lessons Learned from CLher SLaLes .................................................................................... 110
erformance-8ased ConLracLlng ........................................................................................ 113
needs of 1Anl 8eclplenLs wlLh ulsablllLles ........................................................................ 116
lnLegraLlng lndlvlduals wlLh ulsablllLles lnLo rlvaLe-SecLor Workforce ............................. 116
Achlevlng 1Anl Work arLlclpaLlon 8aLes .......................................................................... 121
Ak1 II: MAINL'S WLLIAkL ADMINIS1kA1IVL SS1LMS ...................................................... 12S
9. L||g|b|||ty and Serv|ce-De||very System ........................................................................ 12S
1Anl AppllcaLlon 1rends .................................................................................................... 127
orLland and larmlngLon Cfflces ........................................................................................ 129
8ecenL Changes and Cngolng lmprovemenLs .................................................................... 129
Lnhanclng rogram-lnLegrlLy lnlLlaLlves ............................................................................. 130
10. Ma|ne's ub||c-We|fare Data Systems ....................................................................... 131
Ak1 III: MAINLCAkL .......................................................................................................... 133
11. Ma|neCare Cverv|ew ................................................................................................. 133
1he uoubllng of Lhe MalneCare Caseload .......................................................................... 133
lederal Medlcal AsslsLance ercenLage (lMA) ................................................................ 140
12. Ma|neCare rograms and Wa|vers ............................................................................. 141
MalneCare for Able-8odled AdulLs of Worklng Age ........................................................... 141
Malne rlvaLe PealLh lnsurance remlum rogram (Pl) ................................................ 142
Long-1erm Care SysLems SupporL ...................................................................................... 143

lll
Pome- and CommunlLy-8ased Servlces (PC8S) Walvers .................................................... 144
Medlcald LsLaLe-8ecovery rogram ................................................................................... 143
13. Care Management]Va|ue-8ased urchas|ng In|t|at|ves .............................................. 147
rlmary-Care Case ManagemenL (CCM) ........................................................................... 147
aLlenL-CenLered Medlcal Pomes (CMP) ......................................................................... 147
SLaLe lnnovaLlon Model (SlM) ............................................................................................ 148
PealLh Pomes ..................................................................................................................... 148
14. Ma|neCare Cost Dr|vers ............................................................................................. 149
PosplLals ............................................................................................................................. 149
Long-1erm Care for Llderly and AdulLs wlLh hyslcal ulsablllLles ....................................... 130
lndlvlduals wlLh uevelopmenLal ulsablllLles ....................................................................... 131
MenLal PealLh ..................................................................................................................... 133
1S. harmacy System ...................................................................................................... 1S7
aymenL and rlclng ........................................................................................................... 137
urug Coverage ollcy .......................................................................................................... 139
Abuse of urugs ................................................................................................................... 160
opulaLlon PealLh and harmacy Servlces ......................................................................... 160
16. Med|ca|d I|ex|b|||ty and I|sca| Certa|nty: 1he rom|se of G|oba| keform ................... 163
1he MalneCare Challenge ................................................................................................... 164
llscal 1rends and Cross-ressures ...................................................................................... 167
1he SoluLlon: A Clobal Walver ............................................................................................ 169
Scope of AuLhorlLy 8equesLed under a SecLlon-1113 Walver ............................................ 173
CeLLlng SLarLed ................................................................................................................... 178
Concluslon .......................................................................................................................... 179

Append|x A: Income Cr|ter|a for DnnS rograms ............................................................. 181
Append|x 8: L||g|b|||ty Cr|ter|a for DnnS-CII rograms .................................................... 18S
Append|x C: Ch||d Care ke|mbursement kates ................................................................. 193

1ab|e of Charts ................................................................................................................ 197
L|st of Irequent|y Used Acronyms ................................................................................... 201
Contr|butors to th|s keport ............................................................................................. 203



lv


v





Lxecut|ve Summary


Malne's ueparLmenL of PealLh and Puman Servlces (uPPS) has engaged Lhe Alexander
Croup (AC) Lo prepare a revlew and analysls of Lhe sLaLe's publlc-welfare sysLem, assesslng Lhe
admlnlsLraLlon, dellvery, and ouLcomes of Lhese programs LhaL Malne admlnlsLers Lo help lLs
mosL vulnerable populaLlons. 1hls assessmenL quanLlLaLlvely measures performance,
quallLaLlvely ldenLlfles Lhe sysLem's sLrengLhs and weaknesses, and offers recommendaLlons
LhaL help make Malne's human servlces more effecLlve and efflclenL whlle lmprovlng quallLy.

1he uPPS programs examlned ln Lhls reporL lnclude 1Anl, SnA, Chlld Care and
uevelopmenL lund (CCul) Chlld Care Subsldy rogram, Lhe ulvlslon of SupporL LnforcemenL
and 8ecovery (uSL8), Ceneral AsslsLance, Lhe sLaLe's welfare-Lo-work sysLem, and MalneCare.
Several oLher smaller programs are revlewed, Lhey lnclude AlLernaLlve AsslsLance, 8efugee Cash
AsslsLance (8CA), and Lmergency AsslsLance. 1he AC also examlned mandaLory sLaLe plans
submlLLed Lo federal agencles and examlned how lndlvldual pollcles and proLocols have been
developed by Lhe sLaLe ln order Lo responslbly admlnlsLer Lhese resources.

As a basellne assessmenL of Malne's welfare sysLem aL a parLlcular polnL ln Llme (2013),
Lhe reporL hlghllghLs vla exLenslve daLa analysls whaL ls worklng and whaL needs aLLenLlon, lL
provldes boLh reglonal and naLlonal comparlson daLa for reference, and lL ralses some lssues
and concerns dlscovered durlng Lhe revlew process. lor Lhe purposes of Lhls execuLlve
summary, we hlghllghL our flndlngs and recommendaLlons for Lhe ma[or uPPS programs:
ASl8L-1Anl, SnA, Chlld Care, Ceneral AsslsLance, Welfare-1o-Work, and MalneCare.


ASIkL-1ANI

unLll uPPS lmplemenLed pollcy reforms ln !anuary 2012, Lhe sLaLe's 1Anl program
lagged second from Lhe boLLom ln sLaLe ranklngs of caseload decllnes. rlor Lo !anuary 2012,
Lhe sLaLe dld noL conform Lo federal rules relaLed Lo slxLy-monLh Llme llmlLs for famllles on cash
asslsLance. Malne carrled hlgh caseloads, even when reducLlons were occurrlng ln vlrLually all
oLher sLaLes. ln facL, Malne's hlgh caseloads endured durlng Lhe perlod when federal
regulaLlons, under Lhe ueflclL 8educLlon AcL of 2003 (u8A), lncreased reporLlng requlremenLs
and added prevlously omlLLed sLaLe MCL-funded adulLs Lo Lhe calculaLlon of work parLlclpaLlon
raLes. AddlLlonally, u8A narrowed Lhe deflnlLlon of counLable work acLlvlLles, LlghLened
monlLorlng of parenL acLlvlLles, and lmposed sLrlcLer reporLlng requlremenLs for Lhe broader
work-ellglble populaLlon.

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Malne's pollcles prlor Lo 2012, whlch largely dlsregarded Llme llmlLs, exposed Lhe sLaLe
Lo 1Anl-W8 flnanclal penalLles, as Lhe program was unable Lo engage a sufflclenL number of
parenLs ln counLable acLlvlLles for W8 purposes. ConsequenLly, Malne noL only saw lLs work
parLlclpaLlon raLes decllne slgnlflcanLly beLween 2002 and 2010 buL also falled Lo meeL federal
sLandards ln 2007, 2008, 2009, and 2010. Powever, wlLh sLaLe-MCL funds, uPPS was able Lo
correcL some of Lhese deflclencles ln 2012 and 2013 by lmplemenLlng a worker-supplemenL
program. 1haL lnlLlaLlve allows Lhe sLaLe Lo counL nlneLeen-Lo-LwenLy Lhousand low-lncome
worklng famllles, who are employed aL Lhe requlred number of hours, Loward Lhe 1Anl W8.
Moreover, Lhe sLaLe was able Lo experlence a 20 caseload decllne ln all 1Anl programs
beLween 2012 and 2013. Lven wlLh Lhe recenL efforLs Lo avold penalLles, Lhe sLaLe wlll conLlnue
Lo sLand aL rlsk wlLh 1Anl ln Lhe fuLure unless more sLrldenL changes are made.

1o furLher ensure LhaL Malne avolds fuLure penalLles under 1Anl, Lhe deparLmenL musL
do everyLhlng posslble Lo comply wlLh 1Anl requlremenLs. 1he followlng recommendaLlons are
lnLended Lo bulld up Lhe level of parLlclpaLlon ln approvable acLlvlLles whlle aL Lhe same Llme
help famllles galn access Lo Lhe [ob markeL ln Lhe shorLesL Llme posslble. 1o accompllsh Lhese
goals, Lhe AC recommends Lhe followlng:

1. A||gn Ma|ne's ASIkL program w|th federa| 1ANI countab|e act|v|t|es. 1hls would
ensure LhaL every plan conforms Lo 1Anl and any reclplenL approved for a vocaLlonal
Lralnlng and/or a posL-secondary educaLlon programs would be requlred Lo work aL
leasL LwenLy hours per week afLer hls or her lnlLlal Lwelve monLhs ln ASl8L-1Anl.

2. Adopt a po||cy of un|versa| engagement for a|| app||cants and rec|p|ents so LhaL no
reclplenL ls exempL from ASl8L-1Anl parLlclpaLlon requlremenLs. 1hls
recommendat|on wou|d e||m|nate exempt|ons from act|v|t|es LhaL, under currenL sLaLe
pollcy, allow parenLs Lo recelve beneflLs wlLh no parLlclpaLlon requlremenLs. lull
engagemenL assumes everyone has an acLlvlLy plan, whlch wlll lead Loward [ob
readlness and fuLure employmenL.

3. kequ|re upfront [ob-search act|v|t|es pr|or to acceptance onto cash ass|stance. 1hls
recommendaLlon ls lnLended Lo provlde sound lnformaLlon and guldance backed by
program supporL for appllcanLs who may have opLed ouL of Lhe [ob markeL premaLurely.
AddlLlonally, for Lhose who do noL flnd a [ob durlng Lhelr pre-accepLance perlod, Lhe
upfronL [ob-search experlence beLLer prepares Lhem for parLlclpaLlon ln Lhe work-
program requlremenLs lmmedlaLely upon accepLance onLo ASl8L-1Anl, as opposed Lo
deferrlng Lhelr engagemenL ln a work-acLlvlLy plan, lmprovlng Lhe sLaLe's achlevemenL
of 1Anl work parLlclpaLlon raLes.

4. k|gorous|y mon|tor both case|oads and part|c|pat|on |eve|s by prov|d|ng an ear|y a|ert
system |f the department fa||s be|ow mandatory work part|c|pat|on rate |eve|s. An
early alerL sysLem allows Lhe deparLmenL Lhe opporLunlLy Lo make mld-course
ad[usLmenLs ln order Lo avold cosLly 1Anl W8 flnanclal penalLles.


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3. keexam|ne MCL-case|oad categor|es, part|cu|ar|y two-parent fam|||es that are
current|y def|ned as e|ther |ncapac|tated or unemp|oyed. 1Anl requlres parLlclpaLlon
of boLh of Lhese Lwo-parenL caLegorles, and Lhe deparLmenL should focus on full
engagemenL as soon as posslble. under 1Anl law, 90 of all Lwo-parenL households
supporLed by elLher federal 1Anl dollars or sLaLe-MCL dollars are requlred Lo
parLlclpaLe aL leasL LhlrLy-flve hours per week.

6. Lxpand the coord|nat|on and shared resources of the Ma|ne Department of Labor and
the Department of Lducat|on to strengthen we|fare-to-work |n|t|at|ves. (1hls
recommendaLlon ls developed ln Lhe Welfare-Lo-Work CoordlnaLlon secLlon.)


Supp|ementa| Nutr|t|on Ass|stance rogram (SNA)

lrom 2009 Lo 2013, Lhe Malne SnA caseload lncreased by 31,612 reclplenLs (and
approxlmaLely 32,300 households), a boosL drlven ln parL by Lhe provlslons of Lhe Amerlcan
8ecovery and 8elnvesLmenL AcL of 2009. Pandllng such a rapld lncrease poses challenges Lo
even Lhe mosL efflclenL sLaLe agency, parLlcularly when lL comes Lo keeplng fraud, wasLe, and
abuse aL bay. ?eL Malne has performed admlrably ln managlng Lhe expanded SnA caseload. ln
ll?s 2003, 2006, 2007, and 2008, Malne had comparaLlvely hlgh error raLes ln federal revlews
of lLs food-sLamp program. Powever, uPPS has slnce been able Lo reverse LhaL paLLern. lor l?
2012, uSuA lood and nuLrlLlon Servlces publlshed lLs mosL recenL SnA daLa reporL showlng
sLaLe-level breakdowns ln a number of lndlcaLors. Malne compared favorably agalnsL all oLher
sLaLes on several lndlcaLors relaLed Lo paymenL-accuracy measures.

Malne could conLlnue Lhls progress by Lhe followlng:

1. Aggress|ve|y |mp|ement front-end detect|on protoco|s, w|th adequate systems
support. 1hls process wlll slgnlflcanLly reduce Lhe poLenLlal of fraud, wasLe, and abuse of
beneflLs ln Lhe SnA program before beneflLs are lssued. Such a recommendaLlon would
mean LhaL unlawful or lmproper beneflL overpaymenLs would be reduced slgnlflcanLly
by vlrLue of Lhe facL LhaL a fronL-end deLecLlon process would yleld more Llmely and
accuraLe lnformaLlon abouL reclplenLs, especlally Lhose wlLh earnlngs.

2. ursue approva| to become one of the ten-state p||ot programs to engage adu|ts |n a
mandatory work program, an opporLunlLy ouLllned ln Lhe 2014 larm 8lll. lf Malne
successfully compeLed for Lhe plloL program, Lhe caseload would noL only expand Lhe
number of worklng SnA households, buL would llkely reduce Lhe SnA caseload
because more reclplenLs would have access Lo pald employmenL presumably aL wages
LhaL ellmlnaLe Lhelr ellglblllLy for SnA beneflLs.

3. Lxcept for those who are e|der|y and]or have a d|sab|||ty, narrow the def|n|t|on of
categor|ca||y e||g|b|e househo|ds to on|y those who have a|ready met one of the
federa||y def|ned means-tested cash ass|stance programs (SSI, 1ANI, or Genera|

vlll
Ass|stance). 1hls recommendaLlon would requlre all oLher appllcanL households Lo meeL
lncome and asseL llmlLs of $2,000 ln order Lo be ellglble for SnA beneflLs.

4. Ident|fy mean|ngfu| program-|ntegr|ty pr|or|t|es and esLabllsh measurable goals for
flscal years 2014, 2013, and 2016. Such ground work would conLrlbuLe Lo responslbly
admlnlsLerlng beneflLs Lo Lhose ln need and reduce program fraud, wasLe, and abuse.


Ch||d Care

Llke many sLaLes, Malne's chlld care sysLem follows a Lwo-Lrack model: one program -
under Lhe Cfflce of lamlly lndependence (Cll) - LhaL admlnlsLers servlces for parenLs enrolled
ln Lhe ASl8L-1Anl/aS cash-asslsLance program, and a second program - under Lhe Cfflce of
Chlld and lamlly Servlces (CClS) - LhaL funcLlons under Lhe federal Chlld Care uevelopmenL
lund (CCul) and admlnlsLers quallLy-care lnlLlaLlves and care subsldles for needy parenLs noL
oLherwlse ellglble for ASl8L-1Anl.

WlLhln Lhls model, Malne malnLalns a very generous chlld care program ln Lerms of
ellglblllLy levels and relmbursemenL raLes. 1he sLaLe's ellglblllLy (230 of lL) for recelvlng chlld
care asslsLance ls Lhe hlghesL ln new Lngland and Lhe Lhlrd hlghesL ln Lhe counLry. Measured as
a percenLage of sLaLe medlan lncome, Malne's ellglblllLy level (83) ls also Lhe hlghesL ln new
Lngland. Moreover, Lhe sLaLe's relmbursemenL raLes (for 4-year-olds ln cenLer-based care) are
Lhe hlghesL ln new Lngland and Lhe flfLh hlghesL ln Lhe counLry. 1hose generous relmbursemenL
raLes mean LhaL Lhe annual per-case cosL of ASl8L and 1ranslLlonal Chlld Care parenLs uslng a
llcensed chlld care cenLer ls $8,063, for parenLs uslng a llcensed, famlly-based cenLer ls $6,169.

AC's pollcy recommendaLlons for Lhe sLaLe's chlld care program are as follows:

1. Lstab||sh an |ntegrated ch||d care po||cy and program |eadersh|p ro|e w|th
respons|b|||ty across CCIS and CII. SLrongly conslder consolldaLlon of chlld care
admlnlsLraLlon and pollcy developmenL lnLo a slngle leadershlp funcLlon wlLhln uPPS.

2. Create a un|form ch||d care data-report|ng capab|||ty that captures data from CII and
CCIS. unlformlLy ln daLa reporLlng would effecLlvely lncrease paymenL and daLa
accuracy and reduce redundancy.

3. ay prov|ders d|rect|y as opposed to |ssu|ng payments through parents' L81 cards. 1hls
recommendaLlon would brlng ASl8L-aS meLhod of paylng for chlld care ln llne wlLh
Lhe CCul Chlld Care Subsldy program, whlch always pays Lhe chlld care provlders
dlrecLly on behalf of parenLs, as opposed Lo ASl8L-aS, whlch uses Lhe parenL's L81
card Lo lssue paymenLs for chlld care servlces.

4. Lxp|ore partner support to he|p pay for the cost|y |nvestments |n the state's qua||ty-
care |n|t|at|ves. ursulng alLernaLlve supporL from oLher fundlng parLners would relleve

lx
uPPS from havlng Lo choose beLween malnLalnlng fundlng for quallLy chlld care
lnlLlaLlves versus creaLlng walLlng llsLs for low-lncome worklng famllles.

3. ay after performance, based on prov|der |nvo|c|ng system, use techno|ogy to
automate b||||ng process. 1hls recommendaLlon sLrongly urges a change ln currenL
pollcles, whlch pay provlders ln advance of chlld's aLLendance. 1hls wlll reduce Lhe
poLenLlal for overpaymenL caused when cllenLs experlence false sLarLs ln program
acLlvlLles, and/or ln sLarLlng a new [ob, whlch may noL acLually maLerlallze.

6. Cons|der mov|ng toward sw|pe-card techno|ogy for pay|ng ch||d care subs|d|es. aylng
for aLLendance ls besL achleved when Lhere ls a clear and verlflable process for
recordlng and Lracklng aLLendance. Swlpe-card Lechnology has performed very well ln
oLher sLaLes. AddlLlonally, swlpe-card Lechnology carrles an added degree of
auLhenLlcaLlon LhaL Lhe chlld aLLendance conforms Lo Lhe parenL's acLlvlLy and Lhe
provlder's accuracy ln bllllng.

7. Increase on-s|te mon|tor|ng of ch||d care sett|ngs throughout the system. lncreased
monlLorlng enhances Lhe llkellhood LhaL provlders - who are expecLed Lo provlde hlgh-
quallLy care - undersLand Lhey wlll be vlslLed regularly and assessed on Lhe quallLy and
safeLy of Lhe chlldren under Lhelr care.


Genera| Ass|stance

Malne requlres each munlclpallLy Lo admlnlsLer a Ceneral AsslsLance (CA) program
whlch provldes lmmedlaLe ald, ln Lhe form of vouchers, for persons who are unable Lo provlde
Lhe baslc necesslLles essenLlal Lo malnLaln Lhemselves and Lhelr famllles. LllglblllLy crlLerla are
based on flnanclal need and asseLs, and access Lo Lhese beneflLs ls provlded aL Lhe munlclpal
level. CA ls funded Lhrough a comblnaLlon of sLaLe and munlclpal sources and ls governed by
Lhe provlslons of 1lLle 22, arL 3, ChapLer 1161: Munlclpal Ceneral AsslsLance.

Conslderlng budgeL consLralnLs faclng Lhe sLaLe, uPPS ls encouraged Lo confer wlLh Lhe
Malne leglslaLure Lo seek help ln conLalnlng Lhe ouLflow of dollars belng spenL by Lhe CA
program. 1here ls sound raLlonale for revlslLlng Lhe mandaLes of Lhe law aL Lhls Llme, as Lhe
currenL provlslons have led Lo exLraordlnary growLh ln spendlng.

1here are numerous concerns abouL how Lhe CA program ls currenLly admlnlsLered by
Lhe more Lhan four hundred munlclpallLles LhroughouL Lhe sLaLe. 1here ls no unlformlLy ln
ellglblllLy and beneflL crlLerla, Lhere ls no audlL sysLem Lo Lrack lf and when reclplenLs are
accesslng paymenLs Lhrough more Lhan one munlclpallLy, and Lhere ls no daLa-Lracklng sysLem
Lo flag dupllcaLlon of beneflLs lssued by boLh sLaLe and munlclpal sysLems. 8equesLs for
relmbursemenL Lhrough uPPS are submlLLed wlLhouL any person/household level daLa, whlch
prohlblLs Lhe ablllLy Lo cross-check wlLh oLher beneflLs lssued by oLher programs.

x
1hese Lwo recommendaLlons, whlch have been proposed ln Lhe pasL, remaln vlable for
Lhe sLaLe Lo reconslder ln comlng Lo Lerms wlLh Lhls budgeLary challenge:

1. Lstab||sh a Genera| Ass|stance 8|ock Grant w|th a spec|f|ed amount of money to each
mun|c|pa||ty based on the average expend|ture of a mun|c|pa||ty |n the |ast three
years. As uncapped expendlLures have rlsen under Lhe currenL fundlng formula, a block
granL ls one way Lo preserve adequaLe (capped) fundlng for munlclpallLles whlle sLlll
provldlng a reasonable amounL of flnanclal resources Lo asslsL Lhe mosL needy
lndlvlduals and famllles ln accord wlLh Lhe provlslons of Lhe CA law.

2. L|m|t the fund|ng formu|a to S0 of a mun|c|pa||ty's expend|tures wou|d a|so offer a
way to conta|n overa|| costs. 1hls recommendaLlon would ellmlnaLe Lhe currenL 90
yearly Lhreshold formula LhaL ls, ln effecL, an enLlLlemenL fundlng sLream LhaL ls
flnanclally unsusLalnable.

ln addlLlon, Lhe followlng seven opLlons - lf adopLed - would also resulL ln savlngs for
Lhe sLaLe:

Cpt|on 1: Malne uPPS could assume LoLal admlnlsLraLlon of Lhe CA program and
unlformly apply sLandards of ellglblllLy and beneflLs lssued on a sLaLewlde basls. A number of
efflclencles can be expecLed by operaLlng CA Lhrough Lhe slxLeen reglonal cenLers, where Lhe
provlslon of servlces would be done by experlenced ellglblllLy workers who have access Lo
auLomaLed ellglblllLy, paymenLs/vouchers, and reporLlng sysLems. MosL noLeworLhy ls Lhe
ellmlnaLlon of dupllcaLlon of beneflLs lssued Lhrough Lwo separaLe program operaLlons.

Cpt|on 2: ConLlngenL upon fundlng consLralnLs, uPPS could work wlLh lawmakers Lo
follow Lhe paLLern of oLher sLaLes and ellmlnaLe Lhe CA program alLogeLher.

Cpt|on 3: Malne uPPS could conslder capplng CA program dollars per munlclpallLy,
seLLlng a maxlmum amounL avallable for each year, based on avallablllLy of sLaLe fundlng. Whlle
Lhls ls slmllar Lo Lhe already consldered flxed block-granL proposal, Lhls opLlon would be based
on avallable sLaLe dollars each year, whlch would be sub[ecL Lo annual allocaLlons LhaL may
flucLuaLe up or down.

Cpt|on 4: ulsconLlnue cash beneflLs Lo employable adulLs wlLhouL chlldren, conLlnue MA
lf Lhey are lncome ellglble under Medlcald and have a verlfled need for medlcal servlces and/or
prescrlpLlon drugs.

Cpt|on S: ueny CA emergency cash asslsLance Lo Lhose who are on 1Anl - Lhey
already recelve monLhly cash beneflLs, SnA, and MA Lhrough uPPS and may also quallfy for
emergency asslsLance under cerLaln uPPS rules. uupllcaLlon of asslsLance ls a slgnlflcanL
posslblllLy wlLhln Lhe currenL CA beneflL sLrucLure.


xl
Cpt|on 6: ulsconLlnue llmlLless renewals for Ceneral AsslsLance beneflLs. CLher sLaLes
llmlL asslsLance Lo no more Lhan one Llme per year, or no more Lhan Lhree Llmes per lndlvldual
or famlly per llfeLlme, or one Llme per llfeLlme. Malne has no llmlLaLlon on Lhe number of Llmes
a reclplenL can be approved for beneflLs.

Cpt|on 7: Cap enrollmenLs, effecLlve Sl? 2013. CA caseloads wlll decllne overLlme due
Lo aLLrlLlon, and savlngs can be reallzed Lhrough Lhls llmlL on recelpL of beneflLs.


We|fare-1o-Work Coord|nat|on

Well planned and operaLed welfare-Lo-work programs wlll noL only move lndlvlduals
lnLo [obs, buL wlll also lead Lo susLalned employmenL, career advancemenL, and self-sufflclency.
no slngle sLraLegy or model works for every slngle parLlclpanL of ASl8L-1Anl and/or SnA
programs, yeL our recommendaLlons offer a range of feaslble sLraLegles LhaL are llkely Lo meeL a
broad specLrum of skllls and ablllLles of program parLlclpanLs whlle lmprovlng Lhe deparLmenL's
llkellhood of meeLlng federal work parLlclpaLlon requlremenLs. Cur recommendaLlons call for
greaLer emphasls on engaglng Lhe buslness secLor wlLh lncenLlves Lo hlre welfare reclplenLs,
Lhey also call for relnvesLmenL of 1Anl dollars lnLo performance-based conLracLs LhaL are
geared Loward placemenL and reLenLlon mllesLones of parLlclpanLs who are placed lnLo [obs.

ln addlLlon, Lhe reporL recommends speclallzed servlces for lndlvlduals wlLh dlsablllLles
and envlslons collaboraLlon wlLh experLs from dlsablllLy servlce organlzaLlons. 1hese
recommendaLlons also lnclude changes Lo Lhe admlnlsLraLlve processes LhaL, when comblned
wlLh Lhe work focused lnvesLmenLs, wlll greaLly lmprove overall ouLcomes for famllles and
lndlvlduals. And Lhese recommendaLlons offer promlse LhaL Lhe sLaLe and Lhe deparLmenL wlll
achleve Lhe mandaLed work parLlclpaLlon requlremenLs ln 1Anl, Lhus avoldlng flnanclal
penalLles LhaL have loomed over Lhe sLaLe for Lhe pasL several years.

1. Increase work opportun|t|es through expand|ng |nvestments and co||aborat|on w|th
the Ma|ne Departments of Labor and Lducat|on. lull engagemenL of 1Anl famllles
cannoL be achleved wlLhouL expandlng parLnershlps wlLh Lhose more closely llnked Lo
labor and lndusLry. 1hls would lnclude Lhe Malne Workforce 8oard, Lhe elghL Chambers
of Commerce, apprenLlceshlp opporLunlLles, and creaLlve workslLe-learnlng programs
avallable Lhrough Lhe ueparLmenL of LducaLlon.

2. Invest |n more subs|d|zed [ob p|acements, whlch are deslgned Lo appeal Lo employers
who are lnLeresLed ln hlrlng poLenLlal parLlclpanLs of Lhe ASl8L-1Anl and SnA
programs. Slmpllfylng Lhe process and Lhe paperwork can enhance Lhe poLenLlal for
placlng large numbers of program parLlclpanLs lnLo subsldlzed [obs.

3. Deve|op and fund on|y performance-based contracts w|th [ob-p|acement
prov|ders]vendors. ConLracLs would clearly deflne employmenL servlces for ASl8L-
1Anl parLlclpanLs, lncludlng sklll assessmenL and [ob placemenLs. aymenLs need Lo be

xll
sLrucLured based on achlevemenL of mllesLones LhaL are Lled Lo parLlclpanL's skllls, level
of engagemenL ln [ob-preparaLlon acLlvlLles, [ob placemenL, and employmenL reLenLlon.

4. In accord w|th the Lmp|oyment I|rst Ma|ne Act of 2013, |ntegrate |nd|v|dua|s w|th
d|sab|||t|es |nto the pr|vate-sector workforce by work|ng w|th |arge and sma||
emp|oyers throughout the state. 8epllcaLe Lhe successful models ploneered ln oLher
sLaLes by Lowes, Walgreens, and rocLer & Camble, companles LhaL have - ln creaLlve
parLnershlp wlLh sLaLe deparLmenLs of human servlces, labor, and educaLlon as well as
represenLaLlves of dlsablllLy servlce organlzaLlons - demonsLraLed experLlse ln
maLchlng candldaLes wlLh employers.

3. Conduct an annua| d|sab|||ty emp|oyment summ|t, |nvo|v|ng government agenc|es,
po||cymakers, fam|||es, stakeho|ders, and bus|nesses, to d|scuss how to |mprove the
d|sab|||ty work c||mate and opportun|t|es. Seeklng lnpuL from lndlvlduals wlLh
dlsablllLles offers Lhe besL chance for success, parLlcularly for sLakeholders who wlsh Lo
provlde approprlaLe and effecLlve servlces Lo asslsL Lhese lndlvlduals Lo access [obs.

6. Invo|ve a|| ma[or stakeho|ders |n ach|ev|ng 1ANI work part|c|pat|on rates. 1hose
sLakeholders would noL only lnclude ASl8L-1Anl workers buL also Lhe Malne
ueparLmenLs of Labor and LducaLlon, all conLracLed [ob-preparaLlon and placemenL
provlders or vendors, and - very lmporLanLly - ASl8L-1Anl parLlclpanLs.

7. Set measurab|e goa|s beyond the 1ANI Wk. Coals and measures should lnclude
Lracklng Lhe number of parLlclpanLs placed ln [obs, wage levels aL placemenL, Lhe
numbers of hours worked, Lhe number reLalned [obs beyond one, Lhree, slx, and Lwelve
monLhs, and Lhe number of cash-asslsLance cases LhaL close due Lo employmenL.

8. Adm|n|strat|ve|y deve|op protoco|s that |ead part|c|pants to more rout|ne|y attach to
the |abor system as opposed to the we|fare system. 1hls recommendaLlon lncludes
expandlng Lhe role of MuCL ln handllng cases referred from Lhe ASl8L-1Anl and SnA
programs. Allowlng career cenLers Lo handle changes and ad[usLmenLs Lo case acLlvlLy,
for example, would avold unnecessary appolnLmenLs wlLh uPPS.

9. Create a new work part|c|pat|on spec|a||st pos|t|on to funct|on across agency staff to
track and mon|tor work part|c|pat|on |eve|s by offlce and program and/or conLracLed
vendor. rovldlng Lechnlcal asslsLance when lssues or problems emerge, Lhls speclallsL
would reporL monLhly of Lhe progress ln meeLlng 1Anl work parLlclpaLlon mandaLes.


Ma|neCare

lL comes as no surprlse LhaL expendlLures on MalneCare, Lhe largesL means-LesLed
asslsLance program, represenLed 24.8 of LoLal general-fund spendlng ln Sl? 2013, or $767

xlll
mllllon - noL counLlng admlnlsLraLlve cosLs of $20.9 mllllon represenLlng salary and beneflLs for
MalneCare personnel as well as ouLsourced servlces. When Medlcald Lax revenue ls lncluded,
LoLal non-federal spendlng as a percenL of LoLal non-federal revenue rlses Lo 30.6. Accordlng
Lo analysls by Lhe naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers (nAS8C), Malne ranked hlghesL
ln new Lngland for Medlcald sLaLe spendlng as a percenL of LoLal sLaLe expendlLures and Lhe
flfLh hlghesL among all sLaLes.

ln parL because Malne has elecLed Lo cover more persons and more servlces Lhan
requlred by federal regulaLlons, LoLal MalneCare caseloads more Lhan doubled beLween !une
2000 and !une 2012. 8ased on daLa from Lhe Medlcald SLaLlsLlcal lnformaLlon SysLem for ll?
2010, and populaLlon esLlmaLes for sLaLes from Lhe u.S. Census 8ureau for 2010, Malne
Medlcald enrollmenL as percenL of LoLal populaLlon was 31 exceedlng every sLaLe excepL
Callfornla and Lhe ulsLrlcL of Columbla.

8y caLegory of reclplenLs served, Malne follows Lhe naLlonal paLLern. ln Sl? 2013,
chlldren and famllles comprlsed 74.2 of Lhe MalneCare populaLlon buL accounLed for [usL
38.6 of Lhe spendlng, elderly adulLs comprlsed 7.9 of Lhe populaLlon and accounLed for
18.3 of spendlng, and persons wlLh dlsablllLles comprlsed 18 of Lhe populaLlon and
accounLed for 43 of all expendlLures.

1he blggesL cosL drlvers of MalneCare are 1) hosplLals, 2) long-Lerm care for Lhe elderly
and adulLs wlLh physlcal dlsablllLles, 3) lndlvlduals wlLh developmenLal dlsablllLles, and 4)
menLal-healLh servlces. ln Sl? 2013, MalneCare lnpaLlenL and ouLpaLlenL paymenLs Lo hosplLals
amounLed Lo $618 mllllon, paymenLs for long-Lerm care of Lhe elderly and adulLs wlLh physlcal
dlsablllLles LoLaled $344 mllllon. 1hese Lwo caLegorles alone represenLed 38 of all MalneCare
spendlng ln Sl? 2013. aymenLs for servlces for persons wlLh auLlsm and lnLellecLual
dlsablllLles, whlch ls geared much more Loward communlLy-based walver servlces Lhan large
lnsLlLuLlonal provlders, LoLaled $330 mllllon. llnally, MalneCare spenL $196 mllllon for
communlLy menLal-healLh servlces ln Sl? 2013.

under Lhe Leage admlnlsLraLlon, Lhe sLaLe has lnlLlaLed measures Lo curb Medlcald
caseload growLh, conLaln program cosL, and lmprove Lhe efflclency of servlces. AlLhough Lhese
efforLs have slowed Lhe raLe of growLh ln Medlcald enrollmenL and expendlLures, caseloads
conLlnue Lo lncrease and budgeL shorLfalls perslsL. Lven wlLh modesL economlc lmprovemenLs,
Lhe MalneCare's flscal prognosls pro[ecLs a deflclL for Lhe blennlum 2014-13 budgeL of $78
mllllon. 1hese budgeL pro[ecLlons are Lroublesome because MalneCare consLlLuLes a llon's
share of Lhe sLaLe's annual budgeL when counLlng all fund sources (32.2 ln Sl? 2013).

ConsequenLly, Lhe recenL success ln moderaLlng MalneCare growLh wlll noL be sufflclenL
Lo overcome long-Lerm Lrends and Lhe exlsLlng program sLrucLure LhaL favors lnsLlLuLlonal care
over oLher, less-cosLly care opLlons llke home- and communlLy-based servlces. When
exLrapolaLed by flnanclal modellng, our esLlmaLes lndlcaLe LhaL by Sl? 2023-24, MalneCare wlll
represenL 36.2 of Lhe general-fund budgeL, and 40.2 of Lhe LoLal budgeL, conslsLlng of all
funds.

xlv
kecommendat|on: A G|oba| Wa|ver. 1he presslng challenges of Medlcald, from lLs
enLrenched lnsLlLuLlonal blas and growlng caseload Lo lLs pro[ecLed cosL overruns and
crowdlng ouL" of sLaLe budgeLs, demand a proacLlve response. WlLhouL reforms across Lhe
enLlre enLerprlse, MalneCare's ablllLy Lo serve Lhe mosL vulnerable of populaLlons - namely
Lhe lnLellecLually dlsabled and lndlgenL elderly - sLands aL rlsk, even as more and more of Lhe
abled-bodled populaLlon are added Lo Lhe caseload. A global reform Lhrough a SecLlon-1113
demonsLraLlon walver, modeled afLer 8hode lsland's successful experlmenL secured from CMS
ln 2009, offers Lhe besL mechanlsm for Malne Lo redeslgn lLs MalneCare program, lLs paymenL
sLrucLures and enLlre sysLem, and secure lLs fuLure. Malne needs Lhe flexlblllLy Lo creaLe and
manage a Medlcald program LhaL ls conslsLenL wlLh Lhe sLaLe's needs and culLure.

8y seeklng a global reform, Malne, Loo, could achleve slmllar successes, assurlng Lhe
susLalnablllLy of MalneCare for years Lo come. under a comprehenslve or slngle-walver
demonsLraLlon, uPPS would seek maxlmum flexlblllLy Lo change dellvery sysLems, lncrease
Lransparency and cholce, and share rlsk wlLh Lhe federal governmenL. 1hls would lmprove
servlce dellvery and promoLe reclplenL cholce and lndependence whlle drlvlng down boLh
federal and sLaLe cosLs. uPPS would seek Lhe ablllLy Lo vary Lhe amounL, duraLlon and scope of
servlces offered Lo reclplenLs - regardless of ellglblllLy caLegory - and Lhe ablllLy Lo LargeL
beneflLs Lo speclflc Medlcald populaLlons. uPPS could also requesL a global cap on Medlcald
expendlLures, a proven moLlvaLlon for reduclng spendlng, over Lhe llfe of Lhe demonsLraLlon.

A comprehenslve SecLlon-1113 research-and-demonsLraLlon walver, encompasslng all
servlces and ellglble populaLlons served under a slngle auLhorlLy, would dellver flexlblllLy Lo
manage all programs efflclenLly by:

ConsolldaLlng all Medlcald programs, servlces, walvers, and SCPl under a slngle-walver
auLhorlLy,
SLreamllnlng servlce deflnlLlons across populaLlons,
CommlLLlng Malne Lo maklng key lmprovemenLs Lo Lhe ellglblllLy sysLem (boLh processes
and Lechnology),
romoLlng lncreased uLlllzaLlon and cholces of home- and-communlLy-based servlces for
lndlvlduals ln need of long-Lerm care,
lnLegraLlng prlmary, acuLe, long-Lerm care, and behavloral-healLh care,
uLlllzlng rlsk-based caplLaLlon across all populaLlons,
romoLlng efflclenL and value-added healLh care Lhrough enhanclng currenL Medlcald
accounLable-care organlzaLlon plloLs,
rovldlng flexlblllLy Lo promoLe prlmary- and prevenLlve-care access by balanclng
ellglblllLy and enrollmenL for servlces, beneflLs, and Lhe raLe of paymenL for servlces,
rovldlng flexlblllLy ln admlnlsLraLlon of Lhe program Lo lmplemenL compeLlLlve
conLracLlng, managemenL efflclencles, and purchaslng sLraLegles,
romoLlng healLhler behavlors and personal responslblllLy for reclplenL healLh care
across Lhe enLerprlse, and
lnsLlLuLlng greaLer accounLablllLy for reclplenLs and admlnlsLraLors of Lhe programs.


1





1. Introduct|on


Cverv|ew

1hls reporL provldes a programmaLlc revlew of Malne's publlc-welfare programs,
explorlng deLalls and offerlng recommendaLlons LhroughouL. uurlng Lhe course of work ln
examlnlng Lhese programs, a few observaLlons are offered.

llrsL, Lhe Leage admlnlsLraLlon has made slgnlflcanL lmprovemenLs Lo Malne's publlc-
welfare sysLem, lncludlng lmproved efflclencles, greaLer enforcemenL of program lnLegrlLy, and
enhanclng Lhe quallLy of servlces. lor example, Malne ls one of Lhe flrsL sLaLes Lo creaLe
accounLable-care organlzaLlons (ACCs) - an lnlLlaLlve LhaL, lf fully lmplemenLed, wlll lmprove
care coordlnaLlon, lower expendlLures, enhance Lhe paLlenL experlence, and brlng greaLer
accounLablllLy Lo Lhe healLh-care sysLem. erhaps even more lmporLanLly, based on feedback
from employees, morale and prlde aL uPPS have lmproved, Lhls has led Lo lmproved
producLlvlLy and accounLablllLy LhroughouL Lhe deparLmenL. Conslderlng Lhe flnanclally
consLralned envlronmenL ln whlch sLaLe agencles llve, Lhls ls no small feaL.

1he admlnlsLraLlon has also conLlnued Lo admlnlsLraLlvely sLreamllne operaLlons across
Lhe deparLmenL and bulld on Lhe deparLmenLal consolldaLlon groundwork lald down by Lhe
prlor admlnlsLraLlon - Lhe merglng of Lhe ueparLmenL of Puman Servlces and Lhe ueparLmenL
of 8ehavloral uevelopmenL Servlces lnLo Lhe ueparLmenL of PealLh and Puman Servlces (uPPS)
LhaL became effecLlve on !uly 1, 2004.

Secondly, desplLe all Lhe recenL lncremenLal achlevemenLs, Lhere remalns room for
lmprovemenL. lor slmpllclLy, Lhese can be caLegorlzed lnLo Lwo broad areas. llrsL, numerous
reflnemenLs and lmprovemenLs can be made on Lhe programmaLlc slde. Much of Lhls reporL ls
dedlcaLed Lo ldenLlfylng Lhese lmprovemenLs, whlch lnclude a large array of changes and
lnlLlaLlves. 1he second area conslsLs of sysLemlc lmprovemenLs. 1hese are more dlfflculL Lo
lmplemenL, buL Lhe poLenLlal beneflLs can be far reachlng and dramaLlcally lmprove how Lhe
deparLmenL coordlnaLes resources, reduces redundancles, and poLenLlally lowers expendlLures
Lhrough lmproved paymenL accuracy ln all uPPS programs.

An unforLunaLe feaLure of Lhe Amerlcan welfare sysLem ls LhaL lL ls uncoordlnaLed and
noL lnLegraLed ln any meanlngful way. erhaps lL ls besL summarlzed by Lhe openlng paragraph
on welfare ln 1be cooclse ocyclopeJlo oo cooomlcs:



2
1he u.S. welfare sysLem would be an unllkely model for anyone deslgnlng a welfare
sysLem from scraLch. 1he dozens of programs LhaL make up Lhe sysLem" have dlfferenL
(someLlmes compeLlng) goals, lnconslsLenL rules, and over-lapplng groups of
beneflclarles. 8esponslblllLy for admlnlsLerlng Lhe varlous programs ls spread
LhroughouL Lhe execuLlve branch of Lhe federal governmenL and across many
commlLLees of Lhe u.S. Congress. 8esponslblllLles are also shared wlLh sLaLe, counLy, and
clLy governmenLs, whlch acLually dellver Lhe servlces and conLrlbuLe Lo fundlng.
1


ConsequenLly, every sLaLe musL deal wlLh a sysLem ln whlch numerous responslblllLles
for asslsLance Lo lndlvlduals are spread across mulLlLude federal agencles. Whlle Lhese agencles
provlde fundlng, overslghL, and Lechnlcal asslsLance Lo help sLaLes lmprove on a programmaLlc
level, Lhere ls llLLle Lo no coordlnaLlon - and no lnLegraLlon among Lhe varlous federal
programs from a sysLemlc polnL of vlew. lurLhermore, ofLen losL ln Lhe shuffle ls Lhe lmpacL on
Lhe lndlvldual and Lhe famlly belng served, and lL becomes challenglng for sLaLe governmenLs Lo
lnLegraLe Lhelr programs ln any meanlngful way.

CharL 1-1 on Lhe nexL page graphlcally represenLs Lhe complexlLy sLaLes are deallng wlLh,
uslng Malne as an example. 1here are federal agencles wlLhln agencles and deparLmenLs,
dependlng on how Lhey are counLed, Lhere are aL leasL slxLeen federal agencles LhaL lnLeracL
wlLh uPPS. 1hls complex web makes lL dlfflculL Lo manage welfare programs ln an lnLegraLed
manner.


1. 1homas MaCurdy and !effrey M. !ones, Welfare," 1be cooclse ocyclopeJlo oo cooomlcs, Lhe
LlberLy lund, hLLp://www.econllb.org/llbrary/CLL.hLml.

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4
lrom Lhe polnL of vlew of an lndlvldual or a famlly, Lhe plcLure ls even more complex. An
lmpoverlshed person or famlly may have several needs, from asslsLance ln obLalnlng food,
securlng shelLer, recelvlng help wlLh chlld care, and acqulrlng medlcal asslsLance. 8ecause Lhese
forms of asslsLance are provlded on a plecemeal basls, wlLh confllcLlng and compllcaLed
ellglblllLy rules and program sLrucLures LhaL are dellvered ln a slloed fashlon, Lhey are confuslng
for Lhe reclplenL Lo undersLand and case worker Lo admlnlsLer.

1o lllusLraLe Lhls polnL, we examlned a poLenLlal slLuaLlon for a slngle parenL wlLh Lwo
chlldren: a Loddler and a school-age chlld. lf Lhls famlly's lncome ls low enough, lL can quallfy for
several dlfferenL asslsLance programs. llrsL, Lhere are refundable Lax credlLs where Lhls famlly
can recelve a refund ln excess of lncome Laxes pald. Cn Lhe federal level, Lhere ls Lhe Larned
lncome 1ax CredlL and Lhe AddlLlonal Chlld 1ax CredlL. Malne also has a refundable Chlld Care
1ax CredlL. lrom a pure economlc vlewpolnL, Lhese refundable Lax credlLs are noL Laxes aL all.
1hey are governmenL subsldles. LconomlsLs call Lhem negaLlve lncome Laxes."
2


Second, Lhe famlly may be ellglble for Lhe SupplemenLal nuLrlLlon AsslsLance rogram
(SnA), formerly known as and commonly called food sLamps,
3
and may quallfy for ASl8L-
1Anl cash asslsLance.
4
1hlrd, Lhe famlly may recelve houslng asslsLance from subsldlzed
houslng or Lhe Pouslng Cholce voucher program. lourLh, Lhe famlly may be ellglble for chlld
care subsldles. llnally, Lhe famlly may be ellglble for medlcal asslsLance Lhrough MalneCare,
CubCare, or Lax credlLs avallable Lhrough Lhe Affordable Care AcL (ACA).
3
1he analysls
lncorporaLes Lhe base beneflLs of each program ldenLlfled above buL does noL Lake lnLo
conslderaLlon Lhe pleLhora of speclal allowances avallable for addlLlonal needs, such as
LransporLaLlon, Lools, and educaLlonal supplles. lL also does noL lnclude several smaller
programs, lncludlng energy asslsLance, school-lunch programs, and Lhe supplemenLal
nuLrlLlonal program Women, lnfanLs, and Chlldren (WlC).


2. MllLon lrledman ls credlLed wlLh havlng orlglnaLed Lhe concepL of a negaLlve lncome Lax, whlch he
proposed ln hls book copltollsm ooJ lteeJom (1962).
3. 1he u.S. lood, ConservaLlon and Lnergy AcL of 2008 renamed Lhe food-sLamp program Lhe
SupplemenLal nuLrlLlon AsslsLance rogram (SnA), effecLlve CcLober 1, 2008.
4. ASl8L ls Malne's 1Anl program, creaLed ln !uly 1988 Lo provlde case managemenL, educaLlon,
Lralnlng, supporL, and employmenL servlces. ASl8L sLands for AddlLlonal SupporL for eople ln
8eLralnlng and LmploymenL. 1emporary AsslsLance for needy lamllles (1Anl) ls a federally
sponsored program creaLed by Congress ln 1996 Lhrough Lhe ersonal 8esponslblllLy and Work
CpporLunlLy 8econclllaLlon AcL (8WC8A). lL replaced Ald Lo lamllles wlLh uependenL Chlldren
(AluC).
3. MalneCare ls Malne's Medlcald program. Malne's SLaLe Chlldren's PealLh lnsurance rogram
(SCPl) expanded coverage Lo chlldren uslng a comblnaLlon of a Medlcald expanslon and a
separaLe chlld-healLh program referred Lo as CubCare."


3
1he analysls shows LhaL, wlLhln a llmlLed range for Lhls hypoLheLlcal famlly, Lhe sysLem
provldes flnanclal lncenLlves Lo encourage Lhe slngle parenL Lo work. CharL 1-2 compares Lhe
economlc lmpacL on Lhe famlly for four scenarlos:
l. 1he parenL does noL work.
ll. 1he parenL works LwenLy hours a week for $7.30 an hour.
lll. 1he parenL works forLy hours a week for $7.30 an hour.
lv. 1he parenL works forLy hours a week for $8.00 an hour.

CharL 1-2: Income & 8enef|ts Ca|cu|at|on to 58 per nour



1he more Lhe parenL works (and Lhe hlgher her hourly wage), Lhe hlgher ls her
comblned lncome and beneflLs. lf we focus on Lhe subLoLal afLer Lhe chlld care subsldy, whlch ls
Lhe Lhlrd llne up from Lhe boLLom, Lhe beneflL Lo Lhe famlly lncreases from $1,898 a monLh
wlLhouL work Lo $3,321 for parL-Llme work aL $7.30 per hour Lo $4,072 for full-Llme work aL
$7.30 per hour and flnally Lo $4,127 for full-Llme aL $8.00 per hour. 1hls growLh ln comblned
lncome and beneflLs allgns wlLh Lhe ASl8L program ln helplng famllles by encouraglng work.

lor Lhls lncome range, when medlcal asslsLance ls added, Lhe effecL ls Lhe same. 1he
more Lhe slngle parenL works, Lhe beLLer off she wlll be flnanclally. Medlcal asslsLance ls Lhe lasL
lLem added Lo Lhe analysls because lL may noL always be needed lf Lhe parenL has an employer
who provldes healLh care as a beneflL. 1hls wlll be explalned ln furLher deLall below.

!"#$%&'( ) )) ))) )*
+(,&-. 0%1# 234 56789 56789 5:799
+(,&; 0(&<#= >#& 0##< 9 ?9 @9 @9
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6"78+,*9:" ;*< =&",>#( 0 ?42 10@ 12A
=*(B *+, C!DE F22 @1@ ?11 ?12
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!,FB(B%- HI:G: ?IKJ6 ?IGK6 ?IGG6
=B>:, =*&" C89(>,K 0 F@A 232?@ 232?0
!,FB(B%- HI:G: KIK?H @I96? @IH?6
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)$"(M# %$= N#$#O'B; P%-",-%B'($ O(& !%MQ-# R%M'-. (O LC&##
?9HK A%'$# D%B%


6
ln calculaLlng Lhe numbers for Lhls analysls, lL was necessary Lo make assumpLlons. 1he
numbers represenL a poLenLlal ouLcome, buL clrcumsLances and locaLlon may alLer Lhose
numbers elLher upwards or downwards. 1he paLLern, however, wlll llkely be Lhe same. 1he flrsL
assumpLlon ls LhaL Lhe slngle parenL dld noL recelve any addlLlonal lncome from chlld supporL or
any oLher source. Second, lL was assumed LhaL Lhe slngle parenL was able Lo secure a houslng-
cholce voucher ln orLland from Lhe Malne SLaLe Pouslng AuLhorlLy. 1he calculaLlon assumed a
Lwo-bedroom aparLmenL uslng Lhe sLandard Lable provlded by Lhe AuLhorlLy for deLermlnlng
renL.
6
1hlrd, lL assumed LhaL Lhe parenL placed Lhe chlldren ln a quallLy chlld care cenLer ln
orLland aL Lhe markeL raLe as deLermlned by uPPS.
7
no chlld care servlces were assumed lf
Lhe parenL dld noL work. Powever, lf Lhe parenL worked full Llme, lL assumed full-Llme chlld care
servlces for Lhe Loddler buL only half Llme for Lhe school-age chlld. lf Lhe parenL worked half
Llme, Lhen Lhe parL-Llme raLe was deLermlned for Lhe Loddler. llnally, lL assumed Lhe per-
member-per-monLh cosLs for MalneCare and CubCare. lL also assumed purchase of a sllver
healLh-care plan ln Lhe orLland area on Lhe federal healLh-care exchange when Lhe parenL
becomes lnellglble for MalneCare, and when lL becomes cheaper Lo swlLch Lhe enLlre famlly
over Lo Lhe exchange.
8


lf we expand Lhe analysls beyond Lhe $8 per-hour wage, however, Lhere are unlnLended
consequences. lL does noL always beneflL Lhe parenL Lo earn more money. ln facL, Lhe parenL
loses flnanclally lf she earns more money, shown ln llgure 3. lf Lhe parenL were Lo earn $9 an
hour, lnsLead of $8 an hour, she would lose $281 for Lhe monLh. lL works ouL Lhls way because
she would lose all her SnA beneflLs, and her beneflLs would be reduced for Lhe followlng
programs: Lhe houslng-cholce voucher, Lhe chlld care subsldy, and Lhe refundable Lax credlLs.
1hese reducLlons would be greaLer Lhan Lhe exLra neL lncome earned from Lhe addlLlonal dollar
per hour she mlghL earn. 1hese ouLcomes are conLrary Lo Lhe goals of ASl8L.


6. 1here ls currenLly a walLlng llsL for houslng subsldles.
7. CuallLy chlld care provlders are deflned for Lax purposes as Lhose wlLh a quallLy cerLlflcaLe lssued
by uPPS Cfflce of Chlld and lamlly Servlces. 8egulaLlons of Lhe u.S. AdmlnlsLraLlon for Chlldren
and lamllles (ACl) for Lhe Chlld Care and uevelopmenL lund (CCul) requlre sLaLes Lo conducL local
markeL-raLe surveys LhaL esLabllsh maxlmum permlsslble relmbursemenL raLes for care subsldles.
8. 1he ACA deflnes flve levels of plans: bronze, sllver, gold, plaLlnum, and caLasLrophlc. A sllver plan
pays on average 70 of Lhe cosLs, wlLh Lhe remalnlng 30 comlng ouL of pockeL. 1he analysls
assumes LhaL when lL becomes cheaper for Lhe famlly Lo swlLch over Lo Lhe exchange, lL wlll do so.


7
CharL 1-3: Income & 8enef|ts Ca|cu|at|on to 516 per nour



WhaL makes Lhls phenomenon even worse ls Lhe facL LhaL Lhls parenL would have Lo
earn slgnlflcanLly more Lo recover Lhe loss. ln facL, she would have Lo earn Lwlce as much, LhaL
ls, $16 an hour before she would recover Lhe losL beneflLs from earnlng $8 an hour. CharL 1-4
graphlcally lllusLraLes Lhe full scope of Lhe problem:
1he boLLom blue llne represenLs Lhe neL earned lncome, afLer lncome and payroll Laxes
are deducLed.
1he orange llne lmmedlaLely above Lhe blue llne ls Lhe neL earned lncome, plus
refundable Lax credlLs.

Lach subsequenL llne, worklng upwards, adds on anoLher beneflL ln a cumulaLlve manner.
1he green llne above Lhe orange llne adds SnA and cash beneflLs.
1he gray llne adds houslng vouchers.
1he red llne adds Lhe chlld care subsldy.
llnally, Lhe yellow llne adds medlcal asslsLance, ln Lhe form of MalneCare, CubCare, or
Lhe healLh-care lnsurance Lax subsldy pursuanL Lo Lhe ACA.
9


9. PealLh-care lnsurance subsldles were deLermlned for orLland uslng Lhe subsldy calculaLor
provlded by Lhe Penry !. kalser loundaLlon: hLLp://kff.org/lnLeracLlve/subsldy-calculaLor/.
!"#$%&'( )* * *) ,( -) -))
.(/&01 2%3# 45677 48677 497 ,( 49: 49;677
.(/&< 2(&=#> ?#& 2##= @7 @7 @7 @7
A($,B01 C%,% '$ C(00%&<
neL Cross Larned lncome 1,281 1,441 (a) 2,333
8efundable 1ax CredlLs 614 393 (a) 302
Cash and SnA 361 0 (a) 0
!/D,(,%0 EFE:; EF7G@ (a) EF5GH
Pouslng Cholce voucher 741 692 (a) 383
!/D,(,%0 EF88H EFHE; (a) GFEE7
Chlld Care Subsldy 1,130 1,120 (a) 936
!/D,(,%0 @F9EH GF5@; (a) @F9:;
Medlcal AsslsLance 716 716 (a) 407
I(,%0 @F5@G @F:;9 (a) @F:;@
)$"(J# %$> K#$#L',< M%0"/0%,'($ L(& !%JN0# O%J'01 (L IB&##
E79G A%'$# C%,%
noLe: (a) uaLa omlLLed for scenarlos vl Lhrough xl.


8
CharL 1-4: Comb|ned Income and 8enef|ts Mapp|ng for Iam||y of 1hree



1hus, Lhe Lop yellow llne provldes all neL lncome and beneflLs, conslsLlng of neL earned
lncome, refundable Lax credlLs, cash asslsLance, SnA, houslng-cholce voucher, chlld care
subsldles, and medlcal asslsLance.

A dlsLlncLlve feaLure of CharL 1-4 ls Lhe [agged edge of Lhe Lop Lwo llnes. 1he red llne, or
Lhe second from Lhe Lop, ls perhaps Lhe mosL lmporLanL one. lL represenLs Lhe poLenLlal
summaLlon of lncome and welfare beneflLs wlLhouL any medlcal asslsLance. 1he peaks lllusLraLe
Lhose wage levels LhaL maxlmlze comblned neL lncome and beneflLs before Lhey drop afLer an
lncrease ln wages. 1hese peaks and subsequenL reducLlons have been called welfare cllffs.
1hese are Lhe polnLs where lndlvlduals geL Lrapped because of Lhe perverse economlc
lncenLlves lnherenL ln Lhe federal-sLaLe publlc-welfare sysLem. ln Lhls lllusLraLlon, Lhe slngle
parenL geLs Lrapped earnlng $8 per hour and would lose flnanclally lf she earned hlgher wages,
unless she earned $16 per hour. 8uL Lhen, however, she would hlL anoLher welfare cllff and
would lose agaln lf she earned more unless she earned aL leasL $22 per hour. AL $23 per hour,
she hlLs a Lhlrd cllff and would noL recover unLll she earned aL leasL $30.

!
"!!
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#$"!!
%$!!!
%$"!!
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'$!!!
'$"!!
"$!!!
! "!! #$!!! #$"!! %$!!! %$"!! &$!!! &$"!! '$!!! '$"!! "$!!! "$"!! ($!!!
)
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+
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4
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-
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<
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=
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6
;
>6*;; 456./0 7.8*+/ -. <*==56;
7.8*+/ 5.0 9/./:-3; ?5@@-.A :*6 B5+@=/ C5+-=D *: EF6//G B-.A=/ H56/.3 @=I; EJ* )F-=06/.
2/3 456./0 7.8*+/ K E5L )6/0-3; K B2MH K )5;F K N*I;-.A K )F-=0 )56/ K ?/0-85= M;;-;35.8/
2/3 456./0 7.8*+/ K E5L )6/0-3; K B2MH K )5;F K N*I;-.A K )F-=0 )56/
2/3 456./0 7.8*+/ K E5L )6/0-3; K B2MH K )5;F K N*I;-.A
2/3 456./0 7.8*+/ K E5L )6/0-3; K B2MH K )5;F
2/3 456./0 7.8*+/ K OP/:I.05,=/Q E5L )6/0-3;
2/3 456./0 7.8*+/ O?-.I; 7.8*+/RH5D6*== E5L/;Q
#G# 6/:/6/.8/ =-./
ST @/6 F*I6 J5A/
S#( @/6 F*I6 J5A/ S%& @/6 F*I6 J5A/
S&& @/6 F*I6 J5A/


9
1he yellow llne, whlch lncludes medlcal asslsLance, shows Lhe same problem, excepL $8
per hour ls Lhe hlghesL of all peaks, and Lhe charL shows LhaL she would requlre $33 per hour Lo
recover Lhe same level of lncome and beneflLs. 1he yellow llne, however, needs Lo be vlewed
wlLh some caveaLs. llrsL, Lhe analysls uses Lhe per-member-per-monLh (or MM) cosL for
MalneCare and CubCare and compares LhaL Lo Lhe Lax subsldles provlded by Lhe ACA. 1hls
comparlson ls Lrue ln Lerms of cosL of Lhe program, buL Lhe reclplenL may vlew lL dlfferenLly
because she would noL necessarlly know Lhe Lrue cosLs.

Cn Lhe oLher hand, Lhe llne remalns by colncldence lnsLrucLlve. 1he Lax subsldles under
Lhe ACA are less Lhan Lhe cosL of MalneCare or CubCare, Lhus lL shows a relaLlve drop aL $11 per
hour when Lhe parenL loses MalneCare coverage and anoLher drop aL $13 when lL would be
advanLageous for her Lo swlLch Lo a famlly plan on Lhe exchange. 1he parenL, however, would
sLlll need Lo welgh Lhe rlsk of havlng ouL-of-pockeL expenses for a pollcy obLalned Lhrough Lhe
exchange. Second, Lhere ls Lhe posslblllLy LhaL Lhe parenL would be offered healLh coverage
Lhrough an employer. 1hls may negaLe Lhe lmporLance of Lhe medlcal asslsLance, especlally for
Lhe hlgher wages. AL Lhe lower wages, however, MalneCare would llkely be cheaper because
Lhere are no premlum shares," and an employer's plan would llkely requlre an employee
conLrlbuLlon.

llnally, CharL 1-4 underscores why Lhe publlc-welfare sysLem ls broken. lL ls noL
necessarlly any slngle program LhaL ls Lhe problem. 1hey each operaLe by complex rules LhaL
may make sense wlLhln lLs own-slloed purvlew. 1he refundable Lax credlLs are noLable because
Lhey, by Lhemselves, provlde no cllff effecL and would exerL a poslLlve effecL on labor
parLlclpaLlon. Powever, when you sLarL sLacklng programs on Lop of each oLher, whlch ls whaL
happens ln Lhe real world, sysLemlcally you arrlve aL an lrraLlonal and llloglcal answer. lL ls
doubLful LhaL anyone would deslgn a sysLem where Lhe maxlmum beneflLs accrue for an
lndlvldual aL $8 per hour buL decllne lf she earns a llLLle blL more. Cr, a sysLem where a person
earnlng $8 per hour would have more Lhan a person earnlng $24 an hour. 8uL Lhls ls Lhe sysLem
LhaL has been deslgned over many decades by WashlngLon ln a plecemeal and slloed manner.
1he resulL ls an overcompllcaLed sysLem LhaL Lraps lndlvlduals ln low-lncome llfesLyles by lLs
poor deslgn and lack of lncenLlves Lo lncrease wealLh and economlc prosperlLy.

1hese unlnLended economlc consequences affecL real people and Lhelr famllles. lrom a
mlcroeconomlc perspecLlve, humans behave ln raLlonal ways LhaL maxlmlze Lhelr beneflLs. lf
welfare sysLems were Lo be redeslgned wlLh Lhls facL ln mlnd, lL would be posslble LhaL Lhe
sysLem could be Lruly a helplng hand durlng Llmes ln need and help lndlvlduals and famllles ln
ways LhaL beneflL Lhelr wellbelng and move Lhem Loward flnanclal lndependence from
governmenL asslsLance. As [usL demonsLraLed, Lhe Amerlcan sysLem of welfare, however, has
embedded perverse economlc lncenLlves LhaL encourage dependency.

A few sLaLes have experlmenLed wlLh small demonsLraLlon pro[ecLs ln an aLLempL Lo
lnLegraLe welfare programs ln a more meanlngful way, buL none has fully lnLegraLed Lhese
servlces ln ways LhaL help needy famllles lnLegraLe lnLo socleLy wlLhouL Lhe need for
governmenLal asslsLance. Pouslng asslsLance, for example, ls pracLlcally enLlrely ouLslde Lhe


10
sLrucLure of any sLaLe welfare sysLem, desplLe Lhe facL LhaL shelLer ls a baslc human need. lL
makes no sense LhaL when looklng aL a case for asslsLance LhaL Lhe need for houslng ls
segregaLed from oLher baslc needs.

1here ls hope. 1he federal governmenL has creaLed llmlLed flexlblllLy wlLhln many of lLs
welfare programs LhaL allow sLaLes Lo experlmenL wlLh beLLer ways of dolng Lhlngs, alLhough
sLaLes are sub[ecL Lo dlfferenL and, aL Llmes, conLrary federal guldance, dependlng on Lhe
admlnlsLraLlon ln WashlngLon. Medlcald, for example, allows for several Lypes of walvers from
federal regulaLlons. 1hese provlslons ln federal law provlde llmlLed opporLunlLles for sLaLes Lo
seek lnnovaLlons, alLhough sLlll ln a slloed fashlon. Such opporLunlLles can allow sLaLes Lo
experlmenL Lo flnd ways of beLLer servlng people and can be used Lo redeslgn Lhe sysLem LhaL
focus on Lhe person and famlly ln a more hollsLlc manner. SLaLes, however, need much greaLer
flexlblllLy and lnLegraLlon auLhorlLy lf Lhey are ever Lo be able Lo Lruly provlde whaL one publlc
welfare program, l.e., Medlcald, sLaLes as lLs purpose, 1o furnlsh rehablllLaLlon and oLher
servlces Lo help such famllles and lndlvlduals aLLaln or reLaln capablllLy for lndependence."
10


ln addlLlon Lo Lhe reasons of beLLer ouLcomes for people and sLreamllnlng of
bureaucracles, Lhere are also economlc and flscal reasons Lo underLake Lhese changes. lor
sLaLes ln general, Medlcald and welfare programs have grown Lo become one of Lhe mosL
domlnanL budgeLary lssues. Lspeclally when all funds are consldered - sLaLe general revenue,
oLher sLaLe revenue, and federal funds - welfare programs have grown boLh ln magnlLude and
proporLlon. CharL 1-3 lllusLraLes Lhls polnL for Malne. lL uses daLa collecLed and publlshed as
sLaLe expendlLure reporLs by Lhe naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers (nAS8C).
11

Medlcald spendlng from all funds, even afLer ad[usLed for lnflaLlon, has nearly qulnLupled ln
Malne ln less Lhan LhlrLy years. 1he Medlcald porLlon of Lhe budgeL ln all funds has doubled
over LhaL Llmeframe from 13 Lo 32.



10. 42 u.S.C. 1396 (2).
11. values for Sl? 2013 are esLlmaLed.


11
CharL 1-3: Ma|ne kea| 8udget Growth |n Magn|tude & ercent



Whlle all sLaLes are sLruggllng wlLh Medlcald spendlng, Malne ranks among Lhe sLaLes
wlLh Lhe hlghesL budgeLary burden. As a percenLage of lLs overall budgeL, whlch lncludes Lhe
general fund, oLher sLaLe funds, and federal funds, Malne now spends Lhe Lhlrd hlghesL
proporLlon of all Lhe sLaLes on Medlcald. As a maLLer of comparlson, Malne ranks LhlrLy-flrsL on
Lhe proporLlon of lLs budgeL spenL on k-12 educaLlon. See CharL 1-6.

Maklng some economlc comparlsons help puL Lhe growLh lnLo perspecLlve. Pere we
compare Lhe lnflaLlon-ad[usLed cosL (all funds) of Medlcald and publlc asslsLance, as publlshed
by nAS8C, Lo Lhree facLors: populaLlon, employmenL, and sLaLe personal lncome. 1he flrsL
comparlson ls Lo Lhe LoLal populaLlon, as publlshed by Lhe u.S. 8ureau of Lconomlc Analysls. 8y
dlvldlng Lhe populaLlon lnLo Lhe lnflaLlon-ad[usLed budgeL, we can see LhaL Lhe per-caplLa cosL
has nearly Lrlpled slnce 1983. 1he per-caplLa cosL was $2,024 ln Sl? 2013. See CharL 1-7.

1he second comparlson ls Lo Lhe LoLal number of employed persons, as measured by Lhe
currenL populaLlon survey of Lhe u.S. 8ureau of Labor SLaLlsLlcs. Agaln, Lhe Malne lnflaLlon-
ad[usLed employed person cosL nearly Lrlpled slnce 1983. ln Sl? 2013, Lhe cosL per employed
person was $4,086. See CharL 1-8.

!
Maine Real Budget Growth in Magnitude & Percent
!"#$% '#$#( )*+,(# -.%% /*0+12
30 45%%5"01 "6 '/7 89:; <"%%$=1
-.+>*1#(+ 6"= 306%$#5"02
<$#$ '"*=?(1@ "#$%&'#( *++&,%#$%&' &- .$#$/ 0123/$ 4--%,/5+6
!"#"$ &'($)*+",-$ .$(/-"07 8'-(#$%&' #291+$/2 1+%'3 $:/
;&'+1</5 =5%,/ 8'2/> &- $:/ ?@.@ 015/#1 &- .$#$%+$%,+@


12
CharL 1-6: Ma|ne's State kank|ng |n Iund|ng Med|ca|d & k-12 Lducat|on



CharL 1-7: er-Cap|ta Cost, Med|ca|d & ub||c Ass|stance


"#$#% $&' ($&) * "#$#% $&' ($&) *
!" $%&'()* ++ !" ,-..(/&- +0
1" 2)3-4)4 +! 1" 5%)).6784)-4 +9
+" :%(&;-4 +! +, -$.&% +/
9" ,-))%.(*4 1< 9" =&->()4 +1
?" @%A4. 1< ?" 2)3-4)4 +1
0+, 1%2 3$4567.8% /+ 09, 1%2 3$4567.8% 10
!"#"$ #&$'#($ )* !"#"$ #&$'#($ +,
+0, -$.&% 0:
;'<=$#.>&
"?@ /A0+ B%8=%&#$C% >D E>#$F "#$#% G<'C%#
-%'.=$.'
Per Capita Cost for Medicaid and Public Assistance


13
CharL 1-8: Cost per Lmp|oyed erson, Med|ca|d & ub||c Ass|stance



1he Lhlrd comparlson ls Lo sLaLe personal lncome, as measured by Lhe u.S. 8ureau of
Lconomlc Analysls. SLaLe ersonal lncome, an overall measure of Lhe LoLal lncome wlLhln a
sLaLe, ls ofLen a preferable economlc lndlcaLor over SLaLe uomesLlc roducL. As a percenL of
SLaLe ersonal lncome, Lhe cosL of Medlcald and publlc-asslsLance programs has approxlmaLely
doubled slnce 1983. 1he cosL of Medlcald and publlc asslsLance was 3.0 of SLaLe ersonal
lncome ln Sl? 2013. See CharL 1-9.

An examlnaLlon of all Lhree comparlsons - per-caplLa, per employed person, and
percenLage of sLaLe personal lncome- demonsLraLe LhaL, ln Lerms of economlc burden, Lhe
growLh has leveled off slnce Sl? 2006 and has come down somewhaL slnce Sl? 2009. 1hls
provldes evldence supporLlng our flrsL observaLlon: Lhe Leage admlnlsLraLlon has slgnlflcanLly
advanced reformlng Lhe sysLem. 1hese long-run Lrends are encouraglng. Powever, Lhere are
sLlll good reasons Lo be cauLlous ln LhaL opLlmlsm.

1he flrsL reason for cauLlon requlres looklng behlnd Lhose numbers. Some of Lhe
lmprovemenL can be accounLed for by lmproved economlc lndlcaLors, such as Lhe lmprovemenL
ln employmenL from Sl? 2002 Lhrough Sl? 2007, or Lhe lmprovemenL ln sLaLe personal lncome
Lhrough Sl? 2008. CLher lmprovemenLs relaLe Lo conLrolllng cosLs. CharL 1-10 shows a hlsLory
Cost per Employed Person for Medicaid & Public Assistance


14
of Lhe LoLal budgeL (all funds) for uPPS slnce Sl? 2002.
12
1he dollars shown are noL ad[usLed for
lnflaLlon. CosLs have been conLalned slnce Sl? 2009.

CharL 1-9: Cost of Med|ca|d & ub||c Ass|stance to State ersona| Income


CharL 1-10: DnnS 1ota| 8udgets by Iund|ng Source


12. 8udgeLs for Sl? 2002, 2003, and 2004 are pre-merger budgeLs of Lhe same program areas.
Increasing Share of Economic Resources
!"#$ !"#$ !"%!
!"%$
!"$#
&"!& !"$$
!"$'
!"%&
!"%(
&"&& &"!%
!")! !"))
!")(
!"*&
!"*+
!"*# !"'!
!"')
!"'&
!"'+
!"'(
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!")*
!"!+ !"!*
&")*
&"''
&"#)
&"(#
&"#) &"(&
&"((
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&"%#
&"%)
&"%!
&"%!
)"))
)"'(
)"#%
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)"$%
*"!+
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*"*(
*"'&
*"*%
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,&"!
,&"+
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,)"+
,*"!
,*"+
-./ )!!) -./ )!!* -./ )!!' -./ )!!+ -./ )!!( -./ )!!# -./ )!!% -./ )!!$ -./ )!&! -./ )!&& -./ )!&) -./ )!&*
1
2
3
3
2
4
5
6
788- 94:;3 1<=>?: @A33 .<5=6B
!"#"$%& ()#* +,-"$ .,%," /"0"#)" 1//1 +,-"$ ("*"$%& ()#*2


13
CharL 1-11 uses Lhe same daLa as CharL 1-10, buL lL compares Lhe growLh raLes beLween
Lwo perlods: Sl? 2002 Lo Sl? 2010, and Sl? 2010 Lo Sl? 2013. lor all funds, Lhe average annual
growLh raLes were 3.3 for Sl? 2002 Lo Sl? 2010, and -0.2 for Sl? 2010 Lo Sl? 2013. lor
sLaLe funds, lncludlng federal economlc sLlmulus money from Lhe Amerlcan 8ecovery and
8elnvesLmenL AcL of 2009 (A88A) lnLended Lo help sLaLes meeL revenue shorLfalls,
13
Lhe
average annual growLh raLes over Lhe same Llme perlods were 3.3 and 1.1, respecLlvely. lor
federal funds, oLher Lhan A88A, Lhe growLh raLes were 3.4 and -1.3, respecLlvely.

1he second reason for cauLlon ls LhaL Malne's burdens sLlll rank hlgh when compared Lo
oLher sLaLes. Malne ranks flfLh on a per-caplLa basls, whlch ls $613 above Lhe sLaLe average,
LenLh on a per employed person basls, whlch ls $1,022 above Lhe sLaLe average, and Lhlrd ln
Lerms of a percenLage of sLaLe personal lncome, whlch ls 1.7 percenLage polnLs above Lhe sLaLe
average. See CharL 1-12. Malne, Lherefore, has an economlc burden 31.6 Lo 34.9 hlgher Lhan
Lhe naLlonal average, dependlng on whlch measure ls chosen. A reasonable pollcy sLraLegy,
Lherefore, would be Lo flnd ways Lo lower Lhe burden.

1hese commlLmenLs Lo fund Medlcald and oLher uPPS programs are slgnlflcanL. CharL
1-13 provldes Lhe LoLal dollar commlLmenL for Sl? 2013.

CharL 1-11: Average Annua| Change |n DnnS 8udget


13. 8ecause A88A funds were lnLended Lo replace sLaLe funds, Lhey are Lyplcally lncluded wlLh sLaLe
funds for comparlson purposes Lo avold a dlsLorLlon of Lhe comparlson. CLherwlse, lL would glve a
mlsleadlng Lrend for boLh sLaLe and federal funds.
S.S
S.4
S.S
1.1
-1.3
-0.2
-1.S
-1.0
-0.S
0.0
0.S
1.0
1.S
2.0
2.S
3.0
3.S
4.0
4.S
S.0
S.S
State Iunds + AkkA Cther Iedera| Iunds A|| Iunds
Average Annua| Change |n DnnS 8udget
SI 2002 to SI 2010 SI 2010 to SI 2013


16
CharL 1-12: 1op States for Med|ca|d & ub||c-Ass|stance Costs


CharL 1-13: DnnS 8udget (A|| Iunds) by rogram, SI 2013


A fourLh reason for cauLlon ls LhaL cosL-savlngs lnlLlaLlves can be abandoned and recenL
lmprovemenLs can be easlly reversed, especlally ln llghL of demographlc and economlc Lrends.
1 Alaska 2,434 $ 1 Alaska 3,243 $ 1 Mlsslsslppl 3.4
2 vermonL 2,381 $ 2 new ?ork 4,849 $ 2 vermonL 3.3
3 new ?ork 2,184 $ 3 Mlsslsslppl 4,630 $ ! "#$%& '()*
4 MassachuseLLs 2,136 $ 4 MassachuseLLs 4,443 $ 4 WesL vlrglnla 4.9
' "#$%& +,)+- . 3 vermonL 4,422 $ 3 new Mexlco 4.9
6 8hode lsland 1,992 $ 6 WesL vlrglnla 4,321 $ 6 Alaska 4.9
7 ennsylvanla 1,906 $ 7 new Mexlco 4,263 $ 7 Arkansas 4.8
8 Mlsslsslppl 1,843 $ 8 8hode lsland 4,147 $ 8 8hode lsland 4.3
9 ConnecLlcuL 1,831 $ 9 Arkansas 4,132 $ 9 ennsylvanla 4.2
10 new Mexlco 1,762 $ 0) "#$%& -,)12 . 10 new ?ork 4.1
!"#!$ % '"$(# % ')'*
345 3&% 67#7&8 $% 94878 :4; "&<$=#$< #%< >?@A$= B88$87#%=&C 6DE +)0!
uaLa Sources: naLl onal Assocl aLl on of SLaLe 8udgeL Cffl cers, SLaLe Lxpendl Lure 8eporL: Lxaml nl ng ll scal
2011-2013 SLaLe Spendl ng, u.S. 8ureau of Lconoml c Anal ysl s, and u.S. 8ureau of Labor SLaLl sLl cs.
>&; 9#5$7# 9487 F#%G >&; HI5A4J&< 9487 F#%G * 67#7& >&;84%#A K%=4I&
+,-,. /0.1-2. +,-,. /0.1-2. +,-,. /0.1-2.
!"#$%&#'()
!+#(""#('+
!'$#,+,#&"-
!')#(("#$(,
!&,#(-)#")$
!&,#-"%#)%%
!""%#(-+#-+)
!",'#&'-#,%$
!$&&#"$)#$",
!$#,&)#%&,#++"
!-$(#%+%#$()
./0 $%"' 122. 3456789 :;; /4<5=
>4;8?@4;84AB; :CCB?A= D?@7<=?<6 E F764;B8GAH .7AI?@7=
1GAG8J7B 1?K E F?I7AI?7L M=H@JB?8A?@ N7<87A= OCC?@7 GC 8J7 NGPP?==?G<7A
:6?<6 E 1?=BQ?;?8H .7AI?@7= .4Q=8B<@7 :Q4=7 E >7<8B; 27B;8J .7AI?@7=
1?=7B=7 NG<8AG; E MA7I7<8?G< NJ?;5 E /BP?;H .7AI?@7=
/BP?;H R<57S7<57<@7 >B?<7NBA7 .7AI?@7=
>B?<7NBA7 .7AI?@7=
:;; O8J7A .7AI?@7=


17
Long-Lerm care ls a slgnlflcanL proporLlon of Lhe cosL of MalneCare, and Lhe elderly populaLlon
ls forecasLed Lo grow dramaLlcally, by as much as 46.3, over Lhe nexL Len years.
14
Llkewlse, Lhe
number of persons llvlng ln poverLy has conLlnued Lo grow, accordlng Lo Census 8ureau
measuremenLs. 1he comblnaLlon of Lhese Lrends wlll place pressure on Lhe deparLmenL's
budgeL. CharL 1-14 provldes an lllusLraLlon on how Lhese facLors may drlve cosLs for MalneCare
servlces relaLed Lo Lhe resL of Lhe budgeL.

CharL 1-14: Ma|neCare Serv|ces and 8udget Growth Compar|son


14. !ulle lrallch eL. al., Clder AdulLs and AdulLs wlLh ulsablllLles: opulaLlon and Servlce use 1rends ln
Malne," cbottbook, 2012 LdlLlon, hLLp://muskle.usm.malne.edu/ubllcaLlons/uA/AdulLs-
ulsablllLles-Malne-Servlce-use-1rends-charLbook-2012.pdf. noLe LhaL Lhe cbottbook reporLed
nearly 99 of Lhe sLaLe's populaLlon growLh would be among Lhose 63 and older. AlLhough Lhls
calculaLlon ls correcL when age brackeLs are aggregaLed ln Lhls manner, lL may be mlsleadlng by
glvlng Lhe false lmpresslon LhaL no caLegory below 63 ls pro[ecLed Lo have growLh when ln facL
four of Lhose slx age caLegorles are pro[ecLed Lo have slgnlflcanL growLh. 1he calculaLlon works ouL
LhaL way because Lhe age caLegorles of 13-24 and 43-34 are pro[ecLed Lo have negaLlve growLh,
whlch negaLes Lhe growLh ln Lhe remalnlng four caLegorles under age 63. erhaps a beLLer way Lo
represenL Lhe growLh would be Lo exclude Lhe Lwo age caLegorles wlLh negaLlve growLh, glvlng Lhe
resulL of approxlmaLely 70 of Lhe growLh aLLrlbuLed Lo age caLegory of 63 and older.
1.0
1.S
2.0
2.S
3.0
3.S
2
0
0
2
-
0
3
2
0
0
3
-
0
4
2
0
0
4
-
0
S
2
0
0
S
-
0
6
2
0
0
6
-
0
7
2
0
0
7
-
0
8
2
0
0
8
-
0
9
2
0
0
9
-
1
0
2
0
1
0
-
1
1
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
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G
r
o
w
t
h

I
a
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t
o
r

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r
o
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8
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e
a
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2
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0
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0
3
State I|sca| ear
Ma|neCare Serv|ces and kest of 8udget Growth Compar|son
State Iunds Cn|y
Ma|neCare Serv|ces
Ma|neCare Serv|ces Iorecast
kest of 8udget (kC8)
kC8 1rend||ne


18
1here ls a relaLed comparlson LhaL can be made. lor each person on MalneCare, Lhere
were 1.8 employed Malners ln Sl? 2012-13. lor obvlous reasons, lL ls advanLageous Lo have a
hlgher number of employed persons supporLlng persons on MalneCare. 8ecause enrollmenL ls
expecLed Lo grow, Lhere ls rlsk LhaL Lhe raLlo could drop ln Sl? 2020 Lo 1.7 employed persons Lo
each person on MalneCare.
13
See CharLs 1-13 and 1-16.

CharL 1-13: "#$%&'()* +&(),"&', -)'#..$,)/ /# -$%.#0$,)/



13. noLe LhaL Lhe employmenL numbers ln CharL 1-13 are sllghLly dlfferenL from Lhose ln our !anuary
reporL because Lhe u.S. 8ureau of Labor SLaLlsLlcs revlsed lLs esLlmaLes. 1he raLlos, however,
remaln unchanged. See vldallna Abadam, nlcole Pavlns, and Llza kelly, 8evlslons ln SLaLe
LsLabllshmenL-based LmploymenL LsLlmaLes LffecLlve !anuary 2014," u.S. 8ureau of Labor
SLaLlsLlcs, hLLp://www.bls.gov/sae/benchmark2014.pdf.
S1S,800
370,200
497,900
336,000
100,000
101,100
61S,800
S99,000
0 200,000 400,000 600,000 800,000
Compar|ng Ma|neCare Lnro||ment to Lmp|oyment
C 2020
Lnro||ment to
Lmp|oyment kat|o:
1 to 1.7
SI 2012-13
Lnro||ment to
Lmp|oyment kat|o:
Ma|neCare
Lnro||ment
|n 2012-13
Ma|neCare
Lnro||ment
|n 2020
Lmp|oyment
|n 2012-13
Lmp|oyment
|n 2020
r|vate
r|vate
Government-->
Government-->
1 to 1.8
Date Sources: Lstab||shment data of the U.S. 8ureau of Labor Stat|st|cs, 2020 ro[ect|ons from the Ma|ne Department of Labor,
Center for Workforce kesearch and Informat|on, Ma|ne Department of nea|th & numan Serv|ces, and A|exander Group Iorecasts.
8ase||ne opu|at|on
8ase||ne opu|at|on


19
CharL 1-16: Iorecasted Ma|neCare-to-Lmp|oyed Ma|ners kat|os


AlLhough MalneCare ls Lhe largesL welfare program, lL does noL represenL Lhe enLlre
welfare populaLlon. noL all persons on welfare, lncludlng Lhose recelvlng SnA beneflLs or chlld
care subsldles, are on MalneCare. CharL 1-17, uslng ennsylvanla daLa, provldes a venn dlagram
Lo lllusLraLe how welfare programs serve overlapplng caseloads.

CharL 1-17: Understand|ng Undup||cated Counts

Ma|neCare
Lnro||ee
Lmp|oyed
Ma|ners
Lach Ma|neCare enro||ee was
supported by 1.8 emp|oyed
Ma|ners |n SI 2012-13.
Lach Ma|neCare enro||ee |s
forecasted to be supported by
1.7 emp|oyed Ma|ners |n 2020.
! "# $%#&'()#* , *-./
Understanding Unduplicated Counts
!"##$%&'(#)( +(,( -./ 0"1,"23"/ 4564
789:;<!
0=8! >,?"/
MA/CPl only
MA/CPl and SnA
SnA
only
MA/CPl,
SnA, and
CLher
MA/CPl
and CLher
CLher only
SnA and CLher
noLe: CLher conslsLs of Ceneral AsslsLance, 1Anl, AsslsLance
for Lhe 8llnd, SSl, Chlld Care Servlces, and Lnergy AsslsLance.
@$)#A !"##$%&'(#)( ($ (# BC(21&"
Program Count Percent
MA/CHIP and
SNAP (No Other)
976,050 35.7%
MA/CHIP only 750,038 27.4%
MA/CHIP, SNAP,
and Other
525,483 19.2%
SNAP only 319,483 11.7%
MA/CHIP and
Other (No SNAP)
141,713 5.2%
Other only 18,792 0.7%
SNAP and Other
(No MA/CHIP)
2,378 0.1%
All Programs 2,733,937 100.0%


20
ln Lhe case of Malne, we dld noL lndependenLly produce an undupllcaLed number uslng
uPPS's daLa sysLem Lo generaLe a venn dlagram. AlLhough Lhe deparLmenL has produced
undupllcaLed numbers on an oJ boc basls, Lhe counLs were ln Lhe aggregaLe on an annual basls
as opposed Lo a polnL-ln-Llme calculaLlon by program lnLersecLlon. llrsL, Lhe oJ-boc
undupllcaLed counLs do noL provlde lnLersecLlon daLa among Lhe programs and do noL lnclude
all programs, lncludlng chlld care servlces Lhrough Lhe Chlld Care and uevelopmenL lund
(CCul). 1hese counLs, Lherefore, cannoL be used Lo produce a venn dlagram.

Second, ln order Lo make a comparlson Lo employmenL daLa, we need Lhe undupllcaLed
counL daLa on a polnL-ln-Llme basls, whlch requlres some explanaLlon. An annual-basls counL
provldes Lhe number of persons who recelve asslsLance aL any Llme wlLhln a course of a year. A
monLhly counL provldes Lhe number of persons who recelve a beneflL aL any Llme wlLhln Lhe
course of a monLh. A polnL-ln-Llme counL selecLs a parLlcular day and counLs Lhe number of
reclplenLs. 8ecause of Lhe churn, l.e., persons comlng on and off programs over Llme, an
annual-basls counL wlll always produce Lhe largesL number. Llkewlse, a polnL-ln-Llme counL
produces Lhe smallesL number. Lach Llmeframe has lLs own purpose. lor example, Lhe
deparLmenL produced an undupllcaLed counL for a uecember 18, 2011, radlo address by Lhe
governor.
16
ln Lhls case, Lhe undupllcaLed number was for calendar year 2010 ln order Lo
compare Lo Lhe number of Laxpayers who pald lncome Laxes for Lhe same year.

8ecause we dld noL have sysLem-generaLed daLa on overlapplng programs, we
esLlmaLed Lhe overlap uslng u.S. Census 8ureau daLa. 1he 2012 Amerlcan CommunlLy Survey
(ACS) lncluded quesLlons on wheLher respondenLs recelved food sLamps/SnA beneflLs and
wheLher Lhey are enrolled ln Medlcald, deflned as any governmenL medlcal asslsLance plan for
Lhose wlLh low lncomes or a dlsablllLy." MalneCare and CubCare are lncluded ln Lhls deflnlLlon.
CharL 1-18 provldes Lhe 2012 survey resulLs for Malne. Accordlng Lo Lhe survey, an esLlmaLed
28.7 of Lhe populaLlon ls enrolled ln Medlcald, or recelve food sLamps, or boLh. An esLlmaLed
23.6 of Lhe populaLlon ls enrolled ln Medlcald, an esLlmaLed 20.3 of Lhe populaLlon recelves
food sLamps, and an esLlmaLed 13.3 of Lhe populaLlon recelve boLh food sLamps and ls
enrolled ln Medlcald.


16. See Covernor Leage's 8adlo Address for uecember 17, 2011, avallable onllne: 1ough CuesLlons
ueserve PonesL Answers,"
hLLp://www.malne.gov/Lools/whaLsnew/lndex.php?Loplc=Cov_8adlo_Addresses&ld=326336&v=a
rLlcle. See also Lrlc 8ussell, Leage's 1axpayer versus Welfare 8eclplenL numbers MosLly 8lghL,"
8angor ually news, uecember 19, 2011,
hLLp://bangordallynews.com/2011/12/19/pollLlcs/lepages-Laxpayer-versus-welfare-reclplenL-
numbers-mosLly-rlghL/.


21
CharL 1-18: ercentage 8reak Cut kece|v|ng Med|ca|d and SNA


1he Census 8ureau daLa are noL preclse, buL offer a good lndlcaLlon of Lhe overlapplng
programs. lL ls noL posslble Lo calculaLe an exacL margln of error uslng ACS daLa, buL Lhe Census
8ureau provldes a meLhodology Lo approxlmaLe Lhe marglns of error. ln Lhe case of CharL 1-18,
Lhe approxlmaLe margln of errors, aL 90 confldence lnLervals, varles from 1.83 (for Lhe
populaLlon LhaL recelves nelLher beneflL) Lo 12.34 for Lhe populaLlon on food sLamps buL noL
enrolled ln Medlcald. 1he esLlmaLe of 23.6 for LoLal populaLlon recelvlng Medlcald ln 2012
compares well Lo our calculaLlon of 24.7 for Sl? 2012-13, uslng enrollmenL daLa.
17


ln addlLlon, Lhere ls anoLher reason why Lhe Census daLa may be less accuraLe. As ls Lrue
wlLh all survey daLa, Lhe survey responses are noL lndependenLly verlfled, whlch allows Lhe
posslblllLy for respondenL error. 8ecause Lhe Census esLlmaLe of 23.6 ls less Lhan Lhe
calculaLed value of 24.7, lL appears Lhere may be an underreporLlng, alLhough Lhe error could
also be due Lo sLaLlsLlcal sampllng.

We can furLher use Lhe Census daLa Lo esLlmaLe Lhe LoLal populaLlon recelvlng elLher
medlcal asslsLance or food sLamps. lrom CharL 1-18, lL can be calculaLed LhaL 82.34 of Lhe
populaLlon LhaL enrolled ln Medlcald or recelved food sLamps or boLh, are enrolled ln Medlcald.
1he enrollmenL ln Sl? 2012-13 was 336,000, glvlng us an esLlmaLed populaLlon of 408,100 for
Lhe undupllcaLed counL of welfare reclplenLs.
18
Pad we applled Lhe percenLage of 28.7 Lo Lhe

17. 1he Alexander Croup, leaslblllLy of Medlcald Lxpanslon under Lhe Affordable Care AcL: A 8evlew
SubmlLLed Lo Lhe Malne ueparLmenL of PealLh and Puman Servlces," !anuary 10, 2014, p. 39.
18. 1hese numbers are rounded Lo Lhe nearesL 100.
!"# $% &%'()
!"# !"#"$ %#!$ &'#($
$% "#!$ )!#'$ )(#*$
&%'() &+#"$ ),#"$ !++#+$
&%#)$
- /01 234516 7189:12 ;179<=97 =2 >=:6 ?9:7 @8 A@514:B1:C
=2292C=:<1 DE=: 8@4 C0@21 F9C0 E@F 9:<@B12 @4 = 792=G9E9C6#> HC
9:<E3712 ;=9:1I=41 =:7 I3GI=41#
*+,%))"- /+ 0"-/1(/- %, 2"1"/3"# 4%%- 5'(67# %, 8%'9
:% ,"#7%+-"+'# ,"1"/3"
;%%- #'(67#<5$=>?
=," ,"#7%+-"+'#
"+,%))"- /+
0"-/1(/-@?
ABCA =6",/1(+ D%66E+/'F 5E,3"F
2"#E)'# ;%, 0(/+"


22
LoLal esLlmaLed populaLlon, Lhe esLlmaLe would be 389,800. We chose Lo use Lhe hlgher
esLlmaLe because of sLaLlsLlcal rellablllLy reasons explalned above.
19


ln addlLlon, because medlcal asslsLance and SnA are Lhe largesL programs, we assume
LhaL Lhe undupllcaLed counL lncludes all persons recelvlng welfare asslsLance. 1hls ls noL
unreasonable when one conslders LhaL daLa for ennsylvanla for Lhose Lwo programs
comprlsed 99.3 of Lhe welfare-dependenL populaLlon ln SepLember 2012. (See CharL 1-17.)
1he u.S. 8ureau of Labor SLaLlsLlcs recenLly revlsed lLs esLlmaLes for SLaLe LsLabllshmenL-based
LmploymenL,
20
glvlng 497,900 average monLhly prlvaLe employmenL for Malne ln Sl? 2012-13
and 101,100 ln governmenL employmenL. 1hese numbers glve us Lhe followlng esLlmaLed
raLlos: for each person recelvlng welfare asslsLance, Lhere are 1.3 Malners employed or 1.2
Malners prlvaLely employed. See CharL 1-19.

CharL 1-19: Lst|mated 8urden on Lconom|c Wea|th roducers


19. Comparlng Lhe Census esLlmaLe from Lhe ACS Lo Lhe known enrollmenL for Lhose on Medlcald
produces a number 4.3 Loo low. lf we ad[usL accordlngly Lo esLlmaLe Lhe LoLal elLher enrolled ln
Medlcald or recelvlng food sLamps or boLh, we also derlve an esLlmaLe of 408,100.
20. See looLnoLe 16.
!"#$"%%
!%&$'%%
(()$%%%
*+($)%%
'%'$'%% +""$%%%
% '%%$%%% *%%$%%% (%%$%%% !%%$%%% +%%$%%% )%%$%%%
,-./012 4256-728.9
:86/018 ;8<=5=8.9>
?8@=<0=@ 4.1-6628.9
A,BC ;8<=5=8.9>
SFY 2012-13 Maine Monthly Averages
4> 9 = 209 8
C1=D098 4256-728.9
E-D81.28.9
4256-728.9
For each person receiving welfare assistance,
1
there are 1.2 Mainers privately employed.
2
4>9=2098@ FG1@8. -. 4<-.-2=< :8069H C1-@G<81>
,IJ4K ,L?F4; IM :4NMB;4 ;4OPCP4,JA B;4 4AJP?BJ4A I,NQR
For each person receiving welfare assistance,
1
there are 1.5 Mainers employed.
2
Note: (1) Medicaid enrollment includes all medical assistance programs, including CubCare. The enrollment numbers were
provided by the Maine Department of Health and Human Services. SNAP recipients are estimated using Maines Statewide
Geographic Benefits and Programs Issuance Reports. The number of welfare assistance is estimated using the Medicaid
enrollment data and estimates from the 2012 American Community Survey; (2) Employment as measured by total
nonfarm employment per the U.S. Bureau of Labor Statistics.


23
8ackground to keport

ln developlng Lhls reporL, Lhe AC has Laken lnLo accounL Lhe mandaLes of Lhe federal
governmenL, Lhe prlorlLles of Lhe sLaLe governmenL, and Lhe range of resources whlch have
been broughL Lo bear on Lhe needs of chlldren, famllles, and oLher speclal populaLlons served
by uPPS. WlLh Lhe asslsLance of Lhe deparLmenL, every efforL has been made Lo undersLand all
programs and servlces and Lo ldenLlfy rooL causes of any underperformance lndlcaLors
ldenLlfled wlLhln respecLlve programs. Where approprlaLe, Lhe reporL offers opLlons and
recommendaLlons Lo asslsL Lhe deparLmenL wlLh global reforms and sLraLegles Lo lmprove
servlces and processes LhroughouL Lhe sysLem.

1hls basellne reporL ls belng complled wlLh Lhe asslsLance of many key sLaffers of Lhe
Malne uPPS and Lhe Malne ueparLmenL of Labor (MuCL), who have been wllllng Lo share Lhelr
knowledge, experLlse, and vlslon for lmprovlng boLh pollcles and ouLcomes for all reclplenLs
served Lhrough uPPS. 1helr cooperaLlon and lnpuL Lo daLe has provlded vlLal lnformaLlon used
ln Lhe flrsL phase of Lhls analysls.

ln addlLlon Lo sLaLe-level admlnlsLraLors and fleld sLaff, we acknowledge our
appreclaLlon Lo Lhe u.S. ueparLmenL of PealLh and Puman Servlces, AdmlnlsLraLlon for Chlldren
and lamllles (ACl), Lhe u. S. ueparLmenL of AgrlculLure, lood and nuLrlLlon Servlces (lnS), and
Lhe u.S. ueparLmenL of Labor for Lhelr asslsLance and guldance ln beLLer undersLandlng Lhe
laws and regulaLlons of varlous federal welfare programs and beneflLs.

A core value used ln guldlng Lhls revlew began wlLh a baslc undersLandlng of uPPS's
clearly arLlculaLed mlsslon sLaLemenL:
21


1he Malne ueparLmenL of PealLh and Puman Servlces has worked long and hard Lo
achleve a balance wlLhln lLs admlnlsLraLlve and budgeLary responslblllLles whlle malnLalnlng a
sLrong focus on Lhe needs of Lhe mosL vulnerable populaLlons: pregnanL women, chlldren and
famllles, lndlvlduals wlLh dlsablllLles, veLerans, and elders. 1he pro[ecL revlew Lhus far has Laken
lnLo accounL a number of well-developed lnlLlaLlves currenLly belng lmplemenLed LhroughouL
uPPS under Lhe dlrecLlon of Commlssloner Mary Mayhew.


21. ueparLmenL of PealLh and Puman Servlces SLraLeglc lan 2013-2013, CcLober 2013, p. 4.

1o promoLe safe, healLhy, lndependenL llves for all, whlle ensurlng
efflclenL and effecLlve use of resources for Malne's mosL vulnerable.


24
Cne lmporLanL achlevemenL Lo daLe ls Lhe early progress by Lhe Cfflce for lamlly
lndependence (Cll) ln redeslgnlng fleld operaLlons. 1hls redeslgn of workflow process
LhroughouL Lhe slxLeen reglonal cenLers has meanL LhaL Lhe AC can focus lLs efforLs ln oLher
areas of concern Lo Lhe ueparLmenL, such as hlghllghLlng emerglng lssues ln federal and sLaLe
programs and pollcy dlrecLlons, examlnlng uPPS pollcles and regulaLlons Lo deLermlne posslble
areas for resLrucLurlng ln order Lo opLlmlze Lhe admlnlsLraLlon and servlce dellvery of beneflLs
provlded Lhrough uPPS. AddlLlonally, Lhe AC ls worklng wlLh Malne's Cll and oLher dlvlslons Lo
assess and forLlfy effecLlve prlnclples of program lnLegrlLy. vlrLually every publlcly supporLed
beneflL on boLh Lhe sLaLe and federal level ls confronLlng Lhe need for greaLer emphasls on
lnLernal sysLems conLrols and program lnLegrlLy. lL ls a mandaLe wlLh new meanlng and Lhe
deparLmenL has arLlculaLed sLrong lnLeresL ln ldenLlfylng meLhods of LlghLenlng conLrols and
accounLablllLy, lncludlng sysLems enhancemenLs.

Lven Lhe early phases of process lmprovemenLs such as Lhe new Lelephone sysLem, and
soon Lo be lmplemenLed cenLrallzed documenL-lmaglng cenLer, are belng meL enLhuslasLlcally
aL Lhe fleld level. 8oLh are dlscussed ln greaLer deLall ln Lhls reporL. 1he lmporLance of Lhls
redeslgned ellglblllLy process for all publlc asslsLance holds Lremendous promlse for all lnvolved,
lncludlng Lhe admlnlsLraLlve level, fleld operaLlonal level, and very lmporLanLly, aL Lhe reclplenL
level by Lhose who rely on uPPS for help.

Also noLeworLhy are Lhe conLlnuous lmprovemenL efforLs of Lhe ulvlslon of Chlld
SupporL LnforcemenL and 8ecovery (uSL8), whlch demonsLraLes hlsLorlcal dedlcaLlon Lo pollcy
and sysLems upgrades, all of whlch effecLlvely sLreamllne and slmpllfy Lhe process for collecLlng
and dlsLrlbuLlng chlld-supporL paymenLs Lo cusLodlal parenLs on behalf of Lhelr chlldren.


Contents and Data Sources

Slnce Lhe enacLmenL of 8WC8A ln 1996, Lhe sweeplng reforms of Lhls law have
reverberaLed LhroughouL vlrLually all publlc-welfare programs offered ln Lhe counLry. 8WC8A
noL only reformed cash asslsLance for needy famllles Lhrough Lhe creaLlon of 1Anl, buL also
changed food asslsLance, chlld care asslsLance, and medlcal asslsLance for all populaLlons.
8WC8A deflned how and when lmmlgranLs could quallfy for asslsLance across programs, and
has broughL abouL lmporLanL lmpacLs wlLhln clvll-rlghLs regulaLlons, as well as [ob Lralnlng, and
employmenL programs for adulLs.

1hls reporL conLalns a revlew of Lhe publlc-welfare programs admlnlsLered by Lhe Malne
uPPS. 1hese programs lnclude 1Anl, SnA, Lhe Chlld Care and uevelopmenL lund (CCul) Chlld
Care Subsldy rogram, Ceneral AsslsLance, Medlcal AsslsLance (MA), as well as uSL8.

Several oLher programs were revlewed, however, Lhese programs served speclflc
populaLlons and were on a smaller scale ln Lerms of numbers served and dollars expended.
1hey lnclude Lhe AlLernaLlve AsslsLance rogram, 8efugee Cash AsslsLance (8CA) rogram, and


23
Lmergency AsslsLance. 1he Alexander Croup (AC) examlned mandaLory sLaLe plans submlLLed
Lo federal governmenL agencles and examlned how lndlvldual pollcles and proLocols have been
developed by Lhe sLaLe ln order Lo responslbly admlnlsLer Lhese resources.

As a basellne reporL, AC has aLLempLed Lo hlghllghL Lhrough daLa analysls whaL ls
worklng and whaL needs aLLenLlon, lL provldes boLh reglonal and naLlonal comparlson daLa for
reference, and lL ralses some lssues and concerns dlscovered durlng Lhe revlew.

Conslderlng Lhe broad specLrum of programs covered ln Lhls revlew, daLa sources used
lncluded varlous federal and sLaLe speclflc daLa reporLs, u.S. Census 8ureau, naLlonal research
organlzaLlons LhaL speclallze ln sLudylng welfare and healLh care on a naLlonal scale. Lvery
efforL has been made Lo base observaLlons, comparlsons, and concluslons on Lhe mosL recenL,
up-Lo-daLe daLa avallable. AdmlLLedly, some references cover perlods relaLlng Lo pre-8WC8A.
Powever, as fooLnoLed below each charL, Lhe prlmary focus of lnformaLlon perLalns Lo sLaLe and
federal flscal years 2011, 2012, and 2013.


Methodo|ogy

AfLer lnLroducLory meeLlngs wlLh uPPS admlnlsLraLlve sLaff, AC began gaLherlng
program lnformaLlon Lhrough face-Lo-face lnLervlews wlLh speclflc program admlnlsLraLors from
ASl8L-1Anl/aS, SnA, Medlcald, and Chlld Care uevelopmenL lund (CCul), whlch ls
admlnlsLered Lhrough Lhe Cfflce of Chlld and lamlly Servlces (CClS). AddlLlonal face-Lo-face
lnLervlews and/or Lelephone lnLervlews were wlLh uPPS admlnlsLraLlve sLaff from uSL8 and
MalneCare. AddlLlonally, lnLervlews were held wlLh represenLaLlves of Lhe Malne ueparLmenL
of Labor (MuCL). Cngolng communlcaLlon wlLh Lhe deparLmenL's ulvlslon of 8uslness
1echnology and lLs respecLlve sysLems conLracLors Look place ln order Lo obLaln essenLlal daLa
reporLs and expendlLure lnformaLlon relaLed Lo Lhe varlous programs' ellglblllLy, parLlclpaLlon,
monLhly expendlLures, and daLa reporLs emanaLlng from Lhe Medlcald ManagemenL
lnformaLlon SysLems (MMlS) and Lhe AuLomaLed CllenL LllglblllLy SysLem (ACLS).

ln addlLlon Lo sLaLe and deparLmenL experLs, federal represenLaLlves of 1Anl, SnA,
chlld care, chlld-supporL enforcemenL, and Medlcald have been conLacLed ln order Lo glean
useful lnformaLlon on currenL and anLlclpaLed developmenLs wlLhln u.S. ueparLmenL of PealLh
and Puman Servlces and Lhe u.S. ueparLmenL of AgrlculLure.

AnoLher lmporLanL aspecL of carrylng ouL Lhls revlew, slLe vlslLs were made Lo Lhe
orLland 8eglonal CenLer and Lhe larmlngLon 8eglonal CenLer, where lnformaLlve lnLervlews
were conducLed wlLh managemenL and servlce-dellvery sLaff aL all levels who shared boLh Lhelr
knowledge and experLlse on mulLlple areas of pollcy, programs, sysLems, and servlce dellvery. A
slgnlflcanL area dlscussed was Lechnologlcal supporL avallable now and anLlclpaLed ln Lhe
fuLure, whlch wlll help Lhe fleld sLaffers Lo carry ouL Lhelr [obs wlLh a hlgh degree of efflclency
and senslLlvlLy Lo Lhe needs of reclplenLs belng served by uPPS.


26



27





A81 l: CLnL8AL u8LlC-WLLlA8L 8CC8AMS

"# $%&'()*)+ ,--.-/*01% 2() 3%%4+ 5*&.6.%- 7$,358


1he 1996 welfare-reform law enLlLles sLaLes Lo a baslc 1Anl block granL equal Lo peak
expendlLures for pre-1Anl programs durlng Lhe l? 1992-93 perlod when cash-welfare rolls
were aL Lhelr all-Llme hlgh. 1he baslc block granL ls leglslaLlvely flxed, whlch means Lhe granL
amounL does noL change when Lhe cash-asslsLance caseload decreases or lncreases, nor ls lL
ad[usLed for lnflaLlon. 1he LoLal amounL of Lhe federal 1Anl block granL ls $16.4 bllllon each
year, whlch ls approprlaLed Lo Lhe flfLy sLaLes and Lhe ulsLrlcL of Columbla. Malne's yearly
allocaLlon ls $78.1 mllllon.
22







1Anl requlres all sLaLes Lo malnLaln spendlng from Lhelr own funds on 1Anl or 1Anl-
relaLed acLlvlLles. 1hls requlremenL ls called Lhe malnLenance-of-efforL" (MCL) level, and LhaL
spendlng musL represenL aL leasL 73 of whaL was spenL from sLaLe funds ln l? 1994 ln 1Anl's
predecessor programs AluC, Lmergency AsslsLance, [ob Lralnlng, and welfare-relaLed chlld care
spendlng. AnoLher 1Anl mandaLe ls LhaL sLaLes musL meeL speclflc work parLlclpaLlon levels, or
face splrallng flnanclal penalLles LhaL may resulL ln Lhe loss of federal dollars. lf a sLaLe falls Lo
meeL 1Anl work parLlclpaLlon requlremenLs, Lhe MCL requlremenL lncreases Lo 80 of sLaLe
expendlLures ln l? 1994.


22. Cene lalk, 1Anl 8lock CranL: A rlmer on llnanclng and lederal 8equlremenLs," Congresslonal
8esearch Servlce, Aprll 2, 2013, pp. 3, 4, 8.

73 of Malne's requlred MCL level ls $37.3 mllllon
80 of Malne's requlred MCL level ls $40.0 mllllon
80 MCL ls requlred lf sLaLe falls Lo meeL Lhe 1Anl 30
work parLlclpaLlon raLe for all famllles and Lhe 90 work
parLlclpaLlon raLes for Lwo-parenL famllles.

$9% +%*)6+ $,35 :*-.1 :6(1; <)*0/ /( =*.0% .- >?@#A &.66.(0#



28
CharL 2-1: Annua| 1ANI 8|ock-Grant and State-MCL Lxpend|tures
Category II 2011 II 2012 II 2013
1ota| 1ANI 8|ock Grant 578,120,889 578,120,889 578,120,889
1oLal 1ransferred Lo CCul 0 0 $ 2,000,000
1oLal 1ransferred Lo SS8C 0 0 $ 7,812,089
1ota| Ad[usted SIAG 78,120,889 78,120,889 568,308,800
SLaLe 1Anl-MCL LxpendlLures 17,430,023 13,260,868 19,396,917
MCL LxpendlLures SeparaLe SLaLe rograms 30,713,730 27,033,171 20,899,121
1ota| Lxpend|tures to Meet kequ|red MCL 548,16S,7SS 540,296,039 540,296,038

CharL 2-2: Comb|ned 1ANI and MCL Lxpend|tures by Categor|es
Category II 2011 II 2012 II 2013
Cash AsslsLance 1o ASl8L/aS lamllles $77,208,893 $73,030,931 $46,404,734
Chlld Care AsslsLance 6,363,467 3,718,480 4,332,303
1ransporLaLlon & CLher SupporL Servlces 11,480,718 10,273,842 9,188,170
non-AsslsLance (CLher Work 8elaLed AcL) 26,113,064 24,899,333 19,346,219
non-8ecurrenL ShorL-1erm 8eneflLs 1,093,037 793,784 303,897
AdmlnlsLraLlon 3,630,271 3,370,793 2,688,177
SysLems 173,192 307,323 42,237
1ota| Lxpend|tures 5126,286,644 5118,416,928 582,70S,779
Sources: ACl-196 flnanclal reporLs submlLLed by Malne uPPS: l? 2011 submlLLed lebruary 13, 2012,
l? 2012 submlLLed lebruary 14, 2013, l? 2013 submlLLed lebruary 2014.


As reflecLed ln CharL 2-1, Malne meL 80 of lLs 1Anl-MCL requlremenL for all Lhree
years. 1he only year where excess" MCL ($8,163,733) was expended was ll? 2011.

CurrenLly, sLaLes musL malnLaln a block granL amounL LhaL ls equal Lo Lhe amounL of
money spenL ln 1994. lf a sLaLe operaLes Lhe program more effecLlvely and efflclenLly resulLlng
ln lower expendlLures, lL musL spend money LhaL advances one or more of Lhe four leglslaLlve
purposes of 1Anl, maklng up Lhe expendlLure dlfference accordlng Lo Lhe MCL rule. lf Lhe sLaLe
falls Lo spend a sufflclenL level of MCL funds, and falls below Lhe MCL mlnlmum spendlng level,
lL wlll lncur a penalLy for falllng Lhe MCL requlremenLs. 1hls penalLy ls equal Lo a dollar-for-
dollar loss ln federal dollars, maklng lL flnanclally lmprudenL Lo fall below Lhe 80 MCL
Lhreshold of $40 mllllon. Malne ls now bumplng up agalnsL LhaL Lhreshold and ls aL rlsk of falllng


29
below lLs MCL requlremenL, unless Lhe sLaLe ldenLlfles addlLlonal ways Lo spend sLaLe dollars ln
1Anl supporLable programs and servlces. lederal rules lncenLlvlze sLaLes llke Malne Lo spend
more sLaLe money even when Lhey accrue some savlngs Lhrough reduced caseloads. Powever,
lf Lhe MCL penalLy were avolded, boLh Lhe sLaLe of Malne and Lhe federal governmenL would
share ln Lhe savlngs. (See 1lLle 43 Cl8 263.1)

ln Malne, Lhe 1Anl program ls called ASl8L (AddlLlonal SupporL for eople ln 8e-
Lralnlng and LmploymenL) and ls admlnlsLered Lhrough Lhe uPPS Cfflce of lamlly
lndependence (Cll) along wlLh numerous oLher publlc-asslsLance programs. unlquely
lnLegraLed lnLo Malne's 1Anl sysLem ls Lhe arenLs-as-Scholars (aS) program, whlch provldes
flnanclal ald Lo parenLs, found ellglble under 1Anl rules, who are enrolled ln a formal posL-
secondary educaLlon plan. Accordlng Lo polnL-ln-Llme daLa provlded by Cll, Lhe ASl8L-aS
caseload reflecLed Lhe followlng:

CharL 2-3: 1ANI Case|oad Data, December 2013

Source: uPPS Cll, uaLa 8eporLs, uecember 2013

Cr|g|ns of the 1ANI Law

ln 1996, Congress passed leglslaLlon Lo replace Lhe AluC program as Lhe prlmary federal
welfare program wlLh 1Anl (L. 104-193). 1he mosL slgnlflcanL aspecL of Lhls reform was LhaL
cash asslsLance for needy famllles was no longer an enLlLlemenL" buL raLher a Llme-llmlLed"
beneflL deslgned Lo help famllles Lo become economlcally self sufflclenL. ln passlng 1Anl,
Congress creaLed a block granL Lo sLaLes whlch was equal Lo peak expendlLures for pre-1Anl
programs durlng Lhe l? 1992-93 perlod. 8ecause Lhe mld-1990s were a perlod when cash-
welfare rolls were aL Lhelr all-Llme hlgh, Lhe block-granL amounL was based on federal
expendlLures on Lhe AluC cash-asslsLance program, Lhe Lmergency AsslsLance program, and
!ob CpporLunlLles and 8aslc Skllls (!C8S) program for AluC famllles - all of whlch exlsLed aL
LhaL Llme. Changlng from an enLlLlemenL-fundlng sLrucLure Lo a block-granL sLrucLure means
7,309 Cases
on 1Anl
12,297
Chlldren on
1Anl
1,383
Lmployed
1Anl Cases
1,318
1wo-arenL
1Anl Cases
4,130
Cne-arenL
1Anl Cases
2,021 Chlld-
Cnly 1Anl
Cases


30
LhaL Lhe baslc block granL amounL Lo sLaLes ls leglslaLlvely flxed, lL does noL change when a
sLaLe's cash-asslsLance caseload decreases or lncreases, nor ls lL ad[usLed for lnflaLlon.

lrom a pollcy and admlnlsLraLlve perspecLlve, Lhe 1Anl block granL provlded sLaLes
greaLer flexlblllLy as a fundlng sLream Lhan Lhe former AluC program by allowlng a wlde range
of servlces and supporL for low-lncome famllles wlLh dependenL chlldren. Powever, ln exchange
for lncreased program flexlblllLy, sLaLes forfelLed Lhelr enLlLlemenL Lo recelve lncreased federal
funds for cash paymenLs, no maLLer how hlgh caseloads lncrease.

WlLh cerLaln resLrlcLlons, sLaLes may use 1Anl funds for any beneflL or acLlvlLy
reasonably relaLed Lo one of four sLaLuLory purposes, whlch are Lo:

1) provlde asslsLance Lo needy famllles so LhaL Lhe chlldren may be cared for ln Lhelr
homes or ln Lhe homes of relaLlves,
2) end dependency of needy parenLs on governmenL beneflLs by promoLlng [ob
preparaLlon, work and marrlage,
3) prevenL and reduce Lhe lncldence of ouL of wedlock pregnancles and esLabllsh annual
numerlcal goals for prevenLlng and reduclng Lhe lncldence of Lhese pregnancles, and
4) encourage Lhe formaLlon and malnLenance of Lwo-parenL famllles.

Whlle Lhe 1Anl block-granL program has broad flexlblllLy, lLs flnanclng ls exLremely
complex and aLLaches many sLrlngs Lo a sLaLe's use of federal and sLaLe 1Anl-MCL funds. 1he
amounL LhaL a sLaLe ls requlred Lo spend of lLs own funds each year musL be used for beneflLs
and servlces LhaL are conslsLenL wlLh aL leasL one of Lhe four purposes of 1Anl.


Changes to 1ANI under the Def|c|t keduct|on Act

1Anl was reauLhorlzed ln 2003 as parL of Lhe ueflclL 8educLlon AcL (u8A). As a budgeL
conLalnmenL measure, u8A affecLed many aspecLs of publlc-welfare asslsLance LhroughouL Lhe
counLry. u8A slgnlflcanLly changed Lhe sLrucLure of 1Anl federal-work requlremenLs noL only
by adopLlng narrow deflnlLlons of work acLlvlLles LhaL counL Loward Lhe work raLes buL also by
lnsLlLuLlng slgnlflcanL new requlremenLs relaLed Lo sLaLe monlLorlng of reclplenLs' parLlclpaLlon
ln work acLlvlLles. 1hese changes puL new requlremenLs on sLaLes ln order Lo successfully meeL
federally mandaLed work parLlclpaLlon raLes.

Some ma[or changes Lo 1Anl under u8A lncluded a new requlremenL Lo submlL a sLaLe
work-verlflcaLlon plan whlch musL lnclude sLrlngenL deflnlLlons of approvable" work acLlvlLles,
speclflc meLhods of documenLlng" weekly hours of each parenL's parLlclpaLlon ln acLlvlLles, and
slgnlflcanLly, u8A expanded Lhe populaLlon of adulLs requlred Lo parLlclpaLe, deflned as work-
ellglble lndlvlduals (WLl), Lo lnclude adulLs noL recelvlng cash for Lhemselves buL who are llvlng
wlLh a mlnor chlld on cash asslsLance, even Lhose famllles whose cash asslsLance ls funded


31
Lhrough a sLaLe's MCL funds. rlor Lo u8A, sLaLes were noL requlred Lo lnclude Lhese adulLs ln
Lhelr work parLlclpaLlon raLe.


1ANI Work art|c|pat|on kequ|rements

1Anl work parLlclpaLlon raLe (W8) requlremenLs are deflned as: 30 of all famllles on
1Anl or ln recelpL of 1Anl-MCL servlces, and 90 of Lwo-parenL famllles on 1Anl or ln recelpL
of 1Anl-MCL servlces. 1hese famllles have aL leasL one work-ellglble lndlvldual ln Lhe
household who ls noL dlsregarded from Lhe parLlclpaLlon requlremenL.

1o be counLed for work parLlclpaLlon purposes, Lhe work-ellglble lndlvldual (usually a
parenL) musL be ln one or more of Lhe Lwelve 1Anl counLable acLlvlLles (llsLed ln law), for a
mlnlmum number of hours per week each monLh, and Lhese acLlvlLles musL be verlfled and
documenLed by Lhe agency. Moreover, Lhe agency musL follow complex and convoluLed rules
Lo calculaLe W8, a measure LhaL does noL accuraLely reflecL full caseload parLlclpaLlon. lor
example, Lhe W8 does noL reflecL Lhe percenLage of cases LhaL close Lo 1Anl due Lo
unsubsldlzed employmenL. AL Lhe same Llme, some parLlclpanLs can meeL Lhe W8 by
parLlclpaLlng ln a mlx of core" and non-core" acLlvlLles wlLhouL ever flndlng employmenL.

MeeLlng Lhe all-famllles raLe (30) - and, ln parLlcular, Lhe Lwo-parenL-famlly raLe
(90) - has been a challenge for all sLaLes. 1he ma[orlLy of sLaLes meeL Lhelr W8 only afLer
Lhey apply a caseload-reducLlon credlL Lo Lhelr counLable cases ln acLlvlLles. lalllng Lo meeL
Lhese raLes can resulL ln flnanclal penalLles on Lhe sLaLe's 1Anl block granL.


Case|oad-keduct|on and Lxcess-MCL Cred|ts

1he caseload-reducLlon credlL reduces a sLaLe's 30 and 90 sLandards based on Lhe
caseload-reducLlon measure from l? 2003. ln effecL, Lhe caseload-reducLlon credlL reduces a
sLaLe's numerlcal sLandards by one percenLage polnL for each percenL decllne ln Lhe caseload.
AddlLlonally, under PPS regulaLlons promulgaLed ln 1999, sLaLes also may recelve credlLs for
spendlng sLaLe dollars ln excess of whaL Lhey are requlred Lo spend under Lhelr MCL
requlremenL.

SLaLes may conslder famllles asslsLed by excess MCL as caseload reducLlon," and
hence recelve exLra caseload-reducLlon credlLs for such famllles. Powever, 1Anl does noL
asslgn credlL Lo sLaLes whose caseload decllne resulLed from changes ln ellglblllLy pollcles.
Caseload reducLlon credlLs are very speclflc.

lor example, lf a sLaLe achleves a caseload reducLlon of 23 (lncludlng Lhe effecL of
caseload reducLlon from excess MCL), Lhe sLaLe's work parLlclpaLlon raLe sLandard for Lhe all-
famlly raLe of 30 ls reduced by LwenLy-flve percenLage polnLs, from 30 Lo 23. lf a sLaLe
achleves a caseload reducLlon of 30, lLs all-famlly sLandard ls reduced by flfLy percenLage
polnLs, from 30 Lo 0. lL ls Lyplcally Lhe comblnaLlon of acLual parLlclpaLlon ln counLable


32
acLlvlLles plus credlL for caseload reducLlons, comblned wlLh credlLs for excess-MCL
expendlLures, whlch wlll resulL ln a sLaLe reachlng lLs W8 LargeLs.

CharL 2-4: Ca|cu|at|ng Work art|c|pat|on kates



Understand|ng the Impact of 1ANI-ena|ty rov|s|ons

SLaLes can lncur one or more flscal penalLles under 1Anl. When Lhose penalLles are
lmposed, Lhere ls a subsLanLlal (and negaLlve) lmpllcaLlon for Lhe 1Anl program, admlnlsLraLlve
agency, and a sLaLe's budgeL, whlch ln mosL cases would be requlred Lo replace any loss ln
federal dollars resulLlng from a 1Anl penalLy. SLaLes LhaL fall Lhe 1Anl work parLlclpaLlon
sLandards are aL rlsk of a flnanclal penalLy. 1he 1Anl sLaLuLe penallzes a sLaLe by 3 of lLs block
granL for Lhe flrsL year LhaL lL falls Lo meeL Lhe work parLlclpaLlon sLandards, wlLh Lhe penalLy
lncreaslng Lwo percenLage polnLs for each subsequenL year's fallure, up Lo a maxlmum of 21
penalLy on Lhe block granL. lor Malne, Lhese penalLles can be subsLanLlal: A 3 penalLy
represenLs $3.9 mllllon, a 21 penalLy represenLs $16.3 mllllon.

CharL 2-3: I|sca| ena|t|es under 1ANI Law
Mlsuse of 1Anl funds AmounL of mlsused 1Anl funds
lnLenLlonal mlsuse of 1Anl AmounL of penalLy +3 of ad[usLed SLaLe
lamlly-AsslsLance CranL (SlAC)
lalllng Lo submlL reporL 4 reducLlon of ad[usLed SlAC for each
quarLer sLaLe falls Lo submlL reporL(s)
lalllng Lo meeL work parLlclpaLlon raLe 3 8educLlon ln 1Anl 8lock CranL (up Lo
21 of ad[usLed SlAC)
lalllng Lo parLlclpaLe ln Lhe lncome LllglblllLy
verlflcaLlon SysLem
2 of ad[usLed SlAC
lalllng Lo meeL 1Anl-MCL requlremenL uollar-for-dollar reducLlon ln SlAC
lalllng Lo sancLlon reclplenLs for non-
cooperaLlon wlLh uSL8
1 Lo 3 of ad[usLed 1Anl block granL
!"# %&
'()&*+,-.
/0*%1%*%.2
34# '5.6%* 7(5
/0*)+-
8.6)0*%(& %&
'+2.-(+6 75(9
::; !44"
3"# '5.6%* 7(5
:+9%-%.2
2.51.6 <%*=
>?0.22 @A>
"4# B(5C
D+5*%0%E+*%(&
8+*.


33
SancLlonlng parenLs w/chlld under 6 who need
chlld care ln order Lo work
up Lo 3 of ad[usLed SlAC
lalllng Lo sancLlon parenLs who refuse Lo engage
ln work requlremenLs
1 Lo 3 of ad[usLed SlAC
lalllng Lo replace penalLy reducLlon wlLh sLaLe
funds
no more Lhan 2 of ad[usLed SlAC, plus
Lhe amounL of Lhe ShorLfall
lalllng Lo enforce Lhe flve-year Llme llmlL 3 of ad[usLed SlAC
lalllng Lo repay federal loan CuLsLandlng loan amounL plus lnLeresL
lalllng Lo remlL conLlngency fund lf Lhls MCL ls
noL meL
AmounL of conLlngency funds noL
remlLLed
lalllng Lo meeL 1Anl-MCL level of welfare-Lo-
work formula granL pald
8educLlon of SlAC payable ln Lhe amounL
welfare-Lo-work granL was recelved (n/A)
New ena|ty Added under DkA of 200S
lalllng Lo lmplemenL procedures and lnLernal
conLrols conslsLenL wlLh federal regulaLlons.
up Lo 3 of ad[usLed SlAC
Source: ubllc Law 104-193, 8WC8A, SecLlon 409.


unLll uPPS lmplemenLed pollcy reforms ln !anuary 2012, Lhe sLaLe's 1Anl program
lagged second from Lhe boLLom ln experlenclng caseload decllnes. rlor Lo !anuary 2012, Lhe
sLaLe dld noL conform Lo federal rules relaLed Lo slxLy-monLh Llme llmlLs for famllles on cash
asslsLance. Malne carrled hlgh caseloads, even when reducLlons were occurrlng ln vlrLually all
oLher sLaLes. ln facL, Malne's hlgh caseloads endured durlng Lhe perlod when federal
regulaLlons, under u8A, lncreased reporLlng requlremenLs and added prevlously omlLLed sLaLe
MCL-funded adulLs Lo Lhe calculaLlon of work parLlclpaLlon raLes. AddlLlonally, u8A narrowed
Lhe deflnlLlon of counLable work acLlvlLles, LlghLened monlLorlng of parenL acLlvlLles, and
lmposed sLrlngenL reporLlng requlremenLs for Lhe broader work-ellglble populaLlon. lL ls noL
unreasonable Lo conclude LhaL Malne's prevlous pollcles, whlch for Lhe mosL parL dlsregarded
Llme llmlLs, exposed Lhe sLaLe Lo 1Anl-W8 penalLles, especlally when Lhe program was unable
Lo engage a sufflclenL number of parenLs ln counLable acLlvlLles.

CharL 2-6 chronlcles how Lhe ASl8L program fared ouL on Lhe 1Anl-W8 sLandards.



34
Chart 2-6: Work art|c|pat|on kates for Ma|ne



A reporL publlshed by Lhe Congresslonal 8esearch Servlce ouLllnes whlch sLaLes falled Lo
meeL 1Anl all-famllles work parLlclpaLlon sLandards beLween l? 2002 Lhrough l? 2010.
23
ln Lhls
reporL, only a few [urlsdlcLlons falled Lo meeL Lhe all-famllles work parLlclpaLlon raLe sLandards
Lhrough l? 2006. ln facL, ln l? 2006, only Lhree [urlsdlcLlons falled Lhe sLandard, and LhaL was
Lhe greaLesL number LhaL falled Lhe W8 beLween l? 2002 Lhrough l? 2006.

Powever, ln l? 2007, flfLeen [urlsdlcLlons falled Lo meeL Lhe all-famllles W8 sLandard.
1hls number decllned Lo nlne ln l? 2008 and elghL ln l? 2009. ln l? 2010, elghL [urlsdlcLlons
falled Lo meeL Lhe sLandard. Cf Lhese, slx (Callfornla, Malne, Chlo, Cregon, uerLo 8lco, and
Cuam) falled sLandards ln all years slnce l? 2007 for Lwo-parenL famllles and a number of sLaLes
reporLed no 1wo-arenL lamllles" were sub[ecL Lo Lhe work parLlclpaLlon sLandard. 1hese
sLaLes, llke Malne, are lndlcaLed wlLh n/A" for LhaL year.

ln l? 2010, LwenLy-flve [urlsdlcLlons reporLed LhaL no Lwo-parenL famllles were lncluded
ln Lhe 1Anl work parLlclpaLlon sLandard calculaLlon. Cf Lhe LwenLy-nlne [urlsdlcLlons LhaL
lncluded Lwo-parenL famllles ln Lhelr 1Anl work parLlclpaLlon calculaLlon, LwenLy-Lhree meL Lhe
sLandard, slx dld noL.

1he followlng charL, whlch was Laken from Lhe Congresslonal 8esearch Servlce reporL,
lndlcaLes LhaL Malne meL lLs Lwo-parenL famlly raLe, buL noL lLs all-famllles raLe for 2007, and
LhaL Malne dld noL meeL lLs W8 sLandards ln l? 2008, l? 2009, and l? 2010.



23. Cene lalk, 1he 1emporary AsslsLance for needy lamllles (1Anl) 8lock CranL: 8esponses Lo
lrequenLly Asked CuesLlons," Congresslonal 8esearch Servlce, CcLober 17, 2013.
F"GH FFG"
!IGI
J!G3
!KGJ !LGL
!3GH
33GF
3LGK
3HGI
"HGI
"KG!
!HG!
J4G3
KGL
3LGL
3IG!
"##$ "##" "##% "##& "##' "##( "##) "##* "##+ "#$#
,-- .,/0-1 2,345 36789,24:3 .,/0-1 2,345


33
CharL 2-7: Ma|ne's Work art|c|pat|on kates, 2001-2010
re-DkA o||c|es ost-DkA o||c|es
Wk Group kesu|ts by ear 2001 2002 2003 2004 200S 2006 2007 2008 2009 2010
All lamlly 8aLes 43.9 44.3 27.7 32.1 28.3 26.6 21.9 11.4 16.8 19.7
1wo-arenL lamlly 8aLes 39.7 38.2 29.2 n/A n/A n/A 30.1 8.6 16.6 17.2
MeL SLandard All-lamlly 8aLes ?es ?es ?es ?es ?es ?es no no no no
MeL SLandard 1wo-arenL 8aLes ?es ?es ?es ?es no no no

Malne correcLed Lhe overall W8 Lhrough a correcLlve-compllance plan as requlred
under 43 Cl8 262.6. 1hls was achleved by Lhe end of ll? 2012. Malne achleved Lhls compllance
by addlng a worker-supplemenL beneflL ($13 per monLh), whlch allowed Malne Lo counL
famllles LhaL have LranslLloned from 1Anl and are worklng Lhe requlred number of hours Lo
meeL Lhe work parLlclpaLlon requlremenL. 1hls beneflL ls provlded Lo approxlmaLely LwenLy
Lhousand famllles per monLh and ls lncluded as parL of Lhe 1Anl-MCL caseload. 1he followlng
charLs provlde daLa on how Lhese cases were added Lo Lhe monLhly MCL caseload beglnnlng
2012. WlLhouL Lhls new lnlLlaLlve, Malne would noL achleve lLs W8.

CharL 2-8: 1ANI and MCL Cash-Ass|stance Cases

$#;'$+
+;'&* +;(%$
+;"'+
+;)&(
+;&'( +;(#$
$#;"(& $#;"&&
$#;)''
$$;$"* $$;$%(
*;+)+
(;)&"
$;(#*
$;(&# $;(%"
$;&**
$;&++ $;+)'
$;+&$
";"$+ ";$)%
%;$"'
%;+%'
&;%#"
$";*+#
$';+)'
!
"
#
$
!
%
#


'
(
)
*
#
$

+
,

-
!
.
#
.

/
#
$

0
#
!
$

,<= 3,:. .>?@A@BC ,<= 3DE>A /74 .>?@A@BC
!444 !443 !44! !44J !44F !44" !44L !44I !44K !44H !434 !433 !43! !43J
lncreased MCL cases ln 2012 & 2013 are due prlmarlly Lo new
Worker SupplemenL program whlch provldes $13/monLh Lo
famllles wlLh chlldren who work aL leasL 30 hours/week. 1hls
sLaLe-funded eorL helps Malne meeL 1Anl W8.


36
Chart 2-9: 1ANI and MCL Case|oad, 2000-2013

");'#(
"';)(*
"';*)'
"(;+$(
"(;'&"
"';"&%
"&;+$(
"&;%(+
"&;$(*
"';"%"
"(;$)$
"';+)+
"#;%#(
$&;)#"
&;$&#
&;%&"
&;'#+
';"'%
';(&&
);#)&
);#+%
);'"#
);&)'
$#;&((
$";*&*
$%;**"
"+;%&(
%%;")%
!444
!443
!44!
!44J
!44F
!44"
!44L
!44I
!44K
!44H
!434
!433
!43!
!43J
,<= 3DE>A 3,:. 2BF@G@BHEC ,<= 3DE>A /74 2BF@G@BHEC


37
CharL 2-10 dellneaLes, by fundlng sLream, famllles and servlces supporLed under elLher
federal 1Anl and/or sLaLe-MCL dollars:

CharL 2-10: 1ANI Verses State-MCL Iund|ng
Source: MCL lnformaLlon obLalned from Malne's ACl-204 8eporL for ll? 2013


Iedera||y Iunded
rograms and Serv|ces
1Anl baslc cash-asslsLance famllles
ASl8L-1Anl supporLlve servlces
arenLs-as-Scholars famllles for flrsL
Lwelve monLhs of posL-secondary
educaLlon
Lmergency-asslsLance paymenLs for
famllles below 100 lL, or ellglble
1Anl, aS, SSl, or worker-
supplemenL program
AlLernaLlve ald (non-recurrenL
shorL-Lerm vouchers)
State-Iunded MCL
rograms and Serv|ces
non-clLlzen famllles noL ellglble
under federal 1Anl
aS famllles afLer flrsL Lwelve
monLhs ln posL-secondary Lwo-year
or four-year degree programs
ASl8L sLaLe-funded supporL
servlces for 1Anl famllles
underemployed Lwo-parenL famllles
lncapaclLaLed one- and Lwo-parenL
famllles
Chlld Care uevelopmenL lund
SLudenLs, ages 18, 19, and 20, and
Lhelr parenLs
Worker supplemenL for 1Anl leavers
who close due Lo earnlngs.
osL-1Anl LranslLlonal
LransporLaLlon and LranslLlonal chlld
care for worklng famllles
Chlld-supporL pass-Lhrough (gap)
paymenLs
SLaLe refundable Lax credlLs, ClrculL
8reaker program, and chlld care Lax
credlLs
Ceneral AsslsLance for shorL-Lerm
crlsls-prevenLlon asslsLance


38
1he Leage admlnlsLraLlon has effecLlvely addressed Lhe LhreaL of penalLles for falllng
Lhe all-famllles work parLlclpaLlon raLe. ln facL, Lhe deparLmenL recelved noLlflcaLlon from PPS
LhaL Lhe ACl has accepLed Malne's correcLlve acLlon plan coverlng 2008, 2009, and 2010.
Powever, Lhe sLaLe sLlll faces poLenLlal penalLles for falllng Lhe Lwo-parenL famlly W8 of 90 ln
ll? 2008, ll? 2009, and ll? 2010.

Accordlng Lo Lhe Congresslonal 8esearch Servlce, PPS has noL announced Lhe sLaLus of
penalLles for any sLaLe for falllng Lo meeL Lhe all- famllles sLandard slnce l? 2007.

Malne may need Lo reconslder lLs accounLlng of Lwo-parenL famllles as parL of 1Anl or
1Anl-MCL. lL may be prudenL Lo fund Lhese famllles under a separaLe sLaLe (non-MCL) fundlng
sLream, Lhus avoldlng Lhe dlfflculLles ln meeLlng Lhe 90 W8 alLogeLher, or Lhe uPPS could
modlfy pollcles relaLed Lo Lwo-parenL famllles who are noL meeLlng Lhelr lndlvldual work
parLlclpaLlon requlremenLs.


Work-L||g|b|e Ind|v|dua|s and Work art|c|pat|on kequ|rements

A work-ellglble lndlvldual (WLl) ls an adulL (or mlnor head-of-household) reclplenL of
1Anl cash asslsLance, or a non-reclplenL parenL llvlng wlLh a chlld LhaL ls recelvlng cash
asslsLance unless Lhe parenL ls:
a mlnor, buL noL Lhe head-of-household,
a non-clLlzen who ls lnellglble Lo recelve asslsLance due Lo hls or her lmmlgraLlon sLaLus,
a SupplemenLal SecurlLy lncome (SSl) reclplenL,
a parenL provldlng care for a dlsabled famlly member llvlng ln Lhe home, or
a parenL recelvlng Soclal SecurlLy ulsablllLy lnsurance (SSul) beneflLs.

1o counL Lowards Lhe work parLlclpaLlon raLe, Lhe WLl musL have verlfled parLlclpaLlon
ln counLable acLlvlLles for a speclflc number of hours each monLh. arenLs wlLh chlldren, 6 years
of age and older, musL parLlclpaLe ln a counLable acLlvlLy for LhlrLy hours a week for each week
Lhey are recelvlng a 1Anl beneflL. arenLs wlLh chlldren under 6 musL parLlclpaLe for LwenLy
hours. lamllles wlLh Lwo parenLs musL parLlclpaLe an average of LhlrLy-flve hours a week.


Lngagement of Work-L||g|b|e Ind|v|dua|s

8oLh ellglblllLy workers and soclal-servlce sLaff locaLed ln slxLeen reglonal offlces
LhroughouL Lhe sLaLe offer ASl8L/aS program beneflLs Lo parenLs wlLh chlldren on cash
asslsLance. 1he goals and ob[ecLlves of Lhe program are Lhe same as Lhe goals and ob[ecLlves of
Lhe famllles seeklng asslsLance: famlly and chlld wellbelng comblned wlLh economlc
lndependence ln Lhe shorLesL Llme posslble. Pow much and how long asslsLance ls needed ls
ofLen Lhe lnLersecLlon where expecLaLlons dlffer.


39
1Anl ls a work program for low-lncome parenLs wlLh chlldren. Whlle educaLlon and
Lralnlng acLlvlLles are allowed, Lhey can only be counLed for a llmlLed perlod of Llme, afLer whlch
parenLs are expecLed Lo work. More Lhan any of lLs predecessor programs, 1Anl ls prescrlpLlve
abouL how success ls aLLalned and measured, boLh for parLlclpanLs and program admlnlsLraLors.
Lven Lhough 1Anl permlLs a perlod of Llme (up Lo LwenLy-four monLhs) before requlrlng
parLlclpaLlon ln counLable work acLlvlLles, experlence has demonsLraLed LhaL lmmedlaLe
engagemenL sLraLegles, as a condlLlon of ellglblllLy, ls an effecLlve way Lo lncrease parLlclpaLlon
ln counLable acLlvlLles and also emphaslze Lhe mandaLory naLure of Lhls program.

1he followlng Lable offers a breakdown of educaLlon and Lralnlng expendlLures for
ASl8L-1Anl cases durlng 2013:

CharL 2-11: Lducat|on & Iob-1ra|n|ng Serv|ces, 2013
LducaLlon rograms $273,277
AdulL LducaLlon Courses/rograms $123,110
College And unlverslLy rograms $23,141
CLu Courses/rograms $12,438
CLher LducaLlon/1ralnlng rograms $81,833
vocaLlonal/1echnlcal College rograms $34,733
!ob reparaLlon rograms $476,691
lleld 1ralnlng Lxpense $29,812
!ob Club 1ralnlng Lxpense $199,837
!ob uevelopmenL $12,163
!ob lacemenL & 8eLenLlon $3,641
CccupaLlonal 1ools/LqulpmenL $42,832
Cn-1he-!ob 1ralnlng $1,430
1rades 1ralnlng Courses/rograms $37,686
unlforms/CccupaLlonal CloLhlng $31,829
vocaLlonal LvaluaLlon $93,439
1ota| Lxpend|tures 57S1,968


Cne observaLlon ls LhaL Lhe ASl8L-1Anl/aS program - comparaLlvely speaklng -
expended llmlLed dollars ($731,968) dlrecLly on Lralnlng and/or [ob-placemenL servlces.


40
lorLunaLely, new collaboraLlon wlLh Malne's ueparLmenL of Labor ls llkely Lo enhance access Lo
[obs and Lhus lmprove Lhe sLaLe's overall work parLlclpaLlon raLe for ASl8L-1Anl parenLs.

1Anl fundlng allows for proper supporLs Lo be provlded such as chlld care,
LransporLaLlon, and oLher famlly supporLs, buL soluLlons musL be found Lo help 1Anl parenLs
move forward lnLo employmenL and ulLlmaLely economlc lndependence. Malne's slxLeen
reglonal offlces are seL up Lo provlde asslsLance by well-Lralned ellglblllLy workers and
ASl8L/aS supporL sLaff who undersLand Lhe lmporLance of Lhelr roles and responslblllLles and
Lhe poLenLlal effecL Lhey have on each person Lhey are asslgned Lo serve.

CharLs 2-12 and 2-13 compare Malne's 1Anl caseload ln uecember 2012 and uecember
2013. ln vlrLually every caLegory, Lhe numbers have decreased subsLanLlally. Many of Lhese
cases were closed due Lo Lhe slxLy-monLh Llme-llmlL pollcy LhaL Look affecL ln 2012. CLher case
closures may have occurred due Lo: lncreased earnlngs, lncreased chlld supporL or boLh,
closures due Lo youngesL chlld reachlng Lhe age of lnellglblllLy, ouL-of-sLaLe moves, and for
some, closures due Lo Lhe new full-famlly sancLlon pollcy.

CharL 2-12: 1ANI Case|oad Dec||nes, 2012-13
rogram December
2012
December
2013
Change ercent
1Anl unemployed arenL, 1wo-arenL lamlly 860 363 -297 -34.3
1Anl lncapaclLaLed 1wo-arenL lamlly 831 733 -76 -9.1
1Anl 1wo-arenL Pouseholds 1,691 1,318 -373 -22.1
1Anl Cne-arenL Pousehold 3,284 4,130 -1,134 -21.8
1Anl Chlld Cnly 2,199 2,021 -178 -8.1
AlLernaLlve Ald Cases 67 67 0 0.0
8efugee Cash AsslsLance Cases 76 83 7 9.2
arenLs-as-Scholars rogram 402 243 -139 -39.6
1ranslLlonal Chlld Care 1,742 1,380 -162 -9.3
1ranslLlonal 1ransporLaLlon rogram 911 363 -346 -38.0
Lmergency AsslsLance 706 324 -182 -23.8
Speclal needs Allowance 2,836 2,236 -620 -21.7
1Anl CareLaker 89 74 -13 -16.9
A|| rograms 17,786 14,224 -3,S62 -20.0
Source: uPPS-Cll uaLa 8eporL, uecember 2013.


41

CharL 2-13: Compar|son of 1wo-arent & Cne-arent 1ANI nouseho|ds
Cff|ce December 2012 December 2013
1wo-arent
nouseho|ds
Cne-arent
nouseho|ds
ercent of
1wo-arent
Cases
1wo-arent
nouseho|ds
Cne-arent
nouseho|ds
ercent of
1wo-arent
Cases
AugusLa 214 376 27.1 143 423 23.3
8angor 173 361 23.6 122 476 20.4
8lddeford 61 233 20.7 33 193 21.3
Calals 22 70 23.9 13 33 21.4
Carlbou 32 193 21.2 30 207 19.3
CenLral Cfflce 0 0 0.0 0 3 0.0
LllsworLh 21 73 21.9 17 66 20.3
larmlngLon 38 121 23.9 23 88 22.1
lorL kenL 13 68 18.1 23 64 28.1
PoulLon 39 130 23.1 24 33 31.2
LewlsLon 282 818 23.6 220 669 24.7
Machlas 12 68 13.0 12 31 19.0
orLland 370 929 28.3 338 741 31.3
8ockland 132 362 21.3 107 388 21.6
Sanford 38 337 14.0 30 288 14.8
Skowhegan 83 273 23.7 60 219 21.3
SouLh arls 97 230 28.0 37 144 28.4
1ota|s 1,691 S,284 24.2 1,318 4,130 24.2
Source: uPPS-Cll uaLa 8eporLs, uecember 2013.


CharL 2-14: ASIkL-1ANI Lmp|oyed Cases, 2013
!anuary 1,690 !uly 1,672
lebruary 1,649 AugusL 1,634
March 1,633 SepLember 1,616
Aprll 1,670 CcLober 1,363
May 1,788 november 1,310
!une 1,732 uecember 1,383




42
1o asslsL parenLs on ASl8L-1Anl/aS Lo parLlclpaLe ln programs leadlng Lo
employmenL, a broad range of supporLlve servlces are provlded Lo remove barrlers Lo
parLlclpaLlon. 1hose who successfully close Lo ASl8L-1Anl and aS due Lo employmenL
conLlnue Lo need supporL unLll Lhelr earnlngs are above Lhe ASl8L-1Anl ellglblllLy levels.

Cn average, approxlmaLely 1,833 ASl8L/aS parenLs recelve supporLlve servlces
monLhly. 1he followlng charL provldes a breadown on Lhe LoLal expendlLures for 2013 ln accord
wlLh Lhe caLegorles of expendlLures provlded by ASl8L/aS:

CharL 2-13: ASIkL Support|ve Serv|ces Spend|ng

Source: uPPS-Cll uaLa 8eporLs, uecember 2013.


CharL 2-16 represenLs supporLlve servlces whlch are provlded Lo ASl8L-1Anl and aS
parLlclpanLs who are ln recelpL of, or recenLly closed Lo, cash asslsLance due Lo lncreased
earnlngs. Cne or more of Lhese supporLs may be provlded ln order Lo help parenLs parLlclpaLe
ln pre-approved educaLlon and employmenL acLlvlLles. lL ls noL posslble Lo dlscern how many of
Lhese separaLe supporLs may have been lssued Lo a slngle ASl8L-1Anl or aS parLlclpanL.



43
Chart 2-16: Support|ve Serv|ces for ASIkL-1ANI and aS


Cther: Maxlmum of $300 per calendar year
Auto Insurance: Maxlmum $300 per enrollmenL perlod
Auto kepa|rs: Maxlmum $300 per calendar year (pre-approval needed),
pald Lhrough parenL's L81 card.
1ransportanon: LlmlLed Lo 400 mlles per week [ 30 cenLs per mlle,
publlc LransporLauon Lhrough use of purchased uckeLs,
car-pool drlver relmburssed [ 30 cenLs per mlle and $2 per day per ASl8L parenL.
Ch||d Care: 8ased on parenL's weekly acuvlues, lncludes Lransluonal chlld care for worklng
parenLs. 8aLes based on 2013 markeL-raLe survey.
Iob Deve|opment: Maxlmum of $800 per enrollmenL perlod (fee for supporuve servlces)
and [ob placemenL up Lo $300 per enrollmenL perlod.
arents as Scho|ars:
Maxlmum of $2,000, ume-llmlL exLenslons may be granLed aL slx-monLh revlew perlods.
ost-Secondary Lducanon &1ra|n|ng Lxpenses:
Maxlmum of $3,300 per academlc year for Luluon and mandaLory fees
8ooks & Supp||es: up Lo $730 per academlc year
C|oth|ng & Un|forms: Maxlmum of $300 per calendar year
Cccupanona| Lxpenses (1oo|s & Lqu|pment): LlmlLed Lo $300 per enrollmenL perlod

Vocanona| Lva|uanon: up Lo $2,300 per calendar year


44
1ranslLlonal Chlld Care (1CC) ls parL of a conLlnuum of supporL provlded Lo parenLs who
have closed Lo ASl8L or aS buL need chlld care asslsLance Lo remaln ln Lhe workforce. 1able 2-
17 provldes a breakdown of cases and expendlLures under Lhe 1CC program:

CharL 2-17: 1rans|t|ona| Ch||d Care rogram, C 2013
Month Cases Lxpend|tures Cost er Case
!anuary 2,707 $1,003,126 $371
lebruary 2,391 $786,013 $303
March 2,363 $783,838 $306
Aprll 2,343 $779,963 $307
May 2,616 $987,198 $377
!une 2,606 $821,608 $313
!uly 2,634 $902,032 $342
AugusL 2,673 $1,098,440 $411
SepLember 2,464 $768,314 $312
CcLober 2,398 $882,997 $368
november 2,339 $333,712 $236
uecember 2,422 $879,700 $363
Average Number of Cases 2,SS2 510,2S1,162 54,017

Cn Lhe followlng page, CharL 2-18 dlsplays Lhe number of cases per monLh and Lhe
average expendlLures per monLh ln supporLlve servlces, whlle CharL 2-19 breaks down
LransporaLlon expenses pald Lhrough ASl8L.




43
CharL 2-18: Average Number of Iam|||es kece|v|ng Support|ve Serv|ces

Source: uPPS-Cll uaLa 8eporLs, uecember 2013.

CharL 2-19: ASIkL 1ransportat|on Lxpend|tures

Source: uPPS-Cll uaLa 8eporLs, uecember 2013.


46
1hrough Lhe end of 2013, Cll had no dlrecL purchase of servlce conLracLs devoLed Lo
preparlng ASl8L/aS parLlclpanLs for work. 1he sLaLe's somewhaL unlque approach has been
Lo provlde lndlvldual LulLlon-asslsLance paymenLs on behalf of parLlclpanLs who pursued a wlde
range of career-Lralnlng programs consldered besL sulLed Lo Lhe parenL's goal for long-Lerm
employmenL. 1he program has also placed a number of parLlclpanLs (prlmarlly Lwo-parenL
famllles) lnLo communlLy work-experlence acLlvlLles. Moreover, Lhe ASl8L/aS program has
provlded a slgnlflcanL amounL of flnanclal supporL ln Lhe form of chlld care subsldles,
LransporLaLlon asslsLance, auLo repalrs, unlforms and cloLhlng for work, and emergency-
asslsLance paymenLs - all of whlch famllles may need durlng and afLer closlng Lo Lhe
ASl8L/aS program.

Malne's aS ls a model LhaL ls unlque Lo 1Anl. uPPS should examlne lLs long-Lerm
reLurn on lnvesLmenL. A sLudy conducLed by Lhe CenLer for 8udgeL ollcles and rlorlLles
demonsLraLed favorable resulLs, however, Lhe sLudy dld noL measure ouLcomes of Lhe program
ln Lerms of [obs and wages buL raLher emphaslzed Lhe value of parenLs achlevlng posL-
secondary degrees. lL would be useful Lo conducL a longlLudlnal sLudy of aS and derlve
flrsLhand daLa as Lo how Lhese parenLs fared ln Lhe [ob markeL, and wheLher recldlvlsm has
been dlmlnlshed relaLlve Lo oLher parenLs who were noL ln Lhe aS program.

CharL 2-20 provldes a comparlson of 1Anl chlld-only cases, a caLegory LhaL occurs when
no adulL ls lncluded ln Lhe beneflL calculaLlon for 1Anl cash asslsLance. 1here are Lwo broad
caLegorles of chlld-only cases: Lhose ln whlch no parenL llves ln Lhe household (whlch ls called
non-parenLal chlld-only cases) and Lhose ln whlch a parenL llves ln Lhe household buL does noL
quallfy for 1Anl for cerLaln nonflnanclal reasons (parenLal chlld-only cases). Some of Lhese
nonflnanclal reasons are common Lo all or mosL sLaLes and oLhers are sLaLe-speclflc.
24


lor Malne, Lhe number of chlld-only cases decreased beLween uecember 2012 and
uecember 2013, a paLLern conslsLenL wlLh oLher Lypes of 1Anl-caseload decllnes durlng Lhe
same perlod. Powever, lf Malne ls Lyplcal of oLher sLaLes, Lracklng Malne's chlld-only cases over
Llme wlll become more lmporLanL Lhan ever, parLlcularly slnce Lhe sLaLe has lmplemenLed Lhe
slxLy-monLh Llme llmlL on 1Anl cash asslsLance.

Where mosL oLher sLaLes enforced a flve-year Llme llmlL from Lhe beglnnlng of 1Anl, Lhe
average chlld-only caseload grew from a prevlous norm of 20 Lo 24 (pre-1Anl) Lo a currenL
norm of 40 Lo 30. Malne ls behlnd Lhe naLlonal curve, buL lL wlll presumably experlence a
slmllar lncrease ln Lhe number of chlld-only cases recelvlng cash asslsLance ln fuLure years.

CharL 2-20 shows a 22.1 decrease ln chlld-only cases beLween 2012 and 2013.


24. Cllvla Colden and Amella Pawklns, 1Anl Chlld-Cnly Cases," 8rlef no. 3, 1he urban lnsLlLuLe,
november 2011.


47
CharL 2-20: 1ANI Ch||d-Cn|y Cases by keg|ona| Cff|ces
Cff|ce December
2012
December
2013
Change ercent
D|fference
AugusLa 214 226 12 3.6
8angor 331 319 -12 -3.6
8lddeford 87 98 11 12.6
Calals 41 32 -9 -22.0
Carlbou 71 68 -3 -4.2
CenLral Cfflce 0 3 3 n/A
LllsworLh 40 39 -1 -2.3
larmlngLon 63 48 -13 -23.8
lorL kenL 13 13 -2 -13.3
PoulLon 42 39 -3 -7.1
LewlsLon 276 290 14 3.1
Machlas 30 26 -4 -13.3
orLland 396 339 -37 -14.4
8ockland 170 132 -18 -10.6
Sanford 138 149 -9 -3.7
Skowhegan 133 116 -17 -12.8
SouLh arls 132 64 -68 -31.3
1ota| 1,691 1,318 -373 -22.1
Source: uPPS-Cll uaLa 8eporLs, uecember 2013.


Ma|ne's 1ANI o||cy Cho|ces, ke|at|ve to other States
23


o||cy Cpt|on 1: 1wo-arent Iam||y kequ|rements

SLaLes can reLaln prevlous AluC rules for Lwo-parenL households as an addlLlonal
ellglblllLy LesL, whlch llmlLs Lhe number of hours a prlnclpal wage earner can work wlLhouL
loslng ellglblllLy. 1hls rule, ln effecL, dlscourages Lwo-parenL households from applylng for
asslsLance.


23. Source for Lhls secLlon: uPPS 1Anl pollcles as of !uly 2012.


48
CharL 2-21: 1wo-arent Iam||y L||g|b|||ty
under 1ANI


o||cy Cpt|on 2: Upfront Iob Search at App||cat|on

CharL 2-22: State o||c|es kequ|r|ng
Upfront Iob-Search Act|v|t|es


o||cy Cpt|on 3: Iam||y-Cap Cpt|on

CharL 2-23: Iam||y-Cap o||c|es among
States, Iu|y 2012


L#
K#
KL#

1 .23245 6374
'8 9:/3;<
=!',
,3>?@?45
A .23245
;423?B4C DEE
F8G; H8;I
=452
I!#
!K#
;.2M 3I
N(M JF
4 34 !4 J4 F4
Malne ls one of 34 sLaLes LhaL does
noL have a famlly-cap pollcy.
17 sLaLes have 1Anl famlly-cap
pollcles.
19 sLaLes (28) requlre upfronL [ob
search as a condlLlon of ellglblllLy.
1yplcally, parenLs musL parLlclpaLe ln
[ob search for up Lo Lhree weeks and
provlde documenLaLlon of Lhe resulLs of
Lhls acLlvlLy.
Malne ls one of 32 sLaLes (72) LhaL
does noL requlre up-fronL [ob search.
Malne ls one of only four sLaLes Lo reLaln Lhe
prevlous AluC work-hour rule for Lwo-
parenL famllles.
44 sLaLes dropped Lhe work-hour rule as a
burdensome pollcy, whlch also undermlnes
1Anl famlly-formaLlon lnLeresLs.
1hree sLaLes, whlch do noL have Lwo-parenL
famllles ln recelpL of 1Anl or 1Anl-MCL,
avold Lhe 90 W8 sLandard.


49
o||cy Cpt|on 4: State 1|me-L|m|t Lxtens|ons

SLaLes have Lhe opLlon Lo exLend famllles beyond Lhe slxLy-monLh federal Llme llmlLs (1L)
lf Lhey meeL sLaLe pollcy condlLlons.

CharL 2-24: Number of States w|th 1|me-
L|m|t Lxtens|on o||c|es



o||cy Cpt|on S: 8ehav|or kequ|rements and Ch||dren

SLaLes have pollcy opLlons LhaL are lnLended Lo lncenLlvlze parenLs Loward healLh and
wellness of Lhelr chlldren by requlrlng healLh screenlngs and assurlng LhaL chlldren recelve
proper lmmunlzaLlons and aLLend school regularly. ln some sLaLes, bonus paymenLs can be
earned by Lhe famlly for school aLLendance and educaLlonal achlevemenLs, as deflned by sLaLe
pollcles. CharL 2-23 provldes a counL of sLaLes chooslng one or more of Lhese pollcles.

CharL 2-23: State 1ANI kequ|rements for
Dependent Ch||dren, Iu|y 2012


Whlle mosL of Malne's pollcles Lend Lo be advanLageous for ellglble famllles, Lhe cash-
asslsLance beneflL levels rank lowesL ln new Lngland and LwenLy-flrsL naLlonally. 1he lasL Llme
Malne's beneflL level was ralsed was ln 2006. CharL 2-26 offers speclflcs on Lhls lndlcaLor.
(
%)
%*
%*
$$
/3;4B25 ?B #CGJ32?8B 8;
"?J2?> 8K L8>452?J "?8@4BJ4
/3;4B2 ?5 M@@ 8; ?BJ3N3J?2324C
-3;45 K8; +264; M@@OMBJ3NPC
/3;4B2 Q8;I5 )?B< '8<8K
I
!J
H
JL
O.+-*=
P05..&%&Q
R99)&%S+*%(&2
P0=((-
T(&)2.2
P0=((-
8.U)%5.9.&*2
3DE>A :DI DJ 5E>EBC
36 sLaLes have school requlremenLs.
23 sLaLes have adopLed
lmmunlzaLlons as a requlremenL.
7 sLaLes requlre healLh screenlngs.
9 sLaLes offer school-achlevemenL
bonuses.
Malne has noL adopLed any pollcles
Lylng behavloral requlremenLs Lo
1Anl.
Malne ls one of slx sLaLes Lo exLend 1Ls for
parenLs ln educaLlon or vocaLlonal Lralnlng.
Malne ls one of 37 sLaLes Lo allow exLenslon
for vlcLlms of domesLlc vlolence.
Malne ls one of 38 sLaLes Lo allow exLenslons
based on lllness or lncapaclLy of parenL.
Malne ls one of 38 sLaLes Lo allow exLenslons
based on lllness or lncapaclLy of anoLher
household member.
Malne ls one of 11 sLaLes Lo allow exLenslons
for parenLs worklng Lhe mlnlmum number of
hours per week.


30
CharL 2-26: New Lng|and 1ANI Month|y Cash-Ass|stance Leve|s
lamlly Slze Ma|ne ConnecLlcuL MassachuseLLs new
Pampshlre
8hode
lsland
vermonL
lamlly of 2 5363 $470 $318 $606 $449 $336
lamlly of 3 548S $376 $618 $673 $334 $640
lamlly of 4 5611 $677 $713 $738 $634 $726
lamlly of 3 5733 $773 $812 $798 $714 $817
lamlly of 6 58S6 $877 $912 $879 $794 $879
Ma|ne's month|y benef|t amount |s the |owest |n New Lng|and
but the 21
st
h|ghest (for fam||y of three) compared to a|| other states.
Source: uavld kassablan eL al., Welfare 8ules uaLabook: SLaLe 1Anl ollcles as of !uly 2012," 1he urban
lnsLlLuLe, submlLLed Lo ACl Cfflce of lannlng, 8esearch and LvaluaLlon, llnal 8eporL 2013, 1able ll.A.4,
hLLp://www.urban.org/uploadedul/412973-2012-wrd.pdf


Ma|ne's 1ANI n|gh-erformance Measures ke|at|ve to Cther States

ACl complles daLa reporLs on sLaLes Lo deLermlne wheLher 1Anl goals are belng meL.
uslng complex formulas wlLhln elecLronlc daLa-maLchlng flles, Lhese measures lndlcaLe how
each sLaLe compares on work-relaLed, chlld care, SnA, and famlly-formaLlon measures.
Sources of daLa lnclude: 1Anl admlnlsLraLlve daLa, unemploymenL-lnsurance wage records,
naLlonal ulrecLory of new Plres, SnA admlnlsLraLlve daLa llnked Lo 1Anl, Amerlcan
CommunlLy Survey daLa, Census 8ureau, and sLaLe admlnlsLraLlve daLa. Whlle Lhls llsL ls noL all-
lncluslve, lL covers sources relaLed Lo work-and-famlly well-belng hlgh-performance measures.

CharL 2-27: Ma|ne's erformance under 1ANI n|gh-erformance Standards
Measure kate State kank|ng
!ob LnLry 8aLe 26.34 33
rd

!ob 8eLenLlon 8aLe 63.32 22
nd

Larnlngs Caln 8aLe 27.63 40
Lh

8aLe of Low-lncome Worklng lamllles on SnA 73.10 1
sL

lamlly lormaLlon/SLablllLy 8aLe 66.03 26
Lh

Source: AdmlnlsLraLlon for Chlldren and lamllles, Plgh-erformance Measures, erformance ?ear 2011,
1ables 3(a), 3 (b), 3 (c), 3, and 7.


31
nC1L Lo CharL 2-27: 1hese measures are based on Lhe mosL recenL daLa reporLed ln ll? 2011 by PPS'
AdmlnlsLraLlon for Chlldren and lamllles. unLll 1Anl hlgh-performance bonus funds were exhausLed,
Lhese measures were used Lo award Lhe Lop Len performlng sLaLes ln one or more of Lhe speclflc
measures wlLh bonus dollars. ACl conLlnues Lo measure sLaLe-performance lndlcaLors buL sLrlcLly for
purposes of lnformlng sLaLes how Lhey compare wlLh naLlonal daLa.

Chart 2-28: Compar|son of 1ANI Law vs. Asp|re-1ANI rogram o||c|es
1ANI Law ASIkL-aS rob|ems and]or Incons|stenc|es
w|th ASIkL rogram
Work-act|v|ty
kequ|rements

SLaLe musL meeL annual work
parLlclpaLlon raLes:
30 all-famlly raLe
90 Lwo-parenL famlly raLe
Same as 1Anl SLaLe falled W8 ln ll? 2007, 2008,
2009, and 2010
Week|y
part|c|pat|on
requ|rements
by fam||y type
1-arent kequ|rements
30 hours per week lf parenL's chlldren
are 6+ years old
20 hours per week lf parenL's chlldren
are under 6
2-arent kequ|rements
33 hours per week lf Lwo-parenL
household

Same as 1Anl

Same as 1Anl


Same as 1Anl
Malne's work-ellglble lndlvlduals
(74) parLlclpaLed ln acLlvlLles buL
only 14.4 had enough hours Lo
counL.
1here are 12 work acLlvlLles under 1Anl law. nlne of Lhese 12 are core caLegorles LhaL can counL Loward hours of
parLlclpaLlon, parLlclpaLlon ln Lhe Lhree non-core caLegorles can only counL lf Lhe lndlvldual also parLlclpaLes ln Lhe
core acLlvlLles for aL leasL 20 hours per week (30 hours for Lwo-parenL famllles). ln addlLlon, under a speclal rule,
secondary or CLu-relaLed school aLLendance, or educaLlon dlrecLly relaLed Lo employmenL can counL as
parLlclpaLlon for parenLs under age 20, even lf lL would oLherwlse be a non-core acLlvlLy LhaL can only counL afLer 20
hours per week of core parLlclpaLlon.

Core Act|v|t|es under 1ANI
S|ng|e arents
Core Act|v|t|es under
ASIkL or aS
Countab|e?
1ANI 12
Countab|e
Work Act|v|t|es










1. unsubsldlzed employmenL unsubsldlzed employmenL,
lncludes pald employmenL," self-
employmenL, on-Lhe-[ob Lralnlng,
Work SLudy, ASl8L chlld care
employmenL, and apprenLlceshlp.
?es
2. Subsldlzed prlvaLe-secLor
employmenL
Subsldlzed prlvaLe-secLor
employmenL
?es
3. Subsldlzed publlc-secLor
employmenL
Subsldlzed publlc-secLor
employmenL
?es
4. Work experlence (lncludlng
work assoclaLed wlLh Lhe
refurblshlng of publlcly asslsLed
houslng) lf sufflclenL prlvaLe-
secLor employmenL ls noL
avallable
Work experlence, lncludes fleld
Lralnlng (skllls)

?es


32


































3. Cn-Lhe-[ob Lralnlng Cn-Lhe-[ob Lralnlng, whlch
consldered Lo be unsubsldlzed
employmenL
?es
6. !ob-search and [ob-readlness
asslsLance
!ob search & [ob readlness (6
weeks ln any 12-monLh perlod, 12
weeks ln any 12-monLh perlod for
sLaLes such as Malne, wlLh needy
SLaLe sLaLus), [ob-search and [ob-
readlness acLlvlLles lnclude
lndlvldual [ob search, group-[ob
search, pre-vocaLlonal (ASl8L),
pre-vocaLlon (referred), subsLance-
abuse/menLal-healLh LreaLmenL,
fleld Lralnlng (readlness),
placemenL asslsLance, and [ob
developmenL.
?es
7. CommunlLy servlce programs CommunlLy-servlce programs:
AcLlvlLles lnclude 1LM (regular),
1LM (u), and volunLeerlng.
?es
8. vocaLlonal-educaLlonal Lralnlng
(noL Lo exceed 12 monLhs wlLh
respecL Lo any lndlvldual)
vocaLlonal-educaLlonal Lralnlng:
AcLlvlLles lnclude assoclaLe's
degree (aS), 8A/8S degree (aS),
college courses, communlLy-
college degree (aS), communlLy-
college cerLlflcaLe, communlLy-
college courses, adulL ed (skllls),
employer-sponsored Lralnlng, and
Lechnlcal/Lrades courses.
arLlclpanLs are llmlLed Lo 12
monLhs of vocaLlonal-educaLlonal
Lralnlng ln Lhelr llfeLlme.
Cne hour of sLudy Llme wlll be
counLed Loward parLlclpaLlon for
every verlfled hour of classroom
parLlclpaLlon.
CounLable up Lo
12 monLhs.
Cnly 10 sLaLes
allow 2 year/4-year
posL-secondary
sLand-alone
programs.
Ma[orlLy of oLher
sLaLes approve only
lf parenL flrsL works
20 hours per week.
9. rovlslon of chlld care servlces
Lo an lndlvldual who ls
parLlclpaLlng ln communlLy-
servlce program
rovlslon of chlld care servlces Lo
an lndlvldual who ls parLlclpaLlng ln
communlLy-servlce program.
?es
|us Countab|e Non-Core Act|v|t|es
10. !ob-skllls Lralnlng dlrecLly
relaLed Lo employmenL
!ob-skllls Lralnlng dlrecLly relaLed Lo
employmenL, acLlvlLles lnclude all
acLlvlLles llsLed ln vocaLlonal-
educaLlonal Lralnlng. 1here are no
Llme llmlLs on [ob-skllls Lralnlng
acLlvlLles.
?es
11. LducaLlon dlrecLly relaLed Lo
employmenL, ln Lhe case of a
LducaLlon dlrecLly relaLed Lo
employmenL, acLlvlLles lnclude adulL
?es


33
reclplenL who has noL recelved
a hlgh-school dlploma or CLu
baslc ed (A8L), Lngllsh as a second
language (LSL), adulL ed (dlploma),
hlgh school, and C.L.u. preparaLlon.
12. SaLlsfacLory aLLendance aL
secondary school, or ln a
course of sLudy leadlng Lo a
cerLlflcaLe of general
equlvalence, ln Lhe case of a
reclplenL who has noL
compleLed secondary school or
recelved such a cerLlflcaLe.
SaLlsfacLory aLLendance aL secondary
school, or a course of sLudy leadlng
Lo a cerLlflcaLe of equlvalence, ln
Lhe case of a 1Anl cusLodlal parenL
under 20 years of age and who has
noL compleLed secondary school or
recelved such a cerLlflcaLe,
regardless of age of youngesL chlld

AssessmenL/cllenL evaluaLlon ls
noL a recognlzed acLlvlLy under
1Anl.
AssessmenL/cllenL evaluaLlon
process for up Lo 90 days ls noL a
counLable acLlvlLy (approxlmaLely
20 Lo 23 of caseload pendlng
revlew and assessmenL).
noL counLable
AwalLlng dlsablllLy deLermlnaLlon
for SSl approval, or may have a
shorL-Lerm lllness/dlsablllLy.
noL counLable
osL-secondary degree programs
are noL llsLed as a 1Anl acLlvlLy.
aS Lwo- Lo four-year degree
programs (beyond 12 monLhs).
noL counLable afLer
12 monLhs.
MusL flL wlLhln Lhe [ob-readlness
parameLers.
MenLal healLh, subsLance abuse,
domesLlc abuse servlces.
noL counLable afLer
12 weeks.
8aslc educaLlon, llLeracy, and LSL
programs LhaL are noL dlrecLly
relaLed Lo employmenL.
noL counLable
unless dlrecLly
relaLed Lo
employmenL.
Mlscellaneous acLlvlLles such as
chlld-welfare mandaLes or meeLlng
requlremenLs of probaLlon.
noL counLable as
sLand-alone
acLlvlLles.
L|m|tat|ons on
Count|ng Work
Act|v|t|es under
1ANI
1o be counLable, parenLs wlLh LhlrLy-hour requlremenL musL parLlclpaLe ln core
acLlvlLles for aL leasL LwenLy hours per week, and musL also parLlclpaLe for Len
addlLlonal hours ln non-core acLlvlLles ([ob-skllls Lralnlng, educaLlon dlrecLly relaLed Lo
employmenL, or saLlsfacLory aLLendance of secondary school/CLu).
arLlclpanLs ln vocaLlonal educaLlonal programs can accounL for no more Lhan 30 of
reclplenLs meeLlng Lhelr work requlremenL, and an lndlvldual's parLlclpaLlon ln
vocaLlonal educaLlon, lncludlng aS, can be counLed Loward Lhe work parLlclpaLlon raLe
for no more Lhan 12 monLhs ln hls or her llfeLlme.
!ob Search/!ob 8eadlness ls llmlLed Lo 6 weeks ln a 12-monLh perlod, unless a sLaLe -
such as Malne - ls deLermlned as a needy sLaLe," whlch means Lhey can counL up Lo
12 weeks ln a year for !ob Search/!ob 8eadlness.
ln Lwo-parenL famllles, 33 hours a week ls requlred for famllles noL recelvlng federally
funded chlld care, and 33 hours a week for famllles recelvlng federally funded chlld
care. (1he hours for Lwo-parenL famllles are for Lhe famlly as a whole and can be
dlvlded beLween Lhe Lwo parenLs.)
lf an lndlvldual's average weekly hours of parLlclpaLlon ln a glven monLh do noL reach
Lhe mlnlmum requlremenLs, Lhe sLaLe geLs no parLlal credlL.


34
1|me ||m|t on
cash ass|stance
Maxlmum of 60 monLhs.
SLaLes may walve up Lo 20 of
cases.
Maxlmum of 60-monLh Llme llmlL
(unless parenL quallfles for an
exLenslon).

Lxempt|ons from
t|me ||m|t
Chlld-only cases noL sub[ecL Lo
Llme llmlL.
Chlld-only cases noL sub[ecL Lo 1L.
arenLs of chlld under 12 monLhs
may be exempLed for no more
Lhan 12 monLhs.
Same as 1Anl
Lxtens|ons to
t|me ||m|t
no 1Anl exLenslons. arenLs worklng mlnlmum
number of hours per week can be
exLended on ASl8L/aS.
arLlclpaLlng ln an approved
educaLlon or vocaLlonal, Lhls
lncludes aS parLlclpanLs.
arenLs who are lll or
lncapaclLaLed.
Carlng for an lll or lncapaclLaLed
person.
vlcLlm of domesLlc vlolence.
SLaLe needs Lo
monlLor LhaL lL
does noL exceed
Lhe maxlmum of
20 under walver
provlslons.
Sanct|on po||cy MusL sancLlon non-parLlclpaLlng
famlly wlLh chlldren 6 and older.
May noL sancLlon non-
parLlclpaLlng famlly wlLh chlldren
3 and younger lf chlld care ls noL
avallable.
llrsL Lhree monLhs, sancLloned
household ls noL consldered ln
Lhe work parLlclpaLlon raLe
calculaLlon.
AfLer Lhree monLhs, counLs
agalnsL W8.
llrsL 90 days of sancLlon, parenL ls
removed from paymenL.
AfLer 90 days, full famlly sancLlon
lmposed (closes Lo cash
asslsLance) unLll parenL agrees Lo
comply and slgn a new conLracL.
Appeal rlghLs are deflned ln
pollcy, and lnclude good-cause
provlslons.
1Anl does noL
have any good-
cause provlslons.


kecommendat|ons for Ma|ne's 1ANI rogram





L||m|nate exempt|ons from ASIkL po||c|es. A slgnlflcanL percenLage of AS8l8L cases are
exempLed from any planned acLlvlLles, whlch ouLllne sLraLegles leadlng Lo lmprovemenL ln
famlly llfe and gradual lmprovemenL ln [ob readlness. 1hls may cover healLh servlces, menLal-
healLh servlces, mandaLory chlld-welfare acLlvlLles (parenLlng classes) as approprlaLe, and oLher
acLlvlLles Lo help Lhe parenL and chlldren achleve poslLlve ouLcomes. LxempLlons, a lefLover
sLraLegy from prevlous welfare programs, may seem besL for a parenL aL appllcaLlon. 8uL Loo
1. A||gn the ASIkL program w|th federa| 1ANI program act|v|t|es.


33
ofLen, exempLed famllles are lgnored when lnLervenLlon servlces comblned wlLh monlLored
acLlvlLles are more effecLlve ln helplng Lhan leavlng such famllles Lo fend for Lhemselves.

1|ghten up a||owab|e act|v|t|es |n accord w|th 1ANI countab|e act|v|t|es. CurrenLly, Lhe Al8L-
1Anl program appears Lo emphaslze Lhe long-Lerm beneflLs of Lwo- and four-year degree
programs (provldlng exLenslons Lo Llme llmlLs and exLenslons Lo parLlclpaLlon ln Lhe sLaLe-
supporLed posL-secondary acLlvlLy) knowlng LhaL lL does noL counL beyond Lhe flrsL Lwelve
monLhs for 1Anl. 1hls recommendaLlon does noL dlscounL Lhe value placed on acqulrlng posL-
secondary degrees, buL Lhere are several obvlous concerns:

- 1he sLaLe ls ln severe Lrouble flnanclally by falllng 1Anl W8s. lL has falled Lo achleve
Lhese raLes for flve consecuLlve years. (noLe: 1he mosL recenL lnformaLlon ls LhaL Malne
was noLlfled ln Aprll 2014 LhaL lL falled W8 ln ll? 2011.) 1hls ls due Lo Lhe facL LhaL Lhe
sLaLe has noL been successful ln engaglng enough parLlclpanLs ln counLable acLlvlLles Lo
offseL Lhe number who are elLher unengaged or are engaged ln acLlvlLles LhaL do noL
counL for 1Anl work parLlclpaLlon raLes.
- 1he lnvesLmenLs made Lhus far ln supporLlng posL-secondary degrees earned under Lhe
aS program have never been evaluaLed Lo deLermlne how many compleLe Lhelr
degrees, how many have become employed ln Lhelr degree fleld, how much Lhey have
been able Lo earn, have Lhey closed Lo 1Anl due Lo wages, and ls Lhelr a recldlvlsm raLe
relaLed Lo aS parLlclpanLs? WlLhouL such daLa Lo offseL Lhe problems ln Lhe program, lL
ls Lruly dlfflculL Lo argue Lhe value of aS when Lhe value has noL been measured ln
Lerms of reLurn-on-lnvesLmenL.
- When conslderlng Lhe sLrldenL ad[usLmenLs Lo Lhe overall pollcles whlch musL be made
Lo prove Lo ACl LhaL ASl8L-1Anl should noL lose federal dollars, lL ls dlfflculL Lo lgnore
Lhe overwhelmlng exposure Lhe sLaLe has ln supporLlng such a sLand-alone long-Lerm
supporL Lo aS famllles when funds may be losL Lo oLher famllles LhaL have never, or
could never, be parL of Lhe posL-secondary Lrack Lo self-sufflclency.

lor aS, follow 1Anl rules - approve aS for Lwelve-monLhs and requlre aS parenLs Lo
work a mlnlmum of LwenLy hours per week afLer Lwelve monLhs, whlle Lhey compleLe Lhelr
posL-secondary degree programs.






AdopL a pollcy LhaL everyone should have an acLlve plan LhaL, ln Lhe shorLesL Llme
posslble, wlll develop lnLo acLlvlLles and hours whlch conform wlLh 1Anl core and non-core
acLlvlLles. 1h|s recommendat|on assumes everyone can be do|ng someth|ng to prepare for
and acqu|re a [ob, and no one |s |eft beh|nd. 1he approach Lo 1Anl, whlle challenglng, means
no one ls accepLed onLo Lhe programs wlLhouL expecLaLlons and servlces. 1o creaLe a muLually
agreed upon plan - LhaL meeLs each lndlvldual where he or she ls - lncludlng a plan Lo flnd
2. Iu||y engage app||cants and rec|p|ents.


36
permanenL houslng or Lo address healLh-relaLed needs ls doable. As parL of a sound welfare-Lo-
work model, full engagemenL ls regarded by experLs ln Lhe fleld as Lhe besL famlly supporL
approach and leads Lo beLLer ouLcomes for chlldren and famllles.




upfronL [ob search ls someLlmes Lhe besL meLhod of assesslng a person's [ob readlness,
compared Lo all Lhe LesLlng and assessmenL Lools avallable, because a [ob offer Lrumps full
ongolng welfare asslsLance. Lven ln a LlghL labor markeL, overcomlng dlscouragemenL aL noL
havlng a [ob may be a self-lmposed faulLy concluslon on Lhe parL of Lhe appllcanL. lor some,
provldlng sound lnformaLlon backed by slmple program supporL can make a slgnlflcanL
dlfference for Lhose who have opLed ouL of Lhe labor markeL premaLurely. Lven lf 3 Lo 3 of
Lhe appllcanLs who conducL a mandaLory [ob search flnd employmenL, Lhose few can galn
poslLlve affecLs Lo Lhelr self esLeem and Lo an lmporLanL exLenL, Lhelr famlly llfe.

Lstab||sh a Do||ar]Data Work 1eam comprlsed of flnanclal managemenL, 1Anl flscal
offlcer, 1Anl admlnlsLraLor, 1Anl pollcy speclallsL, a reglonal offlce manager, and lmporLanLly,
an l1 daLa-reporLlng speclallsL. 1hls Leam would be able Lo provlde up-Lo-Lhe mlnuLe
lnformaLlon on 1Anl caseload dynamlcs such as:

! MonLhly appllcaLlons counLs - recelved/accepLed/denled/sancLlons/closures ln 1Anl-
ASl8L, aS, SnA, chlld care, medlcal asslsLance, and general asslsLance,
! 1racklng of number of famllles reachlng 1Anl Llme llmlLs along wlLh Lhe number
recelvlng exLenslons Lo Llme llmlLs,
! CharacLerlsLlcs of all famllles new Lo 1Anl (famlly slze, number of chlldren, one-
parenL/Lwo-parenL/chlld-only cases) and number of work-ellglble cases,
! MonLhly number of employed famllles,
! 1rends ln Lype of chlld care belng used and bllled (lnfanL care, Loddler care, school-age
care, and monLhly-expendlLure amounLs,
! 1rends ln Lhe sLaLe's unemploymenL raLes for each monLh,
! CLher lndlcaLors of currenL or fuLure lmpacLs on Lhe caseloads for each program
referenced above, measures LhaL can asslsL uPPS Lo beLLer forecasL and adapL Lo
changlng Lrends ln Lhe caseload.
4. Cont|nuous|y mon|tor case|oad and part|c|pat|on |eve|s.
3. kequ|re upfront [ob-search act|v|t|es
pr|or to acceptance onto cash ass|stance.


37
An effecLlve dollar/daLa Leam can learn Lo funcLlon wlLh a unlfled purpose and ensure
LhaL all flscal and programmaLlc declslon-maklng ls shared and analyzed on a regular basls (no
less ofLen Lhan monLhly). redlcLlng exposures Lo shorLfalls or poLenLlal penalLles provldes for
an lnformed and prepared admlnlsLraLlon, and offers leadershlp Lhe advanLages of a bullL-ln
early-alerL" sysLem on all beneflLs admlnlsLered by uPPS. Conversely, Lhe dlsconnecL amongsL
and beLween Lhese cruclal funcLlons wlLhln Lhe deparLmenL (flscal, program, pollcy, servlce, and
l1) can resulL ln mlssed opporLunlLles Lo ad[usL expendlLures, change pollcles, and -
lmporLanLly - avold cosLly flnanclal penalLles from Lhe federal governmenL.



keassess and engage as many as poss|b|e |n approvab|e act|v|t|es and at the |eve|
requ|red under federa| |aw. 1Anl does noL recognlze a Lwo-parenL lncapaclLy" caLegory and
Lherefore expecLs full parLlclpaLlon (aL leasL LhlrLy-flve hours per week), or Lhe case counLs
agalnsL Lhe sLaLe's W8.

keassess act|v|ty |eve|s of a|| two-parent Unemp|oyed Iam|||es and engage as many as
poss|b|e |n approvab|e act|v|t|es and at the hour|y requ|rement out||ned |n federa| |aw. 8oLh
parenLs can parLlclpaLe and Lhelr blended hours of parLlclpaLlon, whlch meeL or exceed 33
hours per week, can be counLed.





8u||d|ng and strengthen|ng the connect|on to MDCL he|ps the ASIkL-1ANI program
||nk more part|c|pants to the |abor force as opposed to be|ng attached to the we|fare system.
A naLural offshooL of Lhls llnkage beglns Lo make parLlclpanLs more comforLable Lo be aL Lhe
Career CenLers LhroughouL Lhe sLaLe. Some long-Lerm unemployed are lnLlmldaLed Lo walk lnLo
Lhe sLaLe's Career CenLers and Lhus feel severely llmlLed ln chooslng Lo go Lo work. Closer
llnkage such as Lhe new collaboraLlve parLnershlp wlll only enhance Lhe shared roles ln helplng
Malne's unemployed, many of whom may feel unlnvlLed Lo Lhe cenLers and Lhus unllkely Lo
successfully compeLe for [obs, whlch may be avallable Lhrough MuCL.

S. keexam|ne MCL-case|oad categor|es, part|cu|ar|y the two-
parent fam|||es, a|| of whom are |nc|uded |n the 1ANI-Wk
ca|cu|at|on. Under 1ANI |aw, 90 of a|| two-parent househo|ds
supported by e|ther federa| 1ANI do||ars or state MCL do||ars
are requ|red to part|c|pate.
6. Lxpand the coord|nat|on and shared resources of the Ma|ne
Department of Labor and Department of Lducat|on.


38
Co||aborate w|th the Ma|ne Department of Lducat|on to estab||sh |earn|ng
env|ronments that are work-s|te based, or are work-||ke des|gned, and comblne baslc
educaLlon and work-place sklll knowledge ln acLlvlLles LhaL can sLlll be counLable for 1Anl W8.






Chapter 8, We|fare-1o-Work Coord|nat|on, prov|des add|t|ona|
recommendat|ons that are des|gned to meet the un|que cha||enges of
1ANI wh||e at the same t|me creat|ng more effect|ve ways of he|p|ng
|ow-|ncome fam|||es of Ma|ne.


39





3. Supp|ementa| Nutr|t|on Ass|stance rogram (SNA)


Cverv|ew

SnA (formerly known as Lhe food-sLamp program) provldes food asslsLance Lo low-
lncome lndlvlduals and famllles who meeL lncome and household needs, as deLermlned by
appllcaLlon and ellglblllLy deLermlnaLlon sysLem. lederal fundlng ls drlven by caseload slze: ln
2012 Malne's federal and sLaLe SnA expendlLures were:

CharL 3-1: Iedera| and State Lxpend|tures for SNA, 2012
Category of Lxpend|tures 1ota| Lxpended Iund|ng Source
SnA 8eneflLs Lo Pouseholds $376,732,999 100 lederal
SLaLe Share of AdmlnlsLraLlve CosLs $ 8,762,473 30 SLaLe
lederal Share of AdmlnlsLraLlve CosLs 7,849,830 30 lederal
1ota| SNA Adm|n|strat|ve Costs 516,612,32S
Source: uSuA, lnS SnA SLaLe AcLlvlLy 8eporL, llscal ?ear 2012, lssuances, p. 9.


SnA beneflLs are pald 100 by federal uSuA, admlnlsLraLlve cosLs are prlmarlly based
upon a flfLy-flfLy maLchlng requlremenL. AdmlnlsLraLlve cosLs are affecLed by a number of
facLors lncludlng parLlclpaLlon levels, Lhe number and salary level of sLaLe sLaff, lnflaLlon, Lhe
locaLlon of sLaLe agency offlce(s), Lype of lssuance sysLem, worker-Lralnlng cosLs, degree of
auLomaLlon, level of fraud-conLrol acLlvlLy. Whlle all sLaLes sLrlve Lo achleve Lhe mosL
approprlaLe balance beLween servlce dellvery and accounLablllLy, lL becomes even more crlLlcal
ln Llmes of budgeLary consLralnLs.


Changes |n the SNA Case|oad

CharL 3-2 chronlcles how Lhe Malne SnA caseload, from 2009 Lo 2013, lncreased by
31,612 reclplenLs (and approxlmaLely 32,300 households), a boosL ln parL drlven by Lhe
provlslons of Lhe Amerlcan 8ecovery and 8elnvesLmenL AcL of 2009.



60
CharL 3-2: Ma|ne SNA Iacts, 2009 to 2013
II 2009 II 2010 II 2011 II 2012 II 2013
8eclplenLs 201,248 229,731 247,943 232,860 249,119
Pouseholds 98,337 114,211 126,184 131,133 130,374
8eneflLs lssued $292,704,383 $336,097,333 $382,131,426 $376,730,999 $367,069,888
Average MonLhly
8eneflL er erson
$121.20 $129.17 $128.43 $124.16 $122.79
Average MonLhly
8eneflL er
Pousehold
$243.01 $239.83 $232.36 $239.38 $234.66
Source: uSuA, lnS SnA rogram uaLa, Annual SLaLe Level uaLa lor l? 2009-13,
hLLp://www.fns.usda.gov/pd/snapmalne.hLm


1he number of SnA reclplenLs lncreased ln every sLaLe, sLaLes LhaL were hlL hardesL by
Lhe recesslon saw Lhe largesL caseload lncreases. lor example, nevada, llorlda, ldaho, and uLah
- Lhe four sLaLes wlLh Lhe greaLesL growLh ln Lhe number of unemployed workers beLween
2007 and 2011 - also had Lhe greaLesL growLh ln Lhe SnA caseload.

1he flgures demonsLraLe a sllghL decllne ln 2013: from 232,860 reclplenLs ln 2012 Lo
249,119 reclplenLs ln 2013, a decrease of 3,741 reclplenLs, and 131,133 households ln 2012 Lo
130,374 ln 2013, a decrease of 779 households. A paper publlshed by Lhe CenLer for 8udgeL and
ollcy rlorlLles flnds a slmllar paLLern ln 2013, ldenLlfylng Malne among slx sLaLes showlng Lhe
largesL caseload decllnes. 1hese sLaLes lnclude uLah (-6 percenL), norLh uakoLa (-6 percenL),
Malne (-3 percenL), Mlchlgan (-3 percenL), Mlssourl (-3 percenL), and ldaho (-3 percenL).
26
lf
Lhe economy lmproves, Lhe Congresslonal 8udgeL Cfflce expecLs LhaL Lhe number of SnA
reclplenLs wlll fall by 2 Lo 3 each year over Lhe nexL decade: from 47.7 mllllon naLlonally ln
l? 2013 Lo 47.6 mllllon ln 2014, 46.3 mllllon ln 2013, and 34.3 mllllon by 2023.

Malne's uPPS Cfflce of lamlly lndependence (Cll) rogram and 8eneflLs ulsLrlbuLlon
8eporL" for uecember 2012 and uecember 2013 conflrms LhaL a modesL decllne ls occurrlng.


Ma|ne SNA erformance Ind|cators

Applylng for SnA beneflLs has become slmpllfled ln recenL years because of Lhe sLaLe's
on-llne appllcaLlon process and on-golng efforLs Lo make access Lo asslsLance for Lhose Lruly

26. SnA CosLs are Levellng Cff, AlmosL CerLaln Lo lall nexL ?ear, 1rends 8eflecL llaL Caseloads and
8ecenL 8eneflL CuL," CenLer for 8udgeL ollcles and rlorlLles, november 2013.


61
ellglble as sLralghLforward for resldenLs of Malne as posslble. AddlLlonally, sLaLe sLaff reporL
recerLlflcaLlon pollcles and procedures are deslgned Lo be reclplenL frlendly, and fleld
operaLlons are responslve and commlLLed Lo a hlgh degree of efflclency and senslLlvlLy Lo
reclplenL servlces. Powever, handllng large caseloads ln any asslsLance program, parLlcularly
SnA, creaLes challenges Lo even Lhe mosL-efflclenL agency. Looklng aL ll?s 2003, 2006, 2007,
and 2008, Malne was found Lo have comparaLlvely hlgh error raLes ln federal revlews of Lhe
food-sLamp program. Powever, uPPS has been able Lo reverse LhaL paLLern ln recenL years. lor
l? 2012, uSuA lood and nuLrlLlon Servlces publlshed lLs mosL recenL SnA daLa reporL showlng
sLaLe-level breakdowns ln a number of lndlcaLors. Malne compares favorably agalnsL all oLher
sLaLes on several lndlcaLors relaLed Lo paymenL-accuracy measures:

CharL 3-3: Ma|ne SNA erformance Ind|cators, 2012

Source: uSuA, SnA SLaLe AcLlvlLy 8eporL, llscal ?ear 2012, age 33, 1able 39, uSuA lnS CuallLy ConLrol
Lrror 8aLe CharL, l? 2012, hLLp://www.fns.usda.gov/pd/snapmaln.hLm.


Ma|ne's SNA Lrror kates Dec||ne

1he SnA error raLe ls calculaLed for Lhe enLlre program, and ls a comblnaLlon of
overpaymenLs Lo Lhose who are ellglble for smaller beneflLs, overpaymenLs Lo Lhose who are
noL ellglble for any beneflL, and underpaymenLs Lo Lhose who do noL recelve as much as Lhey
should. CharL 3-4 demonsLraLes [usL how effecLlve Lhe Cll efforLs have been ln reduclng error
raLes over Lhe mosL recenL flve-year perlod.


1oLal federal
cosL per case
per monLh
54.99
1hlrd lowesL ln
Lhe counLry
.
AdmlnlsLrauve
cosL per case
per monLh
510.S6
Second lowesL
ln Lhe counLry
CverpaymenL
error raLe
1.83
LowesL ln
new Lngalnd
Cverall paymenL
error raLe
2.16
1enLh lowesL ln
Lhe counLry


62
CharL 3-4: Ma|ne SNA Lrror-kate Dec||ne, 200S to 2012

Source: uSuA, lnS SnA MulLl-?ear CuallLy ConLrol Lrror 8aLes,
hLLp://www.fns.usda.gov/pd/snapmaln.hLm.


Movlng from a hlgh error-raLe sLaLus over four years, whlch ls consldered a penalLy
phase ln SnA, Lo a slgnlflcanL decrease ln error raLes ln Lhe subsequenL four years ln a row, ls
evldence LhaL Lhe deparLmenL alLered lLs focus Loward paymenL accuracy and should be
credlLed for effecLlvely brlnglng Lhls measure lnLo compllance.


Iraud Invest|gat|ons

AnoLher area of concern ls Lhe lncldence of fraud ln Lhe SnA program. 8oLh naLlonally
and wlLhln each sLaLe, Lhere ls wlde lnLeresL ln assurlng LhaL beLLer conLrols are ln place Lo
ldenLlfy any poLenLlal lssues of fraud, wasLe, and abuse. uSuA examlnes how sLaLes address Lhls
maLLer and reporLs annually on how sLaLes approach fraud lnvesLlgaLlons and recovery, when
fraud ls verlfled.

Accordlng Lo Lhe SnA SLaLe AcLlvlLy 8eporL, fraud lnvesLlgaLlons are broken lnLo Lwo
caLegorles: pre-cerLlflcaLlon lnvesLlgaLlons and posL-cerLlflcaLlon lnvesLlgaLlons. re-cerLlflcaLlon
lnvesLlgaLlons are cases LhaL are referred and lnvesLlgaLed prlor Lo belng approved/cerLlfled for
SnA beneflLs.
200S 2006 2007 2008 2009 2010 2011 2012
MAINL 7.S9 9.SS 10.S4 8.36 2.S1 3.49 3.28 2.16
U.S.AVG. S.84 S.99 S.64 S.01 4.36 3.81 3.8 3.24
)I'+
+I''
$#I'&
*I%(
"I'$
%I&+
%I"*
"I$(
'I*&
'I++
'I(&
'I#$
&I%(
%I*$ %I*
%I"&
0
2
4
6
8
10
12

e
r
c
e
n
t
a
g
e

L
r
r
o
r

k
a
t
e
s




63
CharL 3-3: New Lng|and SNA Iraud Invest|gat|ons, I 2012
State re-Cert.
Negat|ve
re-Cert.
os|t|ve
ost-Cert.
Negat|ve
ost-Cert.
os|t|ve
1ota|
Invest|gat|ons
Comp|eted
ConnecLlcuL 1,148 677 43 34 1,924
Malne 3 3 131 201 360
MassachuseLLs 0 0 4,114 413 4,327
new
Pampshlre
263 239 622 136 1,280
8hode lsland 49 36 906 136 1,147
vermonL 22 13 143 219 397
Source: lood and nuLrlLlon Servlce, SupplemenLal nuLrlLlon AsslsLance rogram, rogram AccounLablllLy
and AdmlnlsLraLlon ulvlslon, SupplemenLal nuLrlLlon AsslsLance rogram SLaLe AcLlvlLy 8eporL, llscal
?ear 2012," SepLember 2013.


re-cerLlflcaLlon lnvesLlgaLlons obvlously provlde a measure of lnoculaLlon from havlng
Lo chase and collecL on payouL errors LhaL have already occurred. lorLunaLely, Malne ls ln Lhe
process of lmplemenLlng a fronL-end deLecLlon sysLem for all of lLs asslsLance programs.

Cne cauLlonary noLe relaLes Lo SnA appllcaLlons and Lhe Llmellness sLandards deflned
ln federal regulaLlons. 1he new fronL-end deLecLlon sysLem musL be seL up Lo accommodaLe
processlng sLandards for deLermlnlng ellglblllLy of SnA appllcaLlons. lalllng shorL on
appllcaLlon-processlng sLandards can easlly place Lhe sLaLe ln [eopardy of faclng penalLles from
uSuA. Adequacy of sLafflng levels aL Lhe polnL of appllcaLlon as well as wlLhln Lhe lnvesLlgaLlve
unlL ls Lhe only way Lo sLrlke Lhe proper balance ln lssulng beneflLs only Lo Lhose who quallfy.

Iood-Stamp keforms under the 2014 Iarm 8|||

AlLhough Lhe farm blll" was due for reauLhorlzaLlon ln CcLober 2013, Congress was
unable Lo reach agreemenL on proposed changes Lo Lhe leglslaLlon unLll lebruary 2014. Cn
lebruary 7, 2014, resldenL Cbama slgned lnLo law Lhe AgrlculLural AcL of 2014. SLaLes can
begln Lhe work of lmplemenLlng SnA (food-sLamp) reforms, Lhe flrsL ln Lhe program slnce Lhe
welfare reforms of 1996, whlch are dellneaLed below:

Closes Lhe heaL-and-eaL" loophole LhaL arLlflclally lncreased beneflL levels when sLaLes
provlded Lhe nomlnal Low lncome Pome Lnergy AsslsLance rogram (LlPLA).
LsLabllshes a Len-sLaLe plloL Lo empower sLaLes Lo engage able-bodled adulLs ln
mandaLory work programs.


64
rohlblLs uSuA from engaglng ln SnA recrulLmenL acLlvlLles, lncludlng adverLlslng SnA
on 1v, radlo, and blllboards and Lhrough forelgn governmenLs.
Lnsures LhaL lllegal lmmlgranLs, loLLery wlnners, LradlLlonal college sLudenLs, and Lhose
who are deceased, do noL recelve beneflLs.
Lnsures SnA reclplenLs are noL recelvlng beneflLs ln mulLlple sLaLes.
revenLs abuses such as waLer dumplng Lo exchange boLLles for cash.
uemands ouLcomes from exlsLlng employmenL and Lralnlng programs.
rohlblLs sLaLes from manlpulaLlng SnA beneflL levels by ellmlnaLlng medlcal marl[uana
as an allowable medlcal expense.
Allows sLaLes Lo pursue reLaller fraud Lhrough a plloL lnvesLlgaLlon program and Lo crack
down on Lrafflcklng Lhrough daLa mlnlng, Lermlnal lu, and oLher measures.
lncreases asslsLance for food banks.
27



rogram Integr|ty |n SNA

Accordlng Lo uSuA, program-lnLegrlLy efforLs of lnS and lLs sLaLe parLners are yleldlng
resulLs and Lrendlng ln Lhe rlghL dlrecLlon. 1wo areas showlng excellenL resulLs relaLe Lo
cerLlflcaLlon errors: when an ellglblllLy worker auLhorlzes beneflLs ln Lhe wrong amounL, and
Lrafflcklng, whlch occurs when SnA beneflLs are Lraded for cash. ln l? 2012, lnS redoubled
efforLs Lo prevenL and ldenLlfy fraud, and hold vlolaLors accounLable for mlsuse of funds.

Much of lnS efforLs are focused on lmprovlng lnLegrlLy aL Lhe reLall level. Powever, no
sLaLe ls exempL from LlghLenlng varlous aspecLs of lLs program, such as forLlfylng efforLs Lo
screen ouL lndlvlduals who are lnellglble for beneflLs, worklng wlLh L81 processors Lo
sLrengLhen fraud-deLecLlon sysLem reporLlng, followlng up lndlvlduals found Lo have
lnvolvemenL wlLh Lrafflcklng aL Lhe reLall level, worklng wlLhln Lhe sLaLe sysLem, conLlnulng Lo
sLrengLhen and lmprove Lhe quallLy-conLrol sysLem and Lo perfecL any meLhods belng used Lo
lmplemenL Lhe new rule regardlng avoldlng of negaLlve errors (lmproper denlals, suspenslons,
or LermlnaLlon of beneflL), and worklng wlLh federal parLners ln LargeLlng Lechnlcal asslsLance
Lo sLaLes where poor performance ls noLed.

Assurlng responslble admlnlsLraLlon of Lhls admlLLedly cosLly program Lo Amerlca's
Laxpayers ls lmperaLlve. lor Lhls reason, Lhe uSuA and Congress have esLabllshed measures Lo
avold, deLecL, and acL aggresslvely Lo mlLlgaLe fraud, wasLe, and abuse ln Lhls program.

WlLh Lhe supporL of Covernor Leage and uPPS Commlssloner Mayhew, Lhe Cll added
Len full-Llme sLaff Lo Lhe deparLmenL's fraud, lnvesLlgaLlon, and recoverles unlL (elghL fraud
lnvesLlgaLors and Lwo fraud-lnvesLlgaLlon supervlsors), brlnglng Lhe LoLal number of
lnvesLlgaLors ln Lhe fleld Lo sevenLeen. WlLh Lhe addlLlonal lnvesLlgaLors, Lhe unlL dlrecLor, wlLh

27. lrank Lucas, ress 8elease, lebruary 7, 2014, hLLps://agrlculLure.house.gov/


63
hls supporL sLaff, Lralned and creaLed speclallzed Leams composed of lndlvlduals wlLh law
enforcemenL backgrounds, and lndlvlduals wlLh experlence ln program pollcles and servlces, ln
May 2013. 1he comblnaLlon of such experLlse enabled Lhe unlL Lo launch a ma[or efforL Loward
lnvesLlgaLlng a greaLer number of cases for posslble fraud, wasLe, and abuse.

1hese lnvesLlgaLors have lncreased Lhe number of lnvesLlgaLlons carrled ouL, wlLh
resulLs belng reporLed as follows:
A comparlson of overpaymenLs esLabllshed ln 2012 versus 2013 show LhaL Lhe number
of lnLenLlonal-program-vlolaLlon (lv) overpaymenLs LhaL were deLecLed lncreased by
79 - from 169 ln 2012, Lo 303 ln 2013. 1he amounL represenLed ln lv overpaymenLs
ln 2013 was $688,828.28, an lncrease of $188,000 over 2012.
Slnce each lv case creaLed resulLs ln a Lwelve-monLh sancLlon, lL ls reasonable Lo
exLrapolaLe an acLual cosL-avoldance amounL due Lo Lhe work of Lhls unlL.

Assumlng LhaL each case was a slngle lndlvldual recelvlng $200 per monLh ln beneflLs
amounLs Lo $2,400 per case over Lhe course of Lwelve monLhs, we can esLlmaLe LhaL 303
conflrmed and sancLloned cases, mulLlplled by $2,400, amounLs Lo $727,200 ln cosL avoldance
for Lhose affecLed cases.

SNA o||cy kecommendat|ons

lf caseload Lrends conLlnue Lhelr modesL decllnes, uPPS can successfully lmplemenL Lhe
already planned process redeslgn and may expand auLomaLlon Lo Lhe polnL where meLlculous
aspecLs of program lnLegrlLy and paymenL accuracy ls wlLhln reach, lncludlng greaLer assurance
LhaL cosLs are belng responslbly conLalned LhroughouL all areas of SnA.

1. Aggress|ve |mp|ementat|on of front-end detect|on protoco|s, wlLh adequaLe sysLems
supporL, ls urged, as Lhe long-Lerm yleld Lo Lhe sLaLe, Lhe SnA program, and Lhe Laxpayers
cannoL be oversLaLed.

2. ursue approva| to become one of the ten-state p||ot programs Lo engage adulLs ln a
mandaLory work program. CoordlnaLe Lhls efforL wlLh Lhe full-engagemenL 1Anl lnlLlaLlve.

3. Lxcept for those who are e|der|y and]or have a d|sab|||ty, narrow the def|n|t|on of
categor|ca||y e||g|b|e househo|ds to on|y those who have a|ready met one of the federa||y
def|ned means-tested cash ass|stance programs (SSI, 1ANI, or Genera| Ass|stance). 1hls
recommendaLlon would requlre all oLher appllcanL households Lo meeL lncome and asseL llmlLs
of $2,000 ln order Lo be ellglble for SnA beneflLs.

4. Ident|fy program-|ntegr|ty pr|or|t|es for 2014, 201S, and 2016, and estab||sh
measurab|e goa|s for each f|sca| year. 8ulld upon Lhe already successful efforLs Lo reduce
errors LhroughouL Lhe SnA program, and lnvolve Lhe enLlre workforce ln a focused
commlLmenL Loward lmprovlng accuracy ln ellglblllLy deLermlnaLlons and beneflL lssuances.


66



67





4. Ch||d Care Ass|stance rograms


Accordlng Lo Lhe 2014-13 Chlld Care uevelopmenL lund (CCul) sLaLe plan, uPPS ls Lhe
deslgnaLed lead agency Lo admlnlsLer Lhe CCul program and Lhe chlef execuLlve offlcer for
CCul ls Commlssloner Mary Mayhew.









no more Lhan 3 of Lhe aggregaLe CCul funds can be expended on admlnlsLraLlon
cosLs, however once all l? 2014 funds have been llquldaLed, sLaLe MCL funds are noL sub[ecL Lo
Lhls 3 llmlLaLlon. Also noLed ln CCul plan, SLaLe urchased Soclal Servlces CranL, Lhe sLaLe
general fund, and lund for PealLhy Malne are used Lo meeL Lhe CCul sLaLe-maLchlng
requlremenL.

CharL 4-1 provldes a Lhree-year perspecLlve on how federal CCul dollars are allocaLed.
Whlle mandaLory dollars remaln level, as do sLaLe MCL dollars, oLher allocaLlons vary, and are
affecLed by changes ln Malne's lMA raLes each flscal year.

2014-1S Ch||d Care Deve|opment State |an Iund|ng
lederal CCul allocaLlon: $16,137,880
lederal 1Anl Lransfer Lo CCul for 2013: $2,000,000
ulrecL 1Anl and sLaLe spendlng on chlld care: $20,691,243
-Moloe ccul 5tote lloo, 2014-15.


68
CharL 4-1: CCDI Iund|ng A||ocat|ons for Ma|ne
2011 2012 2013
MandaLory $3,018,398 $3,018,398 $3,018,398
lederal Share MaLchlng 3,849,296 6,023,942 3,922,420
SLaLe MCL 1,749,818 1,749,818 1,749,818
lMA 63.80 63.27 62.37
SLaLe Share MaLchlng lunds 3,318,880 3,498,227 3,342,831
ulscreLlonary lunds lncludlng
1argeLed (SeL-Aslde) lunds
7,347,802 7,791,183 7,216,862
1argeLed
(SeL-Aslde)
lunds
School-Age Chlld Care
8esource & 8eferral
rograms
63,004 63,301 37,362
CuallLy Lxpanslon 610,227 647,263 398,941
lnfanL & 1oddler 333,402 374,834 347,729
ulscreLlonary lunds Lxcludlng
1argeLed (SeL-Aslde) lunds
6,321,169 6,703,763 6,212,830
1ota| Iedera|-Cn|y Iunds 516,21S,696 516,83S,723 516,1S7,880
Source: Annual CCul allocaLlon Lables show allocaLlons, or Lhe amounL of fundlng awarded Lo each
sLaLe, LerrlLory, or Lrlbal granLees based on congresslonal approprlaLlons for each flscal year.
hLLp://www.acf.hhs.gov/programs/occ/resource/fy2011, fy2012, fy 2013-ccdf-flnal-allocaLlons-
lncludlng-realloLed-funds.


CharL 4-2 dlsplays Lhe CCul sLaLe plan fundlng levels for ll? 2014-13 by caLegory,
lncludlng Lhe LoLal amounL of chlld care fundlng planned Lhrough ASl8L-1Anl and 1CC
programs. 1hese pro[ecLlons lnclude boLh sLaLe and federal dollars.




69
CharL 4-2: CCDI Iund|ng |an, II 2014

Source: PPS, ACl Cfflce of Chlld Care, CCul llnal AllocaLlons CharL lssues !uly 2013,
hLLp://www.acf.hhs.gov/programs/occ/resource/fy2012-ccdf-flnal-allocaLlons-lncludlng-realloLed-funds,
ACl CCul ACl-196 llnanclal 8eporL, l? 2013 submlLLed by uPPS Servlce CenLer, and CCul sLaLe plan for
2014-13.


AdmlnlsLerlng governmenL funded chlld care programs ls complex, expenslve, and
fraughL wlLh challenges. lL ls a beneflL lnLended Lo supporL prlmarlly worklng parenLs, buL lL ls a
servlce LhaL ls provlded Lo and for low-lncome chlldren up Lo Lhe age of 13. 1he federal
AdmlnlsLraLlon for Chlldren and lamllles, Lhrough lLs regulaLlons and Lechnlcal guldance, offers
every sLaLe speclflc guldance Lo ensure a unlform undersLandlng LhaL chlld care musL be safe,
affordable, accesslble, and of Lhe hlghesL quallLy posslble.


Structure of DnnS Ch||d Care rograms

under Lhe umbrella of uPPS, Lhere are Lhree offlces wlLh responslblllLles relaLed Lo chlld
care ln Malne. 1hey are lnLerconnecLed by vlrLue of laws, regulaLlons, and operaLlonal Lle llnes,
all of whlch ensure LhaL Lhe overslghL of Lhls program ls carrled ouL responslbly.

1ota| Amount of
Iedera| CCDI
A||ocanon
516,1S7,880
Mandatory Iedera|
Iund|ng
53,018,S98

Iedera| Share of
Match|ng
5S,922,420
I 2013 IMA
kate: 62.27
State MCL
51,749,818
State Share of
Match|ng
53,S42,8S
CCDI D|screnonary
Iunds 57,216,862
CCDI 1argeted
(Set-As|de) Iunds
51,004,032
Sch. Age]kes. &
kef.: 5S7,362
ua||ty Lxpans|on
5S98,941
Infant]1odd|er
5347,729
CCDI Not 1argeted
56,212,830
1ANI & State
D|rect Spend|ng
on Ch||d Care
520,691,243


70
1he ulvlslon of Llcenslng and 8egulaLory Servlces ls responslble for lssulng chlld care
cenLer llcenses, famlly chlld care cerLlflcaLes, and nursery school llcenses. 1hls lncludes
monlLorlng compllance wlLh regulaLlons seL by uPPS under dlrecLlon of Lhe sLaLe leglslaLure.

WlLh regard Lo Lhe provlslon of chlld care servlces, Lhe sLaLe admlnlsLers pollcles,
programs, and subsldles for famllles Lhrough Lwo separaLe buL coordlnaLed servlce-dellvery
sLrucLures:

1he Cff|ce of Ch||d and Iam||y Serv|ces (CCIS) admlnlsLers quallLy program lnlLlaLlves
and chlld care subsldles under Lhe federal Chlld Care uevelopmenL lund (CCul), whlch ls
used by low-lncome worklng parenLs or low-lncome parenLs ln Lralnlng or educaLlon and
whose lncome renders Lhem lnellglble for chlld care Lhrough ASl8L-1Anl.

1he Cff|ce of Iam||y Independence (CII) admlnlsLers chlld care asslsLance for parenLs
on ASl8L-1Anl/aS cash asslsLance, and/or parenLs who have recenLly closed Lo cash
asslsLance (wlLhln Lhe recenL Lhree monLhs) due Lo lncreased earnlngs from work or
because Lhey have recenLly enLered Lhe [ob markeL. ASl8L-1Anl/aS chlld care ls a
supporLlve servlce Lo parenLs who musL fulflll Lhelr 1Anl work parLlclpaLlon
requlremenLs, whlle 1ranslLlonal Chlld Care ls a Lemporary subsldy for former ASl8L-
1Anl/aS reclplenLs who close Lo cash asslsLance due Lo employmenL.




71
CharL 4-3: Ma|ne's 1wo-1rack Ch||d Care rogram Structure
Ch||d Care Deve|opment Iund (CCDI) Cff|ce of
Ch||d and Iam||y Serv|ces (CCIS!
ASIkL-1ANI Ch||d Care Cff|ce of Iam||y
Independence (CII)
AdmlnlsLers CCul Chlld Care Subsldy rogram
for low-lncome worklng famllles (and) lncome-
ellglble famllles aLLendlng vocaLlonal educaLlon
or Lralnlng.
AdmlnlsLers ASl8L chlld care supporLlve servlces
and 1ranslLlonal Chlld Care supporLlve servlces for
worklng famllles recenLly closed Lo 1Anl/aS cash
asslsLance.
r|mary ayment Method
rovlders pald afLer performance
8lweekly bllllng based on chlld aLLendance
CClS-CCul auLhorlzaLlon unlL
aymenLs prlmarlly vla dlrecL deposlL
r|mary ayment Method
ald one week ln advance of servlces used
aymenLs lssued prlmarlly Lo parenLs on L81
card or lf requesLed, paymenLs made dlrecLly
Lo chlld care (CC) provlders
1yplcally, Cll relmburses parenL who Lhen
pays provlder for CC servlces.
LllglblllLy for CCul Chlld Care Subsldy rogram and ASl8L-1CC ls deLermlned by Cll
ellglblllLy workers ln 16 reglonal cenLers.
CClS chlld care sLaff monlLor and renew CCul CC subsldy cases
Cll-ASl8L speclallsLs monlLor and renew ASl8L-1CC cases
8easons for parenLs recelvlng CC subsldles
83 - employmenL
4 - Lralnlng/educaLlon
11 - parenLs ln boLh employ. & Lralnlng
8easons for recelvlng CC asslsLance
31 - employmenL (1CC)
49 - educaLlon/Lralnlng
Average number of famllles: 1,800/monLh
Average number of chlldren: 2,700/monLh
Average number of 1CC famllles: 2,332/monLh
Average number of ASl8L-CC cases: 1,033/monLh
99 CCul famllles use llcensed/regulaLed CC
seLLlngs
1 CCul famllles use unllcensed CC seLLlngs
60 ASl8L & 62 1CC parenLs use llcensed CC
24 ASl8L & 38 1CC parenLs use unllcensed CC
1,041 prov|ders rece|ved CCDI funds |n I 2012
390 were ||censed ch||d care centers
6S1 were regu|ated ch||d care fam||y homes
ApproxlmaLely 40 of ASl8L-1CC parenLs choose lnformal/unregulaLed chlld care seLLlngs,
LoLal number noL quanLlflable.


1he Cfflce of Chlld and lamlly Servlces/CCul Chlld Care Subsldy rogram sLaff adheres
Lo wrlLLen pollcles on monlLorlng chlld care (CC) provlders who parLlclpaLe ln Lhe subsldy
program. 1he followlng ls a seL of guldellnes followed by CC subsldy program sLaff:

Goa| 1: AudlLlng flles of 10 of provlders wlLh chlld care subsldy auLhorlzaLlons each
quarLer. llles musL be checked for:



72
CompleLed and slgned provlder agreemenL
Chlld care conLracL and pollcles lncludlng holldays, vacaLlon, and lnclemenL-weaLher
closures, and paymenL pollcles for each
Copy of Lhe uPPS llcense
rovlder's CuallLy-for-Malne cerLlflcaLe
ALLendance records used
WaLer analysls LesL resulLs (unllcensed provlders)
lmmunlzaLlon records of chlldren ln care (unllcensed provlders)
CompleLed healLh and safeLy checkllsL (unllcensed provlders)

Goa| 2: lleld audlLlng of 3 of chlld care provlders per year - random selecLlon from
pool of chlld care provlder aLLendance and reporLlng/bllllng per monLh. lleld audlLs lnclude:

Comparlson of bllled hours and aLLendance sheeLs
arenLs' slgnaLures on aLLendance sheeLs
ulscusslons wlLh faclllLy managemenL regardlng any areas of concern or confuslon
relaLed Lo
! rovlder agreemenL requlremenLs
! rovlder pollcles on holldays, vacaLlon, and weaLher-relaLed closures, and
paymenL pollcles for each
! 8ecelpLs for parenL co-paymenL fees
! Chlld care subsldy program award leLLers

CharL 4-4 provldes a breakdown of Lhe chlld care appllcaLlons recelved by uPPS Cfflce
of Chlld and lamlly Servlces for C? 2013. 1hls charL also provldes a breakouL of deLermlnaLlons
made on Lhe 1,441 new appllcaLlons recelved ln 2013:



73
CharL 4-4: CCDI Ch||d Care Subs|dy rogram


1hose who apply for chlld care Lhrough Lhe Cfflce of Chlld and lamlly Servlces musL flll
ouL a paper appllcaLlon, and as lnsLrucLed aL Lhe boLLom of Lhe form, musL mall Lhe appllcaLlon
Lo Lhe CClS Chlld Care Subsldy rogram offlce locaLed aL 2 AnLhony Avenue, AugusLa, Malne.
AppllcanLs may also be referred Lo CC subsldy program Lhrough slxLeen Cll reglonal offlces as
well as referrals Lhrough ouLslde resources LhaL work wlLh Lhe low-lncome worklng famllles.

llnanclal ellglblllLy ls deLermlned by Lhe Cll-ellglblllLy workers who are locaLed
LhroughouL Lhe reglonal cenLers. Cll ellglblllLy workers noLlfy Lhe CClS CCul Chlld Care Subsldy
rogram sLaff LhaL a famlly ls flnanclally ellglble, CCul subsldy sLaff Lhen Lakes ownershlp of Lhe
case and monlLors ongolng need for chlld care, l.e., employmenL, changes ln famlly
clrcumsLances, and verlfles LhaL famlly ls connecLed Lo provlder. ulfferenL from Lhe Cll-ASl8L
1CC program, Lhe CClS-CC subsldy program sLaff also has an acLlve role wlLh chlld care
provlders. 1he Lyplcal caseload slze ln Lhe CC subsldy program ls approxlmaLely four hundred
and flfLy cases per worker.


1AR
91R
11R
DR
1R
SR
DR
New App||canons for 2013
1,441 CC Appllcauons
8ecelved
933 lamllles Awarded
CC Subsldy
1,403 Chlldren
Awarded CC SloLs
32 Appllcauons
uenled
112 Appllcauons
lncompleLe
216 Appl's Closed
(Lacklng
uocumenLauon)
33 1oLal no. endlng
8evlew


74
ua||ty In|t|at|ves |n Ma|ne's Ch||d Care rograms

under SecLlon 638C of Lhe Chlld Care and uevelopmenL 8lock CranL AcL and exlsLlng
regulaLlons aL 98.31(a)(1), lead agencles musL use noL less Lhan 4 of CCul funds for acLlvlLles
LhaL are deslgned Lo provlde comprehenslve consumer educaLlon Lo parenLs and Lhe publlc,
acLlvlLles LhaL lncrease parenLal cholce, and acLlvlLles deslgned Lo lmprove Lhe quallLy and
avallablllLy of chlld care, lncludlng resource and referral servlces. Lead agencles have broad
flexlblllLy Lo deLermlne whaL may consLlLuLe quallLy acLlvlLles as long as Lhose deflnlLlons flL
wlLhln Lhe broad sLaLuLory requlremenL.

Malne CCul admlnlsLers a Chlld Care CuallLy 8aLlng and lmprovemenL SysLem (C8lS) on
a sLaLewlde basls. Also referred Lo as CuallLy for ML," Lhe four-sLep lmprovemenL sysLem ls
deslgned Lo lncrease awareness of Lhe baslc sLandards of early care and educaLlon, recognlze
and supporL provlders LhaL are provldlng care above and beyond Lhose sLandards, and educaLe
Lhe communlLy of Lhe beneflLs of hlgher quallLy care. 1he C8lS was also creaLed Lo ldenLlfy
Lhose programs LhaL may need addlLlonal resources or supporLs Lo lncrease Lhelr level of quallLy
as measured by Lhe CuallLy for ML sysLem. All sLaff and provlders worklng ln faclllLles LhaL
parLlclpaLe ln CuallLy for ML are requlred Lo reglsLer ln Lhe Malne 8oads Lo CuallLy 8eglsLry.

1he Malne C8lS lncludes mulLlple-provlder lncenLlves, whlch lnclude:

rlorlLy access Lo scholarshlps for lncome-ellglble sLaffers LhaL wlsh Lo pursue early-
chlldhood educaLlon degrees.
A relmbursemenL dlfferenLlal for each chlld whose care ls subsldlzed by uPPS' Cfflce
of Chlld and lamlly Servlces:
1. 10-quallLy dlfferenLlal for programs LhaL have reached SLep 4 ln Lhe C8lS
2. 3-progress dlfferenLlal for programs LhaL have reached SLep 3
3. 2-quallLy dlfferenLlal for programs LhaL have reached SLep 2
4. uouble chlld care sLaLe lncome-Lax credlL for parenLs whose chlld ls enrolled ln a
program aL Lhe SLep 4 level
3. A chlld care Lax credlL for expenses made Lo lmprove quallLy for programs LhaL
pay sLaLe Laxes and have a Cl sLaLus.

Accordlng Lo a sLaLewlde reporL complled by CClS, Lhe Malne C8lS daLa showed LhaL of
Lhe 1,234 llcensed famlly chlld care provlders, 302 (40.7) are enrolled ln C8lS, and 12 (1.0)
of Lhese provlders have walvers.

Cf Lhe 713 llcensed cenLer-based provlders, 432 (63.4) are enrolled ln C8lS and 19
(2.7) llcensed cenLer-based provlders have walvers. CharL 4-3 provldes a breakdown of
provlder enrollmenL levels by seLLlng Lype and quallLy sLep:



73
CharL 4-3: Ch||d Care Lnro||ments by Sett|ngs, as of November 4, 2013
Care
ua||ty

Iam||y Ch||d Care
rov|ders
Iam||y CC
ercentage
Center-8ased
CC]nead Start
rov|ders
Center-8ased
CC]nead Start
ercentage
Step 1 343 68.7 204 43.1
Step 2 78 13.3 89 19.7
Step 3 32 10.4 39 8.6
Step 4 27 3.4 120 26.3
1ota| 302 100.0 432 100.0


1he CCul sLaLe plan shows LhaL approxlmaLely $3.4 mllllon ls belng allocaLed for quallLy
lnlLlaLlves as follows:

- $300,000 - allocaLed for lnfanL-Loddler chlld care (LargeLed/seL-aslde)
- $300,000 - allocaLed for school-age CC and CC resource & referral (LargeLed/seL-aslde)
- $1,300,000 - allocaLed for Lralnlng, Lech. asslsLance, & prof. dev. (LargeLed/seL-slde)
- $1,300,000 - allocaLed for chlld care llcenslng (quallLy funds, noL lncludlng seL-aslde)

Malne appears Lo be expendlng a slgnlflcanLly hlgher percenLage of lLs CCul funds on
quallLy lnlLlaLlves Lhan Lhe 4 mlnlmum requlred by chlld care regulaLlons, especlally when
compared Lo oLher sLaLes, whlch may expend aL or somewhaL above Lhe 4 mandaLe.

Why |s th|s Noteworthy?

uurlng early 2012, due Lo fundlng consLralnLs, Malne was forced Lo esLabllsh a walLlng
llsL of low-lncome famllles who needed chlld care ln order Lo work. ?eL Lhe ongolng lnvesLmenLs
ln quallLy chlld care lnlLlaLlves, whlch were far above Lhe 4 mlnlmum federal requlremenL,
remalned lnLacL even durlng dlfflculL budgeLary declslon-maklng. noLwlLhsLandlng Lhe facL LhaL
Lhe ACl Cfflce of Chlld Care has ldenLlfled quallLy lnlLlaLlves and program lnLegrlLy as lLs Lwo
prlmary goals for 2014, Lhe pollcy cholces ln Malne of conLlnulng Lo malnLaln slgnlflcanL
lnvesLmenLs ln lnfrasLrucLure when Lhe sLaLe declded Lo lnsLlLuLe a walL llsL, ls a cholce LhaL may
need Lo be reconsldered ln Lhe fuLure.

As one alLernaLlve, Lhe deparLmenL has Lhe opLlon Lo esLabllsh a flscal formula whlch
scales back a porLlon of quallLy lnlLlaLlve spendlng ln order Lo avold esLabllshlng walL llsLs of
low-lncome worklng famllles. Such an alLernaLlve may offer beLLer balanclng of resources
beLween lnfrasLrucLure and chlld care subsldles and ls a conversaLlon LhaL should Lake place,
especlally conslderlng LhaL one of Malne's prlmary goals ls Lo supporL sLrong, healLhy, worklng
famllles. ln addlLlon, lL may be prudenL Lo explore any poLenLlal for flnanclal conLrlbuLlons from
ma[or sLakeholders who have been acLlve parLners ln C8lS. 1hls may lnclude Pead SLarL, Lhe


76
Malne ueparLmenL of LducaLlon, early-chlldhood educaLlon programs, and oLher vesLed
parLners who parLlclpaLe ln Lhe sLaLe's CCul quallLy lnlLlaLlves. ueveloplng Lhls poLenLlal may
represenL a broader and more susLalnable fuLure for Malne's commlLmenL Lo early care and
educaLlon Lhrough CuallLy for Me.

lurLher analysls ls needed Lo deLermlne Lhe exacL raLlo of dollars devoLed Lo quallLy
lnlLlaLlves versus chlld care subsldles, especlally ln Lhe envlronmenL of budgeLary consLralnLs,
and Lhe sLaLe should conslder ad[usLmenLs and/or alLernaLlves Lo how quallLy lnvesLmenLs are
supporLed golng forward


Ma|ne's CCDI o||cy Cho|ces ke|at|ve to Cther States

ln Lerms of oLher cholces, Lhe uPPS chlld care program malnLalns very generous
ellglblllLy crlLerla and relmbursemenL raLes. Accordlng Lo Lhe naLlonal Women's Law CenLer,
whlch analyzed chlld care asslsLance pollcles ln all sLaLes, Malne's lL-ellglblllLy levels and
relmbursemenL raLes are Lhe hlghesL ln new Lngland and among Lhe Lop flve ln Lhe counLry.
28


Chart 4-6: Malne Chlld Care rogram lacLs





28. karen Schulman and Pelen 8lank, lvoL olnL, SLaLe Chlld Care AsslsLance rograms," naLlonal
Women's Law CenLer, 2013.
n|ghest ch||d-care
e||g|b||ty |n New Lng|and
230 lL
83 SMl
1h|rd-h|gh|est IL rate
|n country,
exceeded only by
Alaska (278) &
Colorado (298)
n|ghest ch||d-care
re|mbursement rate ln
New Lng|and for 4-year-
olds ln cenLer-based care
I|hh-h|ghest
re|mbursement rate |n
country for 4-year-olds
ln cenLer-based care
Ch||d Care rogram Iacts, 2013


77
CharL 4-7 compares ellglblllLy raLes, pollcles on sLaLe medlan-lncome levels, and acLual
gross-dollar amounLs LhaL are ln effecL ln each of Lhe slx new Lngland sLaLes.

CharL 4-7: New Lng|and Ch||d Care o||c|es, Income-L||g|b|||ty Leve|s
Ma|ne Connect|cut Massachusetts New
nampsh|re
khode
Is|and
Vermont
ercentage of IL for
CC L||g|b|||ty
230 219 216 244 176 187
ercentage of State
Med|an Income (SMI)
83 30 30 62 46 37
Actua| Gross Income $48,828 $42,829 $42,096 $47,723 $34,362 $36,131
Source: karen Schulman and Pelen 8lank, lvoL olnL, SLaLe Chlld Care AsslsLance rograms," naLlonal
Women's Law CenLer, 2013.


arent's Co-ayment kate

Accordlng Lo Lhe uPPS Cfflce of Chlld and lamlly Servlces ollcy Manual, SecLlon 6.02.3
(Chlld Care Subsldles), a graduaLed fee percenLage of gross famlly lncome wlll be applled Lo
each of Lhe lncome ranges hlghllghLed ln Lhe charL below: ConslsLenL wlLh CCul rules, Lhe LoLal
amounL of parenL fees assessed Lo a famlly should noL exceed 10 of Lhe famlly's gross lncome,
lrrespecLlve of Lhe number of chlldren enrolled ln Lhe subsldy program.

CharL 4-8: Ch||d Care Co-ayment Iees















overty
Gu|de||ne
kange
arent's Co-ayment Iee
as ercentage of Gross
Iam||y Income
up Lo 23 2
26 Lo 30 4
31 Lo 73 3
76 Lo 100 6
101 Lo 123 8
126 Lo 130 9
131 Lo 200 10
201 Lo 230 10


78
Ch||d Care ke|mbursement kates

1he followlng charLs hlghllghL flndlngs from naLlonal sLudles on pollcy cholces, and how
Lhose pollcles compare wlLh Malne. Conslderlng Lhe unlque clrcumsLances LhroughouL Lhe
counLry, sLaLes dlffer ln Lhelr chlld care program deslgns, pollcles, and raLe sLrucLures. CharLs 4-
9 and 4-10 compare raLes of relmbursemenL for 4-year-olds ln slx new Lngland sLaLes and
LhroughouL Lhe counLry.
29


CharL 4-9: Ma|ne Leads New Lng|and |n ke|mbursement kates


CharL 4-10: n|ghest ke|mbursement kates for Center-8ased Care


29. lbld., pp. 30-31.
VL"4
VIH"
VI3!
VLK4
V"L3
VK34
'(&&.0*%0)*
T(2*(&M @+G
N.< O+9EG
8=(6. R2-+&6
W.59(&*
@+%&.
Ma|ne Leads New Lng|and |n ke|mbursement
kates for 4-ear-C|ds |n Center-8ased Care
VK34
VKJK
VH4F
VH4H
V3M43K
@+%&.
@%&&.2(*+
NG;G '%*X
YG'G
W%5Q%&%+
n|ghest ke|mbursement kates for 4-ear-
C|ds |n Center-8ased Care, Nanona||y


79
All sLaLes musL conducL a blennlal markeL-raLe survey (M8S) ln accord wlLh CCul
regulaLlons. 8esulLs of each sLaLe's M8S are used Lo gulde" sLaLes ln deLermlnlng a reasonable
level of relmbursemenL based on Lhe raLes pald by non-subsldlzed payees. Lmplrlcal evldence
lndlcaLes LhaL Lhe blennlal M8S has lncreased access Lo quallLy chlld care for low-lncome
famllles. Whlle surveys are mandaLed by CCul regulaLlons, Lhe resulLs are lnLended Lo be used
only as a guldeposL, CCul rules recommend" LhaL sLaLes pay up Lo Lhe sevenLy-flfLh percenLlle
of markeL raLes, buL lL ls lefL up Lo each sLaLe Lo seL lLs own raLes.

naLlonal sLudles have shown Lhere ls greaL varlablllLy ln relmbursemenL raLes. Llke
Malne, many sLaLes have large dlfferences ln raLes, whlch are lnfluenced by employmenL raLes,
local and munlclpal economles, geographlc condlLlons, and oLher facLors LhaL may affecL supply
and demand for chlld care. Malne's M8S resulLed ln slxLeen raLe areas across Lhe sLaLe. 1he
maLrlx of chlld care relmbursemenL raLes cover full-Llme/parL-Llme care, age groups of chlldren
needlng care (l.e. lnfanLs, Loddlers, pre-school, and school age), ln-school/ouL-of-school care, as
well as before-and-afLer school care. (See Appendlx C for a compleLe llsL of Malne chlld care
relmbursemenL raLes.)

CharL 4-11: Week|y ke|mbursement kates for Iu||-1|me Infant Care
County L|censed Center-
8ased Care
L|censed nome-
8ased Care
Un||censed
rov|der Care
Androscoggln $133 $130.00 $91.00
AroosLook $140 $93.00 $66.30
Cumberland $223 $160.00 $112.00
lranklln $143 $117.30 $82.23
Pancock $180 $123.00 $87.30
kennebec $160 $130.00 $91.00
knox $170 $133.00 $94.30
Llncoln $170 $130.00 $91.00
Cxford $143 $123.00 $87.30
enobscoL $160 $123.00 $87.30
lscaLaquls $130 $123.00 $87.30
Sagadahoc $173 $133.00 $94.30
SomerseL $130 $123.00 $87.30
Waldo $187 $123.00 $87.30
WashlngLon $173 $123.00 $87.30
?ork $193 $130.00 $103.00
Source: uPPS CClS ollcy Manual, CcLober 1, 2013.
lull-Llme ls deflned as 30+ hours per week.


80
Accordlng Lo Lhe naLlonal Women's Law CenLer 8eporL ln lebruary 2012, chlld care
lnLake ln Malne was frozen for famllles who applled for chlld care asslsLance. ln March 2012, a
walLlng llsL was formally esLabllshed, famllles who had applled durlng Lhe freeze" perlod were
placed on a walLlng llsL ln Lhe order of Lhelr appllcaLlon daLe. As of !uly 2012, 368 chlldren were
on Malne's chlld care walLlng llsL. Powever, Lhe Malne uPPS currenLly reporLs LhaL Lhe walL llsL
has been ellmlnaLed.

CharL 4-12: ASIkL and 1rans|t|ona| Ch||d Care Costs
1ype of Care
Month|y Cost
er Case
Annua| Cost
er Case
Llcensed, uaycare CenLer $672.07 $8,064.82
Llcensed, lamlly-8ased $314.07 $6,168.82
unllcensed, lamlly, non-8elaLlve $398.27 $4,779.28
unllcensed, lamlly, 8elaLlve $397.89 $4,774.73
unllcensed, ln-Pome, non-8elaLlve $322.33 $6,268.00
unllcensed, ln-Pome, 8elaLlve $381.44 $4,377.23
Source: uPPS-Cll uaLa 8eporLs, uecember 2013.


81
CharL 4-13 offers a perspecLlve on Lhe Lypes of chlld care seLLlngs chosen by parenLs ln
ASl8L, 1ranslLlonal Chlld Care (posL 1Anl), and CCul chlld care subsldy program for low-
lncome worklng parenLs (noL on 1Anl). lormal care ls deflned as llcensed cenLers and llcensed
famlly-based provlders, lnformal care ls deflned as regulaLed buL noL llcensed, or unregulaLed
care (nelghbor or relaLlve care). As CharL 4-13 lndlcaLes, approxlmaLely 40.2 of ASl8L
famllles, and 38 of 1CC famllles choose lnformal chlld care provlders, and approxlmaLely 60
choose formal llcensed chlld care provlders. lnLeresLlngly, 99 of chlld care subsldy's low-
lncome worklng famllles choose formal (llcensed) provlders.

CharL 4-13: Ch||d Care Sett|ngs, 2013

Sources: uPPS-Cll uaLa 8eporLs, uecember 2013, ACl-801 CCul daLa for ll? 2012, CcLober 23, 2013.


14.8
47.2
13.7
0.0
13.8
10.3
16.3
43.3
8.7
6.1
8.9
16.3
32
67
0
0
0
0
Llcensed, lamlly-8ased
Llcensed, uay Care CenLer
unllcensed, lamlly,
8elauve
unllcensed, ln-Pome,
8elauve
unllcensed, lamlly, non-
8elauve
unllcensed, ln-Pome,
non-8elauve
CCul Asplre 1ransluonal


82
ConslsLenL wlLh economlc decllnes ln Lhe counLry, as well as gradual caseload decllnes ln
Lhe sLaLe's 1Anl program, CharL 4-14 provldes a snapshoL of Lhe chlld care caseload decllne by
each monLh. 1he Lrend llne ln Lhls charL, as well as Lhe yearly paLLern hlghllghLed ln CharLs 4-13
on Lhe followlng page, capLurlng Lhe use of llcensed famlly provlder seLLlngs as well as lnformal
provlder seLLlngs, ls less dramaLlc compared Lo llcensed cenLer-based seLLlngs, whlch follows a
sLeeper decllne. More analysls ls needed Lo dlscern lf Lhe dlfference ls sLaLlsLlcally slgnlflcanL.

CharL 4-14: ASIkL]1CC Ch||d Care Sett|ngs, 2009-13

Source: uPPS-Cll uaLa 8eporLs, uecember 2013.



83
CharL 4-13: ASIkL Ch||d Care Sett|ngs, 2009-13

Source: uPPS-Cll uaLa 8eporLs, uecember 2013.




84
CharL 4-16 hlghllghLs Lhe lengLh of Llme LhaL famllles recelve chlld care subsldles Lhrough
Cll's ASl8L and 1ranslLlonal Chlld Care programs.

CharL 4-16: ASIkL & 1CC Cases by Durat|on

Source: uPPS-Cll uaLa 8eporLs, uecember 2013.

Accordlng Lo ouLslde sLudles of chlld care uLlllzaLlon and duraLlon, some famllles have
eplsodlc, seasonal, or Lemporary employmenL. ConsequenLly, aL recerLlflcaLlon Llme a parenL or
spouse may be unemployed, maklng Lhe famlly lnellglble for chlld care subsldy. lL was noL
posslble Lo dlscern how much of Lhls occurs ln Lhe Malne chlld care caseload, however lL ls
reasonable Lo speculaLe LhaL Malne famllles experlence slmllar clrcumsLances LhaL can lnLerrupL
care needs. uaLa was noL avallable Lo verlfy Lhe lncldence and frequency of eplsodlc use of care
ln Lhe ASl8L-1Anl chlld care, 1CC, or Lhe CCul Chlld Care Subsldy rogram.




83
CharL 4-17 dlsplays Lhe number of famllles uslng ASl8L and 1CC by Lhe number of Lhelr
chlldren (one or more) ln subsldlzed care.

CharL 4-17: Number of Iam|||es by Number of Ch||dren |n Care, 2013

Source: uPPS-Cll uaLa 8eporLs, uecember 2013.


lor budgeLary purposes, lL ls useful Lo gauge Lhe number of famllles needlng chlld care
for more Lhan one chlld, however such daLa ls noL avallable Lhrough Lhe CCul CC subsldy
program as lL ls noL requlred for Lhe federal ACl 801 reporL.

WhaL we do know, accordlng Lo Lhe ACl 801 reporL, ls LhaL Lhe CCul Chlld Care Subsldy
rogram served approxlmaLely elghLeen hundred famllles per monLh and LwenLy-seven
hundred chlldren per monLh LhroughouL 2012. 8ased on percenLages of famlly uLlllzaLlon ln
ASl8L CC and 1ranslLlonal CC, lL ls probable LhaL approxlmaLely 60 of CCul famllles have one
chlld ln care, approxlmaLely 28 Lo 30 have Lwo chlldren ln care, and approxlmaLely 10 have
Lhree or more chlldren ln care.
$;&+*
)&)
$*+
'$
&
(
#
$
$;'$*
(%'
$&*
&)
$#
&
#
#
# "## &## (## *## $;### $;"## $;&## $;(##
D -6?@C
9 -6?@C;4B
1 -6?@C;4B
A -6?@C;4B
S -6?@C;4B
T -6?@C;4B
U -6?@C;4B
V -6?@C;4B
,CG@KB LL 3K>HC@E@DH>A


86
kecommendat|ons for Ch||d Care rograms

1. Strong|y cons|der conso||dat|on of ch||d care
adm|n|strat|on and po||cy deve|opment |nto a s|ng|e
|eadersh|p ro|e w|th|n the department. 1here ls experLlse on
boLh sldes of Lhe exlsLlng sLrucLure, buL Lhere ls a blfurcaLlon
ln Malne's chlld care program LhaL leads Lo redundancy ln
some areas, and lnefflclencles ln oLher areas. AL Lhe case
level, lL ls dlfflculL for famllles Lo undersLand how Lo sLraddle
Lhe Lwo sysLems, buL lL ls also challenglng Lo admlnlsLer Lhe
dlfferenL pollcles, procedures, reporLlng, and budgeLlng whlch uPPS musL deal wlLh as parL of
Lhelr commlLmenL Lo responslble governmenL. 1hls recommendaLlon does noL suggesL changes
Lo servlce dellvery, buL raLher suggesLs bulldlng a more unlfled approach Lo pollcy and program
developmenL and Lo sysLems coordlnaLlon, especlally ln Lhe areas of federal and sLaLe Lracklng
and reporLlng of expendlLures. 1he deparLmenL has Lremendous sLrengLhs on all sldes of Lhe
equaLlon, Lhls recommendaLlon could beLLer allgn pollcles and procedures lnLo one efflclenL
and cosL-savlng admlnlsLraLlve sLrucLure LhaL would ln many ways offer slmpllflcaLlon and
sLreamllnlng ln Lhe servlce-dellvery sysLem. As lmporLanLly, Lhere would be one lndlvldual wlLh
responslblllLy Lo manage daLa reporLlng for all faceLs of chlld care auLhorlzaLlons and Lhls same
person Lo represenL Lhe commlssloner on all maLLers perLalnlng Lo chlld care.

2. Un|form|ty |n ch||d care data report|ng |s recommended by creaLlng a new lnLegraLed
chlld care reporL capablllLy LhaL would comblne CCul Chlld Care Subsldy rogram daLa
elemenLs wlLh ASl8L-1Anl and 1CC daLa elemenLs. Such a reporL produced elLher monLhly,
quarLerly, or annually, would slgnlflcanLly asslsL Lhe sLaLe Lo dlscern exacLly who recelves chlld
care, Lhe duraLlon of care LhaL ls pald for by Lhe respecLlve programs, and could prompL beLLer
Lracklng of Lhe care cholces of parenLs, Lhus
lmprovlng program plannlng and flscal pro[ecLlons.
1he currenL sLrucLure has lmporLanL lnformaLlon
gaps on boLh sldes of chlld care daLa reporLlng, l.e.,
auLhorlzaLlons, uLlllzaLlon and expendlLures.

1he CClS sysLem LhaL admlnlsLers CCul ls
mandaLed Lo reporL annually under federal CCul
801 reporLs. 1he CCul 801 reporL capLures crlLlcal daLa on famlly proflles, chlld care provlders,
levels of chlld care pald for, and a lengLhy llsL of oLher Lypes of daLa LhaL are exLremely useful Lo
federal and sLaLe admlnlsLraLlon when deallng wlLh LlghL budgeLs and program accounLablllLy.

1he Cll sysLem, whlch admlnlsLers ASl8L-1Anl/aS, reporLs supporLlve-servlce
expendlLures and case counLs Lhrough monLhly 1Anl reporL Lransmlsslon. 1he ASl8L-
1Anl/aS program conslders chlld care a supporL servlce llke LransporLaLlon. As such, Lhe
sysLem capLures general daLa on provlders, monLhly case counLs Lled Lo ASl8L-1Anl acLlvlLles
and/or 1ranslLlonal Chlld Care, counLs of llcensed or unllcensed provlders, and monLhly
expendlLures ln each caLegory. lL ls noL evldenL LhaL Lhe reporLs Lrack acLual CC sLarL-and-end
2
Lstab| | sh an
| nteg rated ch| | d care
po| | cy and prog ram
| eadersh| p ro| e w| th
respons| b| | | ty across
CCIS and CII.
1
Create a un| form ch| | d
care data-report| ng
capab| | | ty that captures
data from CII and CCIS.


87
daLes by case level, changes ln CC provlder Lypes, and wheLher CC ls full Llme or parL Llme. nor
ls Lhere an apparenL sysLem for collecLlng or checklng records of chlld aLLendance, whlch ls of
parLlcular concern glven Lhe facL LhaL 40 of ASl8L-1CC famllles use lnformal provlders.

A number of sLaLes operaLe under dlfferenL chlld care sLrucLures, dependlng on
deslgnaLed admlnlsLraLlve agencles. Powever, wlLh regard Lo reporLlng of daLa, lL ls noL
advanLageous for a sLaLe Lhe slze of Malne, Lo reporL chlld care daLa and expendlLures of Lwo
separaLe sysLems especlally when Lhe CCul daLa ls analyzed naLlonally and Lhe ASl8L-
1Anl/1CC daLa ls omlLLed from LhaL sysLem. A soluLlon could be Lo reprogram ACLS Lo produce
an ASl8L-1Anl/aS chlld care daLa reporL LhaL repllcaLes Lhe same elemenLs requlred under
Lhe CCul 801 reporL and submlL a comblned reporL annually Lo ACl Cfflce of Chlld Care.
Powever, lL musL be acknowledged LhaL ACLS has slgnlflcanL llmlLaLlons and lLs adapLablllLy Lo
coordlnaLlon of daLa producLlon ls unforLunaLely rlsky.

3. Un|form|ty |n the ch||d care payment po||cy would
greaLly lmprove paymenL conLrols and accounLablllLy.
ASl8L/aS pollcy permlLs chlld care paymenLs Lo be lssued Lo
parenLs on Lhelr L81 cards, Lhe expecLaLlon ls LhaL Lhe parenL
wlll Lhen pay hls/her provlder for chlld care. MosL parenLs
manage well wlLh Lhls sysLem of paymenL, and Lhere are
efflclencles for Lhe Cll ASl8L workers who revlew and
approve chlld care paymenLs uslng Lhe L81 sysLem. Powever,
chlld care provlders wlll frequenLly complaln abouL never recelvlng paymenLs from some of Lhe
parenLs. ln Malne, as well as ln oLher sLaLes where such a sysLem had been followed, Lhe parenL
can walk away from LhaL provlder and go Lo a new provlder wlLhouL ever looklng back. lL ofLen
leaves Lhe chlld care provlders holdlng Lhe bag" for unpald servlces. AddlLlonally, Lhls meLhod
of processlng paymenLs vla L81, may lead parenLs Loward more lnformal" Lypes of care, noL
always as safe or sLable, as Lhe more formal chlld care seLLlngs.

4. Lxp|ore partner support to he|p pay for the cost|y
|nvestments |n the state's qua||ty |n|t|at|ves. 1he goal ls Lo
avold Lhe budgeLary Lenslon uPPS faces when savlngs are
mandaLed and Lhe only prevlous cholce relaLed Lo creaLlng
walLlng llsLs versus cuLLlng funds ln Malne's CCul quallLy
lnlLlaLlves budgeL. An alLernaLlve worLh conslderlng ls Lo lnvlLe
oLher agencles Lo conLrlbuLe Lo Lhe sLaLewlde quallLy
lnvesLmenLs for chlldren.

AddlLlonally, relnforce Lhe speclfled ob[ecLlves of Lhe
sLaLe's C8lS by provldlng ongolng Lechnlcal asslsLance (1A) for all
C8lS provlders Lo ensure LhaL benchmarks are belng meL and LhaL Lhe four-sLep lncenLlve plan
ls successfully dellverlng Lhe hlghesL sLandards ln early care and educaLlon for chlldren enrolled
ln Lhese programs. ConLlnuous overslghL and 1A wlll help forLlfy Lhe achlevemenL of sLrong and
success-bound ouLcomes for chlldren.
ay ch| | d care
prov| ders d| rect| y
as opposed to
| ssu| ng payments
through parents'
L81 cards#
Seek f| nanc| a|
contr| but| ons from
var| ous
stakeho| ders
| nvo| ved | n
Ma| ne' s qua| | ty
care | n| t| at| ves.


88
S. ay|ng for ch||d care one week |n advance of actua|
ch||d attendance shou|d be recons|dered, as prepaymenL
carrles a hlgh poLenLlal for over-paymenLs caused when cllenLs
experlence false sLarLs" ln programs Lhey slgned up for, and/or
ln [ob enLrles LhaL ofLen do noL maLerlallze. Such reallLles are
noL uncommon ln welfare-Lo-work programs, paylng ln
advance can resulL ln care never used or, ln facL, never needed.
1hls problem ls furLher compounded by Lhe need Lo chase
down paymenLs already made and spenL by elLher parenL or
provlder.

1he CClS Chlld Care Subsldy rogram pays Lwo weeks afLer chlld care has been
provlded. Whlle posL-paymenL, Loo, has dlsadvanLages, parLlcularly ln Lhe sLarLup phase, Lhe
long-Lerm advanLages of paylng for servlces afLer Lhey are recelved ls much preferred from a
program lnLegrlLy and budgeLary perspecLlve. As wlLh Lhe ellglblllLy revlew, Lhe close scruLlny of
bllls, paymenLs, and monlLorlng of chlld-aLLendance pracLlces needs Lo be done wheLher lL ls a
llcensed or unllcensed provlder seLLlng.

6. Cons|der mov|ng toward sw|pe-card techno|ogy
for pay|ng ch||d care subs|d|es and bulld ln safeguards for
chlldren ln care by Lracklng aLLendance, arrlval Llmes, and
plck-up Llmes. Swlpe-card Lechnology has been found Lo
be one of Lhe mosL rellable ways Lo Lrack aLLendance,
proper proLocols furLher conLrlbuLe Lo safeLy measures for
monlLorlng LhaL chlldren ln care are exacLly where Lhe
parenL placed Lhem. As of March 2011, nlne sLaLes have lmplemenLed swlpe-card Lechnology:
Alabama, Colorado, lndlana, norLh Carollna, Chlo, Cklahoma, 1exas, vlrglnla, and Wyomlng.
AddlLlonal sLaLes have moved Loward use of a swlpe card buL are noL yeL counLed ln Lhe federal
reporL.
30
Whlle Lhls Lechnology would necesslLaLe an upfronL lnvesLmenL, lL ls conslsLenL wlLh
Lhe deparLmenL's modernlzaLlon efforLs and would LlghLen conLrols on expendlLures of sLaLe
and federal dollars LhroughouL Lhe sysLem of chlld care.

7. Increase]expand on-s|te mon|tor|ng v|s|ts of a|| ch||d care prov|ders wlLh Lhe goal of
beLLer assurlng quallLy care for chlldren whlle aL Lhe same Llme lmprovlng paymenL accuracy
based on perlodlc checks on chlld-aLLendance
lnformaLlon. 1hls recommendaLlon assumes pollcy
coordlnaLlon beLween Cll and CClS whereby any
provlder recelvlng federal and/or sLaLe paymenLs ls held
Lo a mlnlmum seL of sLandards, especlally Lhose LhaL
safeguard Lhe wellbelng of chlldren.

30. ACl, Cfflce of Chlld Care, Chlld Care AdmlnlsLraLor's lmproper aymenLs lnformaLlon 1echnology
Culde, arL 1: lnvenLory of SLaLe Chlld Care lnformaLlon SysLems," March 2, 2011.
I nvest | n automated
support for attendance
report| ng.
ay after
performance, based
on prov| der
| nvo| c| ng system,
use techno| og y to
automate b| | | | ng
process.
I ncrease on-s| te
mon| tor| ng of ch| | d care
sett| ngs throug hout the
system.


89





S. Ch||d-Support Lnforcement v|a DSLk


8ackground

Cn !anuary 4, 1973, resldenL Cerald lord slgned Lhe Soclal Servlces AmendmenLs of
1974, whlch creaLed parL u Lo 1lLle lv of Lhe Soclal SecurlLy AcL. Commonly referred Lo as 1lLle
lv-u," Lhe amendmenL creaLed a naLlonal chlld-supporL enforcemenL (CSL) and paLernlLy-
esLabllshmenL program, and auLhorlzed federal maLchlng funds Lo Lhe sLaLes for enforclng
chlld-supporL obllgaLlons by locaLlng nonresldenL parenLs, esLabllshlng paLernlLy, chlld-supporL
orders, and collecLlng paymenLs. arL u represenLs one of Lhe four welfare provlslons of 1lLle lv:
arL A for Lhe 1Anl program, arL 8 represenLlng chlld and famlly servlces, and arL L, fosLer-
care and adopLlon servlces. (1here ls no arL C, as Lhls secLlon was repealed).

AlLhough Lhe purpose of Lhe 1973 leglslaLlon was Lo secure relmbursemenL from
absenLee parenLs for Lhe cosL of welfare pald Lo cusLodlal parenLs, Lhe servlces provlded by Lhe
chlld-supporL enforcemenL sysLem are open Lo all parenLs lrrespecLlve of wheLher Lhey recelve
any Lype of publlc asslsLance or noL. Whlle parenLs ln Medlcald, 1Anl, or Lhe federal fosLer-care
program auLomaLlcally recelve chlld-supporL servlces - and aL no-cosL - slngle parenLs ouLslde
Lhe welfare sysLem can apply for chlld-supporL servlces for a modesL fee.

When Congress overhauled Lhe naLlon's cash-welfare program ln 1996 and replaced
AluC wlLh 1Anl, lL lnLroduced ma[or enhancemenLs Lo Lhe CSL sysLem as well, maklng 1Anl
funds conLlngenL on sLaLes ensurlng LhaL Lhelr chlld-supporL enforcemenL sysLems meeL federal
sLandards, and sLarLed Lo base fundlng on performance. 1he 1996 leglslaLlon also requlred
sLaLes Lo lncrease Lhe percenLage of noncusLodlal parenLs ldenLlfled and Lo use more rlgorous
enforcemenL Lechnlques, lncludlng Lechnology, Lo locaLe absenLee faLhers.


Integrat|on of Ch||d-Support Lnforcement w|th Cther DnnS rograms

CharL 3-1 provldes a dellneaLlon of ma[or publlc-asslsLance programs provlded by uPPS-
Cll and Lhe cross-connecLlng pollcles relaLed Lo chlld-supporL enforcemenL. As approprlaLe,
rules requlrlng cooperaLlon wlLh chlld-supporL enforcemenL have been applled and responslble
pollcles and procedures are currenLly ln place LhroughouL Lhe varlous beneflL programs
admlnlsLered by Cll. ln Lhe lnlLlal ellglblllLy for asslsLance as well as Lhe conLlnulng ellglblllLy
process, famllles are counseled on Lhelr chlld-supporL obllgaLlons and Lhere ls an evldenL


90
culLure LhroughouL Lhe sysLem LhaL ls a crlLlcal parL of a famlly's sLream of supporL, lrrespecLlve
of Lhe beneflLs Lhey may be recelvlng Lhrough Lhe deparLmenL.

CharL 3-1: Coord|nat|ng Ch||d Support across Mu|t|p|e rograms
rogram o||c|es & rocedures
1ANI Cash Ass|stance
(or) arents-As-
Scho|ars (aS) Cash
Ass|stance rogram
As a condlLlon of recelvlng 1Anl or aS cash asslsLance,
appllcanL musL provlde known lnformaLlon on non-cusLodlal
parenL, musL cooperaLe wlLh uSL8 ln lLs efforLs Lo collecL CS
unless good cause" ls esLabllshed, and musL asslgn all
supporL rlghLs Lo Lhe sLaLe.
Whenever uSL8 collecLs CS paymenLs ln Lhe monLh lL ls due,
1Anl or aS cusLodlal parenL ls enLlLled Lo Lhe flrsL $30 pass-
Lhrough.
ln addlLlon Lo 1Anl or aS cash and pass-Lhrough paymenLs,
cusLodlal parenL may be enLlLled Lo anoLher paymenL called
gap." Cap paymenLs come from Lhe prlor monLh's LoLal
chlld-supporL collecLlons, less Lhe pass-Lhrough.
All collecLlons from Lax refunds are consldered pasL-due,"
Lhus Lhe cusLodlal parenL would noL recelve a pass-Lhrough
paymenL from Lhese funds.
AfLer cusLodlal parenL sLops recelvlng 1Anl or aS cash
asslsLance, uSL8 auLomaLlcally conLlnues Lo collecL chlld-
supporL ln behalf of Lhe chlld, unless Lhe cusLodlal parenL
lnforms uSL8 ln wrlLlng Lo sLop collecLlons for Lhelr chlldren.
Cood cause" ls granLed Lhrough Cfflce of lamlly
lndependence (Cll).
Ch||d Care Subs|dy
rogram for non-
1ANI work|ng
fam|||es and fam|||es
|n educat|on and
tra|n|ng
AL Llme of appllcaLlon, musL documenL any chlld supporL
recelved for all chlldren of absenL parenL(s), unless good
cause can be shown (or)
MusL show proof of aLLempL Lo collecL chlld supporL Lhrough
uSL8 or Lhe legal sysLem.
lf no CS arrangemenLs are ln place aL appllcaLlon, cusLodlal
parenL musL show proof LhaL supporL has been pursued or
have begun collecLlng chlld supporL wlLhln slx monLhs of
award or asslsLance wlll be LermlnaLed.
Supp|ementa|
Nutr|t|on Ass|stance
rogram (SNA)
Chlld-supporL expenses are excluded from household lncome
calculaLlon ln deLermlnlng ellglblllLy for SnA beneflLs.
no dlsquallflcaLlon lf parenL falls Lo cooperaLe wlLh uSL8,
and/or ls ln arrears wlLh chlld-supporL paymenLs.
SLaLes have Lhe opLlon Lo LreaL legally obllgaLed chlld-supporL
paymenLs made Lo non-household members as lncome


91
excluslon raLher Lhan a deducLlon. 1hls opLlon ls lnLended Lo
help encourage paymenL of CS.
Malne ls one of 16 sLaLes opLlng for CS expense excluslon.
CS-relaLed dlsquallflcaLlon from SnA ls a sLaLe opLlon. Cnly
flve sLaLes dlsquallfy appllcanLs for falllng Lo cooperaLe wlLh
uSL8 and only one sLaLe dlsquallfles appllcanL lf Lhey have CS
arrearages.
Ma|neCare AppllcaLlon for MalneCare requlres lnformaLlon on chlldren
ln household as well as absenL-parenL name(s) and lasL
known address, as approprlaLe. 1hls provlslon does noL apply
Lo pregnanL women or lndlvlduals belng covered under
LranslLlonal Medlcald.
Any chlld supporL recelved should be llsLed as unearned
lncome for Lhe chlld for whom Lhe paymenLs are lnLended.
lor famlly-relaLed caLegorles, Lhe flrsL $30 per monLh of
currenL chlld-supporL paymenLs recelved by Lhe asslsLance
unlL wheLher recelved Lhrough uSL8 or dlrecLly ls excluded.
lor 1Anl reclplenLs, chlld supporL pald by Lhe dlvlslon LhaL ls
ln excess of Lhe monLhly obllgaLlon ls excluded.
Chlld-supporL pald ouL" ls Lhe monLhly amounL pald Lo
comply wlLh courL or chlld-supporL order, and lL ls used as a
deducLlon when flgurlng MalneCare ellglblllLy.
LInLA noL Appllcable
Genera| Ass|stance noL Appllcable
SSI rogram noL appllcable
Source: analysls of uPPS-Cll ollcy Manual and lnformaLlonal maLerlals (appllcaLlon forms,
lnformaLlonal handouLs, as well as lnLervlews wlLh uPPS-Cll program admlnlsLraLors.

Ch||d-Support Lnforcement Act|v|t|es, 2012-13

uurlng Sl? 2012-13, Malne reporLed a LoLal number of 63,433 chlld-supporL cases (or
famllles, meanlng a cusLodlal parenL and an absenLee parenL). Cf Lhls LoLal, 37,347 have Lhe
beneflL of supporL orders, alLhough 6,832 of Lhese orders are medlcal only," leavlng 30,439
oLher cases. Cf Lhese oLher cases, Malne reporLed LhaL 33,339 acLually recelved supporL ln Lhe
same flscal year, leavlng 13,100 cases (or abouL 30) wlLhouL supporL.

Also, Lhe LoLal number (63,433) of chlld-supporL cases ln 2012-13 can be broken down
accordlng Lo Lhree caLegorles speclfled by Lhe uSL8:
Cases LhaL are currenL publlc asslsLance: 7,212
Cases LhaL were formerly on publlc asslsLance: 33,319
Cases LhaL were never on publlc asslsLance: 20,924


92
Moreover, of Lhe 7,212 cases on currenL publlc asslsLance (1Anl), 3,179 (or 44)
recelved chlld-supporL paymenLs ln 2012-13.

Also durlng 2012-13, Malne's uSL8 esLabllshed 6,306 chlld-supporL orders and locaLed
34,028 absenLee parenLs.

1oLal number of parenLs referred Lo uSL8 ln 2012-13:
1oLal new cases were 8,903, 1Anl cases were 2,304 (28 of LoLal new cases).
1oLal number of esLabllshed and enforced medlcal-supporL obllgaLlons, lncludlng
medlcal-only cases: 37,344.

Ma|ne's Ch||d-Support Co||ect|ons |n 2012-13:
1oLal dollars collecLed on behalf of cusLodlal parenLs: 5100,267,284
1oLal dollars collecLed and senL Lo federal governmenL: 511,221,906
1oLal dollars collecLed and senL back Lo sLaLe general fund: 5S,780,98


Ma|ne's DSLk System kank|ngs

A revlew of Lhe l? 2012 chlld-supporL program performance lndlcaLors revealed very
poslLlve daLa for Malne's program compared Lo all sLaLes. 8anklngs are lndlcaLed boLh on Lhe
naLlonal level and wlLhln Lhe new Lngland sLaLes.

CharL 3-2: Ma|ne's DSLk System kank|ngs
DSLk erformance Ind|cator
Ma|ne's Nat|ona|
kank|ng
Ma|ne's kank|ng |n
New Lng|and States
aLernlLy-esLabllshmenL percenLage (L) 9
Lh
1sL
ercenLage of cases wlLh supporL orders 7
Lh
1sL
ercenLage of cases wlLh collecLlons currenL 37
Lh
6Lh
ercenLage of cases wlLh collecLlons ln
arrearages
24
Lh
4Lh
CosL effecLlveness (measured by LoLal
collecLlons per dollar of program spendlng)
43
rd
3Lh


Malne's ranklng relaLlve Lo Lhe oLher sLaLes LhroughouL Lhe counLry ls hlgh on lv-u
paLernlLy-esLabllshmenL percenLage (ranks nlnLh ln Lhe counLry, and ranks flrsL ln new Lngland).
WlLh regard Lo Lhe percenLage of cases wlLh supporL orders, agaln Malne ranks hlgh (sevenLh ln
Lhe counLry, and flrsL among new Lngland sLaLes). 1hese ranklngs have remalned falrly sLeady


93
for Lhe sLaLe and, as ln prevlous years, Malne has earned federal performance lncenLlve dollars
averaglng $2.2 mllllon annually.

CharL 3-3: Ma|ne's DSLk erformance Measures
2012 erformance Measures Ma|ne Conn. Mass. new
Pampshlre
8hode
lsland
vermonL
lv-u paLernlLy-esLabllshmenL
percenLage (L)
106.71 93.43 90.80 107.28 92.34 103.37
ercenL of cases wlLh orders 89.17 73.19 83.33 86.39 67.08 88.67
ercenL of cases currenL S9.10 37.80 69.01 62.86 39.63 69.12
ercenL of cases ln arrearages S7.23 39.49 39.82 64.92 36.73 69.88
CollecLlons per dollar of
program spendlng
53.71 $3.77 $3.90 $4.63 $4.94 $3.30




94



93





6. Genera| Ass|stance rogram


Cverv|ew

1he Ceneral AsslsLance rogram ls governed by Malne Ceneral Law, 1lLle 22, PealLh and
Welfare, arL 3: ChapLer 1161, Munlclpal Ceneral AsslsLance, and ChapLer 1231, Munlclpal
Ceneral AsslsLance program. 1he law ln Malne may requlre each munlclpallLy Lo operaLe a
Ceneral AsslsLance (CA) program whlch provldes lmmedlaLe ald ln Lhe form of vouchers, for
persons who are unable Lo provlde Lhe baslc necesslLles essenLlal Lo malnLaln Lhemselves and
Lhelr famllles. LllglblllLy crlLerla are based on flnanclal need and asseLs, and access Lo Lhese
beneflLs ls provlded by Lhe varlous munlclpallLles LhroughouL Lhe sLaLe. CA ls funded Lhrough a
comblnaLlon of sLaLe and munlclpal conLrlbuLlons. CharL 6-1 provldes a Lhree-year perspecLlve
on LoLal sLaLe dollars expended Lhrough uPPS ln Ceneral AsslsLance.

CharL 6-1: Genera| Ass|stance Lxpend|tures
State I|sca| ear 2011 2012 2013
CA LxpendlLures by year $10,903,361 $13,321,293 $12,061,930
ApproxlmaLe number of lndlvlduals Served* 11,287 12,900 12,486
LsLlmaLed Average CosL er-Case er ?ear $966.03 $966.03 $966.03
Source: uPPS-Cll 2013 flnanclal reporLs, uecember 2013.
*rogram uaLa, uPPS-Cll esLlmaLes for 2013 based on counLs reporLed from Lhree ma[or munlclpallLles
(orLland, LewlsLon, and 8angor), plus acLual counLs reporLed by sLaLewlde shelLers.


rogram Cperat|ons

AppllcaLlons are handled Lhrough each munlclpal CA offlce, where ellglblllLy
deLermlnaLlon ls carrled ouL by Lhe overseer of Lhe munlclpallLy. varlous forms of
documenLaLlon of need are requesLed, buL rules and requlremenLs may dlffer from one
munlclpal program Lo anoLher. lor example, some munlclpallLles requlre CA reclplenLs Lo
parLlclpaLe ln a workfare program.

1he Ceneral AsslsLance law requlres LhaL able-bodled lndlvlduals parLlclpaLe ln a


96
munlclpal work program as a condlLlon of recelvlng flnanclal asslsLance. 1hls program offers
reallsLlc work opporLunlLles ln varlous clLy deparLmenLs. 1he goal ls Lo encourage employmenL
and self-sufflclency.

lncome ellglblllLy sLandards are generally esLabllshed uslng a formula based on 90 of
110 of Lhe u.S. ueparLmenL of Pouslng and urban uevelopmenL falr-markeL value sLandards
esLabllshed by area. ln accord wlLh language ln law, each munlclpallLy has an overseer" who
works dlrecLly wlLh Lhe CA cllenLele.

Cnce a paymenL/voucher ls approved for an ellglble reclplenL, Lhe overseer may make a
paymenL (such as a uLlllLy blll) Lo a vendor on behalf of Lhe ellglble reclplenL. aymenLs dlrecLly
Lo a reclplenL are noL a feaLure of Lhls program. MonLhly Ceneral AsslsLance 8elmbursemenL
8eporLs are fllled ouL by Lhe munlclpal admlnlsLraLor or overseer and submlLLed Lo uPPS
Ceneral AsslsLance Cfflce locaLed ln AugusLa. 1he Lypes of asslsLance paymenLs may lnclude:
houslng, heaLlng, uLlllLles, food, prescrlpLlons, medlcal servlces, denLal, burlals/cremaLlons,
dlapers/baby supplles, household and personal supplles. CA paymenLs may also be used for CA
reclplenLs who perform workfare for a munlclpallLy.

MunlclpallLles submlL relmbursemenL requesLs Lo uPPS-Cll Ceneral AsslsLance
program, on a monLhly basls and Lhe sLaLe, Lhrough uPPS relmburses Lhe respecLlve
munlclpallLles aL a raLe of 30 of Lhose CA expendlLures. Powever a unlque feaLure of Lhe law
sLaLes LhaL once a munlclpallLy reaches lLs respecLlve Lhreshold amounL ln a year - whlch ls
based upon 0.0003 of Lhe properLy valuaLlon of LhaL munlclpallLy - Lhe sLaLe relmbursemenL
raLe lncreases Lo 90 of Lhose expendlLures wlLhouL llmlL.



97
CharL 6-2: Genera| Ass|stance 8||||ng & ayment rocess, ort|and



CharL 6-3: Genera| Ass|stance Spend|ng, 1op I|ve Count|es
County SI 2012
Cost
art|c|pat|ng
Mun|c|pa||t|es
Count
opu|at|on
(2010)
er-Cap|ta
Cost
Mun|c|pa||t|es
& Unorgan|zed
1err|tory Count
opu|at|on
(2010)
kev|sed
er-Cap|ta
Cost
Cumber|and 9,S01,947 26 281,439 33.76 28 281,674 33.73
enobscoL 3,143,681 49 149,261 21.08 66 133,313 20.32
Androscoggln 1,229,713 14 107,702 11.42 14 107,702 11.42
?ork 1,029,311 29 197,131 3.22 29 197,131 3.22
kennebec 336,330 27 117,210 4.73 30 122,131 4.33


1he per-caplLa cosL ln Cumberland ls almosL 7.3 Llmes hlgher Lhan ln kennebec ($33.72
versus $4.33) and 23.7 Llmes hlgher Lhan Lhe lowesL counLy ln Lhe sLaLe, lranklln ($33.72 versus
$1.31 per-caplLa cosL). ln Lerms of expendlLures by munlclpallLy, orLland's 2013 Annual 8eporL
lndlcaLes CA expendlLures of $8,284,043 ln l? 2012, and $9,678,367 ln l? 2013, Lhe hlghesL
level of annual munlclpal expendlLures ln Lhe sLaLe. ln facL, orLland's CA expendlLures have
shown dramaLlc growLh each year slnce 2006, when expendlLures were $3,027,687, Lo 2013
when expendlLures grew Lo $9,678,367, an lncrease of approxlmaLely 69.7.
-@?4B25 ! W * !NN@X
K8; %! 26;8GY6
/8;2@3BC %4B4;3@
!55?523BJ4 /;8Y;3>
/8;2@3BC %!
+74;544;
L424;>?B45 '44C
3BC #@?Y?Z?@?2X
MB Z463@K 8K -@?4B2 ![
%! +74;544; /3X5
(2?@?2X *?@@ L?;4J2@X
28 /;87?C4; \]TEE^
MB Z463@K 8K -@?4B2 *[
%! +74;544; /3X5 D:
)8B26 $4B2 L?;4J2@X
28 _3BC@8;C \]UEE^
/8;2@3BC %! +74;544;
.GZ>?25 )8B26@X
$4`G452 K8;
$4?>ZG;54>4B2 $4N8;2
28 LFF. %! +Ka?J4 \SER
8K ]Db1EE K8; 9 %!
-@?4B25^
LFF. %! +Ka?J4
$4?>ZG;545
/8;2@3BC ]TSE K8;
)8B26


98
CharL 6-4: Genera| Ass|stance er-Cap|ta Costs by County
County SI 2012
Cost
art|c|pat|ng
Mun|c|pa||t|es
Count
opu|at|on
(2010)
er-Cap|ta
Cost
Mun|c|pa||t|es
& Unorgan|zed
1err|tory Count
opu|at|on
(2010)
kev|sed
er-Cap|ta
Cost
Androscoggln 1,229,713 14 107,702 11.42 14 107,702 11.42
AroosLook 289,919 30 63,811 4.41 73 72,480 4.00
Cumberland 9,301,947 26 281,439 33.76 28 281,674 33.73
lranklln 40,196 13 26,337 1.31 26 30,768 1.31
Pancock 122,914 27 48,306 2.33 41 34,418 2.26
kennebec 336,330 27 117,210 4.73 30 122,131 4.33
knox 133,481 14 34,377 4.46 20 39,736 3.86
Llncoln 147,393 13 32,313 4.33 21 34,437 4.28
Cxford 328,233 28 32,961 6.20 39 37,833 3.68
enobscoL 3,143,681 49 149,261 21.08 66 133,313 20.32
lscaLaquls 86,392 14 16,083 3.37 23 17,333 4.93
Sagadahoc 176,070 9 34,866 3.03 11 33,293 4.99
SomerseL 164,003 24 49,380 3.32 37 32,228 3.14
Waldo 112,812 21 34,497 3.27 26 38,786 2.91
WashlngLon 333,937 30 27,273 12.24 48 32,836 10.16
?ork 1,029,311 29 197,131 3.22 29 197,131 3.22
1ota|s 17,418,S34 392 1,27S,S69 13.66 S32 1,328,361 13.11


Ma|ne's GA rogram ke|at|ve to Cther States

Comparlng Malne Lo oLher sLaLes LhaL operaLe general-asslsLance programs, Lhe
ma[orlLy (LwenLy-slx) uses boLh a flnanclal-need crlLerla as well as healLh-and-medlcal needs
crlLerla Lo deLermlne ellglblllLy. Speclflcally, mosL sLaLes conslder: physlcal and/or menLal
lncapaclLy prevenLlng employmenL, speclal populaLlons such as elderly, bllnd, or dlsabled,
adulLs awalLlng SSl deLermlnaLlon, and Lhe long-Lerm unemployed. As referenced above, CA ls
funded wlLh a comblnaLlon of munlclpal funds and general sLaLe funds, whlch are uLlllzed Lo
address speclflc shorL-Lerm crlsls slLuaLlons such as Lo prevenL lmmlnenL homelessness. Whlle
CA can be renewed, Lhls beneflL ls noL lnLended Lo meeL recurrlng or ongolng needs and ls noL
lnLended Lo exLend beyond a four-monLh perlod for Lhe ellglble populaLlon.

A 2011 reporL conducLed by Lhe CenLer for 8udgeL ollcles and rlorlLles reporLed how
naLlonally, CA programs have been weakened conslderably over Lhe years. 1he sLudy looked aL
acLlons ln 2011 sLaLe leglslaLlve sesslons, lncludlng Lhe sLaLe of Malne, and provlded an
overvlew of 2011 program pollcles across Lhe LhlrLy sLaLes:




99
1hlrLy sLaLes

have CA programs, whlch generally serve very poor lndlvlduals who do noL
have mlnor chlldren, are noL dlsabled enough Lo quallfy for Lhe SupplemenLal SecurlLy
lncome program (SSl), and are noL elderly.
Cnly Lwelve of Lhe LhlrLy sLaLes provlde any beneflLs Lo chlldless adulLs who do noL have
some dlsablllLy, Lhe oLhers requlre reclplenLs Lo be unemployable, generally due Lo a
physlcal or menLal condlLlon.
1wenLy-nlne of Lhe LhlrLy sLaLes wlLh CA programs, Lhe maxlmum beneflL ls seL below
half of Lhe poverLy llne for an lndlvldual. ln facL, ln mosL of Lhese sLaLes, Lhe maxlmum
beneflL falls below one-quarLer of Lhe poverLy llne.
1here ls no federally supporLed cash safeLy-neL program for poor chlldless adulLs who
do noL recelve SSl. 1hese sLaLe or local CA programs are generally Lhe only cash asslsLance for
whlch such lndlvlduals can quallfy. Some of Lhese are unlform sLaLewlde programs, oLhers have
sLaLe guldellnes wlLh opLlons for counLy varlablllLy, ranglng from mlnlmal cosL-of-llvlng
ad[usLmenLs Lo slgnlflcanL dlfferences ln ellglblllLy sLandards.

A number of sLaLes have ellmlnaLed Lhelr CA programs alLogeLher, whlle oLhers have cuL
fundlng, resLrlcLed ellglblllLy, lmposed Llme llmlLs, and/or cuL beneflLs. MosL sLaLes LhaL
ellmlnaLed CA programs for people who are noL dlsabled dld so beLween Lhe laLe 1980s and
laLe 1990s. 8eLween 1998 and 2010, flve addlLlonal sLaLes LermlnaLed Lhelr CA programs, and
aL leasL Len oLher sLaLes cuL Lhelr programs back.

ln 2011, as sLaLes sLruggled Lo close large budgeL shorLfalls, Len sLaLes consldered
proposals Lo furLher shrlnk or ellmlnaLe general asslsLance, and seven sLaLes adopLed such
measures. llllnols and kansas ellmlnaLed Lhelr programs, MlnnesoLa resLrlcLed ellglblllLy,
Mlchlgan reduced beneflL levels for all reclplenLs, WashlngLon resLrlcLed ellglblllLy and reduced
beneflL levels for all reclplenLs who sLlll quallfy, and 8hode lsland has cuL beneflLs for some
reclplenLs. 1he ulsLrlcL of Columbla reduced fundlng for lLs program by Lwo-Lhlrds and plans Lo
llmlL Lhe slze of lLs caseload accordlngly.

ln Malne, several lnlLlaLlves Lo conLaln CA expendlLures were enacLed by rule:

- Iug|t|ve from [ust|ce |ne||g|b|e for GA. A fuglLlve from [usLlce ls noL ellglble for CA.

- Ca|cu|at|on of pro-rata share. When an appllcanL shares a dwelllng unlL wlLh one or
more lndlvlduals, ellglble appllcanLs may recelve asslsLance for no more Lhan Lhelr pro-
raLa share of Lhe acLual cosLs of Lhe shared baslc needs of LhaL household. 1he pro-raLa
share ls calculaLed by dlvldlng Lhe maxlmum level of asslsLance avallable Lo Lhe enLlre
household by Lhe LoLal number of household members. lncome of household members
noL legally llable for supporLlng Lhe household ls consldered avallable Lo Lhe appllcanL
only when Lhere ls a poollng of resources.

- Lump-sum ca|cu|ator. All lncome recelved by Lhe household beLween Lhe recelpL of Lhe
lump-sum paymenL and Lhe appllcaLlon for asslsLance ls added Lo Lhe remalnder of Lhe


100
lump sum and Lhe LoLal ls Lhen proraLed. 1he perlod of proraLlon ls Lhen deLermlned by
dlvldlng Lhls LoLal by Lhe verlfled acLual prospecLlve LhlrLy-day budgeL for all of Lhe
household's baslc necesslLles.

- Unemp|oyment benef|ts as ava||ab|e |ncome |n cases of fraud. ConslsLenL wlLh 22
M.8.S. 4317, an lndlvldual who ls found Lo be lnellglble for unemploymenL
compensaLlon beneflLs because of a flndlng of fraud by Lhe Malne ueparLmenL of Labor
pursuanL Lo 26 M.8.S.A. 1031(1) shall be lnellglble Lo recelve general asslsLance Lo
replace Lhe forfelLed unemploymenL compensaLlon beneflLs for Lhe duraLlon of Lhe
forfelLure as esLabllshed by Lhe Malne ueparLmenL of Labor.

- Max|mum |eve| of ass|stance for f|sca| years 2013-14 and 2014-1S. LsLabllshes Lhe
aggregaLe maxlmum level of general asslsLance for !uly 1, 2013, Lo !une 30, 2014, as Lhe
amounL LhaL ls greaLer Lhan 90 of 1100 of Lhe Puu falr-markeL renL for ll? 2013, or
Lhe amounL achleved by lncreaslng Lhe maxlmum level of asslsLance for flscal year
2012-13 by 90 of Lhe lncrease ln Lhe federal poverLy level for 2013 over Lhe federal
poverLy level for 2012. 1he same formula ls used for !uly 1, 2014, Lo !une 30, 2013.

- Ind|an tr|be re|mbursement. LsLabllshes Lhe CA relmbursemenL formula for Lrlbes as
10 of Lhe relmbursemenL amounL, up Lo 0.0003 of Lrlbe's mosL recenL sLaLe valuaLlon
added Lo 100 of Lhe amounL ln excess of 0.0003 of Lrlbe's mosL recenL sLaLe valuaLlon.

- C|rcu|t 8reaker program benef|ts as |ncome. CounLs Lhe ClrculL 8reaker program
beneflLs as lncome when deLermlnlng ellglblllLy for general asslsLance unless Lhe
beneflLs are used Lo provlde baslc necesslLles.

- Mun|c|pa| property tax ass|stance. CounLs Lhe properLy Lax falrness credlL as lncome
when deLermlnlng ellglblllLy for general asslsLance.


kecommendat|ons]Cpt|ons for Genera| Ass|stance

1wo proposals Lo curb CA expendlLures have noL been adopLed buL remaln vlable
opLlons Lo reallze lmporLanL savlngs ln sLaLe dollars:

A CA block granL was proposed LhaL would have provlded a speclfled amounL of money
Lo each munlclpallLy, based on Lhe average expendlLure of a munlclpallLy ln Lhe lasL
Lhree years. under Lhls proposal, munlclpallLles would have been able Lo deslgn Lhelr
own ellglblllLy crlLerla, buL once fundlng was exhausLed, Lhere would noL be any
addlLlonal dollars recelved from Lhe sLaLe.

- AnoLher proposed lnlLlaLlve would have llmlLed all relmbursemenLs Lo 30 of
expendlLures, Lhus ellmlnaLlng Lhe 90 yearly Lhreshold amounL.


101
ln addlLlon, Lhe followlng opLlons - lf adopLed - would also resulL ln savlngs for Lhe
sLaLe:

Cpt|on 1: Malne uPPS could assume LoLal admlnlsLraLlon of Lhe CA program and
unlformly apply sLandards of ellglblllLy and beneflLs lssued on a sLaLewlde basls. A number of
efflclencles can be expecLed by operaLlng CA Lhrough Lhe slxLeen reglonal cenLers, where Lhe
provlslon of servlces would be done by experlenced ellglblllLy workers who have access Lo
auLomaLed ellglblllLy, paymenLs/vouchers, and reporLlng sysLems. MosL noLeworLhy ls Lhe
ellmlnaLlon of dupllcaLlon of beneflLs lssued Lhrough Lwo separaLe program operaLlons.

Cpt|on 2: ConLlngenL upon fundlng consLralnLs, uPPS could work wlLh lawmakers Lo
follow Lhe paLLern of oLher sLaLes and ellmlnaLe Lhe CA program alLogeLher.

Cpt|on 3: Malne uPPS could conslder capplng CA program dollars per munlclpallLy,
seLLlng a maxlmum amounL avallable for each year, based on avallablllLy of sLaLe fundlng. Whlle
Lhls ls slmllar Lo Lhe already consldered flxed block-granL proposal, Lhls opLlon would be based
on avallable sLaLe dollars each year, whlch would be sub[ecL Lo annual allocaLlons LhaL may
flucLuaLe up or down.

Cpt|on 4: ulsconLlnue cash beneflLs Lo employable adulLs wlLhouL chlldren, conLlnue MA
lf Lhey are lncome ellglble under Medlcald and have a verlfled need for medlcal servlces and/or
prescrlpLlon drugs.

Cpt|on S: ueny CA emergency cash asslsLance Lo Lhose who are on 1Anl - Lhey
already recelve monLhly cash beneflLs, SnA, and MA Lhrough uPPS and may also quallfy for
emergency asslsLance under cerLaln uPPS rules. uupllcaLlon of asslsLance ls a slgnlflcanL
posslblllLy wlLhln Lhe currenL CA beneflL sLrucLure.

Cpt|on 6: ulsconLlnue llmlLless renewals for Ceneral AsslsLance beneflLs. CLher sLaLes
llmlL asslsLance Lo no more Lhan one Llme per year, or no more Lhan Lhree Llmes per lndlvldual
or famlly per llfeLlme, or one Llme per llfeLlme. Malne has no llmlLaLlon on Lhe number of Llmes
a reclplenL can be approved for beneflLs.

Cpt|on 7: Cap enrollmenLs, effecLlve Sl? 2013. CA caseloads wlll decllne overLlme due
Lo aLLrlLlon, and savlngs can be reallzed Lhrough Lhls llmlL on recelpL of beneflLs.




102





7. kefugee Cash Ass|stance


Cverv|ew

1hls program lncludes 1Anl-ellglble famllles who are refugees and asylums and
recelvlng soclal servlces Lhrough Lhe 8efugee Cash AsslsLance (8CA) program. 1he servlces
provlded lnclude cash asslsLance, case managemenL, and employmenL and Lralnlng servlces
provlded by local refugee agencles durlng Lhe flrsL elghL monLhs afLer Lhelr arrlval ln Lhe unlLed
SLaLes. 1he Cfflce of 8efugee 8eseLLlemenL (C88) provldes soclal servlces fundlng for
employmenL servlces Lo refugees. 1he 1Anl-ellglble famllles are beLLer served Lhrough Lhls
exLenslve servlce-dellvery sysLem, 1Anl federal funds are used Lo pay for Lhe servlces provlded
Lhese famllles. CosLs are charged Lo 1Anl federal funds, buL 1Anl sLaLe MCL may also be
expended on Lhese servlces. 1he flnanclal ellglblllLy for Lhese servlces ls Lhe same ellglblllLy used
for 1Anl cash asslsLance. 1he followlng number of 8CA cases recelved cash asslsLance:

CharL 6-3: kefugee Cash-Ass|stance Case|oad, 2013

Source: uPPS-Cll Ceographlc ulsLrlbuLlon of rograms and 8eneflLs for 2013.

1he 8CA caseload for 2013 averaged sevenLy-nlne cases per monLh. Looklng back aL
prevlous years, Lhe 8CA rogram has noL grown subsLanLlally, however Lhe 2013 numbers are
showlng a gradual lncrease compared Lo prevlous years.
IJ
K!
KH
H4
I"
K4
I!
IF IF IF
II
KJ
0
10
20
30
40
30
60
70
80
90
100
3
D
E
>
A

/
D
H
E
M
A
N

L
>
C
B
C

1ota| Lxpend|tures for 2013: 52S8,S86


103
CharL 6-6: kefugee Cash-Ass|stance Case|oad, 2006-13
2006 48 2010 49
2007 34 2011 62
2008 38 2012 73
2009 80 2013 83

All refugees have access Lo MalneCare for up Lo elghL monLhs from Lhelr u.S. arrlval
daLe. 1helr MalneCare ls pald for ouL of refugee medlcal-asslsLance money granLed by Lhe
federal governmenL. lollowlng Lhe lnlLlal elghL monLhs of MalneCare, only Lhose who are 63
and older, and Lhose on 1Anl, are ellglble Lo remaln on MalneCare. As of SepLember 2013, 73
refugees were ellglble for MalneCare refugee asslsLance.


kecommendat|ons for kCA

- 8CA agencles are lnLensely grounded ln helplng reclplenLs Lo access employmenL
opporLunlLles. 1he Cll should work closely wlLh 8CA provlders Lo brlng approprlaLe
resources Lo Lhose agencles who work wlLh 8CA famllles.
- AccommodaLe 8CA [ob seekers ln Lhose opporLunlLles now avallable Lhrough Lhe uPPS-
Cll/uCL [ob-readlness program.



104





8. We|fare-to-Work Coord|nat|on


Current In|t|at|ves

1hroughouL 2013, Lhe uPPS Cfflce of lamlly lndependence (Cll) - ln collaboraLlon
wlLh Lhe Malne ueparLmenL of Labor (MuCL), 8ureau of LmploymenL Servlces (8LS) and Lhe
Malne AdulL LducaLlon program - pursued a promlslng lnlLlaLlve Lo asslsL low-lncome parenLs
of Lhe ASl8L-1Anl program as well as reclplenLs of Lhe SnA lood SupplemenL LmploymenL
and 1ralnlng (lSL1) program who need asslsLance Lo enLer Lhe workforce. 8oLh ASl8L and lSL1
parLlclpanLs - referred Lo as Able 8odled AdulLs wlLhouL uependenLs (A8AWus) - are
requlred by federal mandaLes Lo acLlvely engage ln work acLlvlLles LhaL lead Lo long-Lerm
employmenL and, Lo Lhe greaLesL exLenL posslble, lndependence from publlc asslsLance.

A greaL deal of plannlng amongsL Lhe uPPS-Cll, Lhe Malne AdulL LducaLlon program,
and MuCL's admlnlsLraLlve and supervlsory sLaff resulLed ln a model whlch meeLs Lhe needs of
Lhe Lwo speclal populaLlons, ASl8L-1Anl parenLs and A8AWuS. 8elylng on lnformaLlon and
daLa provlded by Lhe Labor ueparLmenL's chlef economlsL on Malne's Workforce Challenges
and CpporLunlLles,
31
boLh deparLmenLs collaboraLed on developlng sLraLegles for llnklng
parLlclpanLs Lo [obs ln a sLreamllned, coordlnaLed process. All referred parLlclpanLs wlll recelve
[ob-readlness assessmenLs, baslc [ob-preparaLlon skllls, and an overvlew of expecLaLlons ln
Loday's [ob markeL, lncludlng how Lo search for a [ob. ln addlLlon, Lhe agreemenL calls for Lwo
componenLs avallable Lhrough Lhls employmenL-servlce reform:

lor ASIkL-1ANI parents, work-experlence placemenLs wlll be sLraLeglcally creaLed ln
areas, whlch are focused on an lndlvldual's vocaLlonal lnLeresLs and occupaLlonal sklll
developmenL. WorkslLe placemenLs wlll lnclude sLrucLured learnlng along wlLh acLual
work experlence, Lyplcally for LwenLy-slx weeks. CusLomlzed placemenLs wlll requlre one
Lo forLy hours per week, and parLlclpanLs wlll be placed ln pald or unpald workslLe
acLlvlLles. 1hese placemenLs may be developed ln Lhe prlvaLe for-proflL secLor, nonproflL
secLor, and/or ln Lhe publlc secLor. arenLs wlll recelve a range of ASl8L-1Anl supporL
servlces such as LransporLaLlon, chlld care, and supporLlve-servlce paymenLs Lo asslsL
parLlclpanLs wlLh work aLLlre, Lools for Lhe [ob, eLc. 1he llkellhood of flndlng permanenL
pald employmenL ls promlslng because Lhls model uLlllzes recenL workslLe learnlng and
bullds credlble deLall for a parLlclpanL's resume, whlch may be used Lo quallfy hlm or her
for a beLLer [ob, even wlLh a dlfferenL employer.

31. See Malne's Workforce CondlLlons & CuLlook, Lhe 8ecesslon and 8ecovery," !anuary 9, 2014.


103
lor SNA-ISL1 A8AWDs, a plloL program wlll provlde shorL-Lerm employablllLy supporL
for up Lo 1,000 reclplenLs, prlmarlly from kennebec and WashlngLon counLles, who wlll
be served Lhrough AugusLa and Machlas Career CenLers. 1he goal ls Lo acceleraLe
success of employmenL and lndependence from Malne's publlc-welfare servlces. As a
volunLary program, refusal Lo parLlclpaLe wlll noL affecL SnA beneflLs. arLlclpanLs wlll
be served for a maxlmum of Lhree monLhs. 1hey wlll begln wlLh an orlenLaLlon sesslon,
followed by compleLe assessmenLs, workshops, and [ob searches as deLermlned by 8LS.
arLlclpanLs may recelve $30 per monLh Lo help wlLh LransporLaLlon expenses.

lundlng for Lhls collaboraLlve efforL comes from boLh ASl8L-1Anl funds and from
SnA-lSL1 funds, whlch are 100 federal dollars. 1hlrLeen full-Llme sLaffers have been
dedlcaLed Lo carrylng ouL Lhe Lwo program models. Accordlng Lo a MuCL press release daLed
Aprll 1, 2014, Commlssloner Mary Mayhew sLaLed:

WlLh nearly seven Lhousand [ob llsLlngs already on Lhe Malne !ob 8ank, 2014 looks Lo be
a sLrong year for hlrlng and creaLlng Lhousands of opporLunlLles for welfare reclplenLs Lo
LranslLlon Lo employmenL. Some of our parLlclpanLs are ready Lo reLurn Lo work almosL
lmmedlaLely, oLhers wlll Lake some Llme Lo learn Lhe behavlors and expecLaLlons
lnvolved ln worklng,'' sald Mayhew. We encourage boLh parLlclpanLs and workslLes Lo
celebraLe Lhe small vlcLorles along Lhe way and Lo recognlze LhaL noL everyone wlll be
successful on Lhe flrsL Lry."

1he value of Lhe mulLl-deparLmenLal parLnershlp cannoL be oversLaLed. uPPS has low-
lncome households aLLached Lo vlrLually every program lL admlnlsLers, aL one Llme or anoLher,
adulLs ln Lhese households wlll need servlces LhaL are avallable Lhrough Lhe MuCL. ln facL, a
slgnlflcanL number of crossover populaLlons (unemployed and under-employed) are known Lo
boLh sysLems. When Lhe unemploymenL raLe rlses, Lhe SnA caseload wlll also rlse, buL Lhe
laLLer Lra[ecLory usually lags changes ln Lhe unemploymenL raLe by approxlmaLely slx Lo Lwelve
monLhs. unLll Lhe Laage admlnlsLraLlon lnlLlaLed Lhls collaboraLlve parLnershlp, llLLle
coordlnaLlon exlsLed beLween Lhe uPPS-Cll and MuCL. 1hls admlnlsLraLlon Lherefore deserves
credlL for creaLlng sLrong collaboraLlon beLween deparLmenLs Lo help ASl8L-1Anl parLlclpanLs
and lSL1 parLlclpanLs move lnLo Lhe [ob markeL.

lor Lhe uPPS Cll, Lhe advanLages are lmmedlaLe: 1hls arrangemenL connecLs Lhe
welfare sysLem Lo Lhe Malne Workforce lnvesLmenL 8oards and Lhe Chambers of Commerce,
whlch can help expand opporLunlLles for parLlclpanLs who need employmenL. 1ogeLher, new
and effecLlve programs can be developed, however, knowlng whlch deslgns are effecLlve
depends on ldenLlfylng effecLlve goals and approaches LhaL have demonsLraLed Lhe mosL
poslLlve resulLs ln Lhe pasL. lor many years, researchers have analyzed welfare-Lo-work
approaches wlLh dlfferenL goals ln mlnd. WheLher Lhe program ls [udged as a success - ln
Lerms of lLs beneflLs Lo parLlclpanLs versus governmenL-cosL savlngs - depends on Lhe
purposes pollcymakers have seL for each program. Several conslderaLlons are offered, based on


106
research reporLed by Lhe Manpower uevelopmenL and 8esearch CorporaLlon (Mu8C) ln
lebruary 2009, Welfare-Lo-Work rogram 8eneflLs and CosLs, A SynLhesls of 8esearch."
32
1he
followlng are excerpLs from LhaL reporL and can be used Lo conslder fuLure dlrecLlons for Lhe
new collaboraLlon:

- lf a chlef goal ls Lo lncrease parLlclpanLs' lncome, Lhen programs LhaL provlde lndlvlduals
wlLh flnanclal lncenLlves or earnlngs supplemenLs lnLended Lo encourage work appear Lo
besL achleve Lhls goal. Whlle beneflclal for parLlclpanLs, earnlngs-supplemenL programs
Lended Lo resulL ln a neL cosL for Lhe governmenL. arLlclpanLs, however, ofLen galned
more Lhan a dollar for every dollar Lhe governmenL spenL, maklng Lhls Lype of program
an efflclenL mechanlsm for Lransferrlng lncome Lo poor famllles.

- lf a chlef goal ls Lo reduce governmenL expendlLures, Lhen programs LhaL requlre
lndlvlduals Lo look for [obs lmmedlaLely, and LhaL asslgn oLher acLlvlLles lf work ls noL
found, are relevanL sLraLegles. 8esearchers found LhaL Lhese programs Lended Lo be
beneflclal for Lhe governmenL budgeL (and Lo be less expenslve Lhan Lhe Lype of
program descrlbed nexL), buL Lhey resulL elLher ln small beneflLs or ln neL cosLs for
parLlclpanLs.

- lf a chlef goal ls Lo balance reduclng welfare expendlLures wlLh lncreaslng parLlclpanLs'
lncome, Lhen programs LhaL requlre lndlvlduals Lo parLlclpaLe lnlLlally elLher ln a shorL-
Lerm educaLlon or Lralnlng acLlvlLy or ln a [ob search acLlvlLy can meeL Lhls goal. 1hls
Lype of program, when LargeLed Lo boLh shorL-Lerm and long-Lerm welfare reclplenLs,
was beneflclal for boLh parLlclpanLs and Lhe governmenL's budgeL.

ln l? 2012, Cll made cerLaln ma[or changes Lo lLs ASl8L-1Anl program pollcles. Cll
lmplemenLed Lhe slxLy-monLh Llme llmlL on cash asslsLance and also modlfled lLs sancLlon
pollcles Lo lmpose full famlly sancLlons lf parenLs falled Lo comply wlLhln nlneLy days of Lhe
lnlLlal sancLlon. lmplemenLlng Lhe slxLy-monLh Llme llmlL on cash asslsLance ls conslsLenL wlLh
Lhe federal 1Anl requlremenLs and, ln effecL, reduced Lhe ASl8L-1Anl caseload by
approxlmaLely elghLeen hundred cases as of !une 2012. Slnce LhaL Llme, Lhe program has seen
beLween sevenLy-flve Lo elghLy-flve cases close monLhly due Lo Llme llmlLs. 1he effecL of Lhe full
famlly sancLlon pollcy has also resulLed ln closlng of cases, buL ln a less slgnlflcanL way.

Malne's welfare-Lo-work lnlLlaLlves lnclude recommendaLlons LhaL alLer Lhe appllcaLlon
and accepLance pollcles for ASl8L-1Anl cash asslsLance. CharL 8-1 lllusLraLes Lhe currenL
appllcaLlon process:


32. uavld P. Creenberg, vlcLorla uelLch, and Cayle PamllLon, Welfare-Lo-Work rogram 8eneflLs and
CosLs, A SynLhesls of 8esearch," Mu8C, lebruary 1, 2009.


107
CharL 8-1: Current App||cant rocess for ASIkL-1ANI rogram

lf uPPS adopLs a unlversal engagemenL/upfronL [ob-search model, Lhe appllcaLlon
process would change accordlngly. CharL 8-2 lllusLraLes whaL LhaL new model mlghL look llke:



Cll ASl8L-1Anl
case manager
conducLs
orlenLauon,
evaluaLes [ob
readlness, and refers
Lo servlce provlders
Cll ellglblllLy
Worker
deLermlnes lf
parenL can
paruclpaLe or lf
she qualles for
an exempuon
MoLher reLurns
Lo omce for
mandaLory face-
Lo-face vlslL
Slngle moLher of
Lwo chlldren
applles for
ASl8L Cash
AsslsLance
urops form o
aL uPPS-Cll
8eglonal CenLer
Cll ellglblllLy
worker revlews
and sends leuer
Lo lnform parenL
of omlce
appolnLmenL
arenL ls
scheduled for
orlenLauon
sesslon wlLhln
Len days
ASl8L-1Anl worker
conducLs assessmenL,
counsels on llfe skllls,
connecLs paruclpanL
Lo educauon, Lesung,
or oLher servlces
CrlenLauon
provldes program
lnformauon on
beneLs &
program
requlremenLs
ASl8L-1Anl worker
provldes chlld care,
LransporLauon, eLc.
and documenLs
progress or
deLermlnes good
cause for falllng Lo
paruclpaLe
noues ellglblllLy of
need Lo sancuon lf
approprlaLe or of
oLher program
changes relLed Lo
parenL's slgned plan.
arenL keeps
appolnLmenL
and submlLs
documenLauon
of nanclal
clrcumsLances
Lo deLermlne
ellglblllLy
Cll ellglblllLy
worker
deLermlnes
ellglblllLy, slgns
plan wlLh parenL,
seLs up chlld care
& LransporLauon,
lf needed


108
CharL 8-2: New App||cat|on rocess for ASIkL-1ANI rogram


noLe: lor appllcanLs who, afLer formal assessmenL and evaluaLlon, are found Lo have lndlcaLlons of
learnlng dlsablllLles, a speclal servlce provlder ls needed who has Lhe experLlse Lo know how sLrong Lhe
poLenLlal ls for placlng lndlvlduals wlLh Lu, and Lo focus on llnklng Lhls [ob seeker Lo a [ob where baslc
accommodaLlons wlll help Lhem Lo perform well (l.e., audlble sLeLhoscopes for CnAs and speclal
sofLware and/or monlLors for deskLop compuLers). 1he ma[orlLy of Lu lndlvlduals have a sLrong deslre Lo
work as opposed Lo pursulng educaLlon, whlch, for Lhem, has ofLen been a negaLlve experlence.
ldenLlfylng Lhelr many sLrengLhs can lead Lo placemenLs wlLh employers who are wllllng Lo glve Lhem a
chance Lo demonsLraLe Lhelr poLenLlal as hlghly creaLlve, hard-worklng, and dedlcaLed employees.


Cash Ass|stance
App||cant
S|ng|e parent of two
ch||dren br|ngs |n
app||canon for ASIkL-
1ANI
LllglblllLy worker provldes
same-day serv|ce, |f
poss|b|e.
AppllcanL ls prescreened for
lncome ellglblllLy and ls Lold
Lo provlde essenual
documenLauon, and
-ls provlded wlLh
lnformauon on upfronL [ob-
search requlremenLs and
aer slgnlng a baslc plan,
-ls approved for shorL-Lerm
chlld care and
LransporLauon supporLs, lf
needed,
-ls glven lnformauon on
MuCL Career CenLers for
addluonal [ob-supporL
asslsLance,
-ls referred Lo uSL8 for help
wlLh chlld-supporL servlces
ALlCAn1 uCLS
nC1 llnu A !C8
arenL responds Lo an
appolnLmenL leuer,
Auends appolnLmenL
wlLh ASIkL e||g|b|||ty
worker:
8rlngs ln her [ob-search
acuvlLy sheeL.
LllglblllLy worker
revlews for compllance
and approves for
ASl8L-1Anl (does noL
exempL from planned
acuvlues).
AkCVLD ICk
1ANI and
referred to:
ASIkL Case Worker
lor assessmenL and/or
evaluauon, acuvlLy-plan
developmenL, and referral
Lo:
1-!ob-preparauon programs
2-MuCL Career CenLer for
SLrucLured !ob Search
Subsldlzed [ob
Work experlence
and/or [ob placemenL wlLh a
conLracLed servlce provlder.
Cn-golng monlLorlng of
progress and reporung
becomes shared eorL
beLween Lhe ASl8L case
worker, Lhe servlce provlder,
and lmporLanLly, Lhe ASl8L-
1Anl paruclpanLG
ALlCAn1 uCLS
llnu A !C8
AppllcanL noues
ellglblllLy LhaL she has
found a [ob and only
needs work supporLs
NC1 CN 1ANI
lamlly ls found ellglble
for SnA, Medlcald, and
chlld care for low-
lncome worklng
parenLs.


109
Lxpand|ng keforms of the ASIkL-1ANI rogram

1he followlng are reforms Lo Lhe currenL ASl8L-1Anl program LhaL are almed Lo
lncrease program parLlclpaLlon, meeL work parLlclpaLlon raLes, and lmprove ouLcomes for all
famllles LhaL rely on Lhe sysLem.

Un|versa| Lngagement. WlLh unlversal engagemenL, Lhe prlnclple of exempLlon from
parLlclpaLlon goes away and ls replaced wlLh Lhe expecLaLlon LhaL all reclplenLs can and musL
parLlclpaLe Lo Lhelr maxlmum level of ablllLy. Lvery reclplenL should have a slgned plan whlch
dellneaLes acLlon sLeps wlLh Llme llnes, and every plan needs Lo be Lracked by Lhe agency Lo
assure LhaL parLlclpanL ls carrylng ouL Lhelr requlremenLs. Lxperlence has shown LhaL engaglng
all reclplenLs ln planned acLlvlLles lncreases work parLlclpaLlon raLes. Lven parenLs who face
barrlers Lo lmmedlaLe employmenL can begln wlLh speclflc sLeps Lo barrler resoluLlon, whlch
over Llme prepares reclplenLs Lo Lake parL ln counLable work acLlvlLles ln Lhe fuLure, and aL Lhe
level of parLlclpaLlon LhaL wlll evenLually counL Loward Lhe sLaLe's work parLlclpaLlon raLe.

Iob Search as a Cond|t|on of L||g|b|||ty. 8equlrlng acLlvlLles of appllcanLs such as
aLLendlng orlenLaLlon, slgnlng a plan, and carrylng ouL [ob-search acLlvlLles ls a common
pracLlce ln many sLaLes, parLlcularly because lL advances lmporLanL purposes. lL noL only
relnforces Lhe lmperaLlve of mandaLory work parLlclpaLlon requlremenLs buL also ensures LhaL
when reclplenLs enLer Lhe rolls, Lhey know ln advance whaL ls expecLed and how Lo comply wlLh
Lhelr employmenL plan, Lhey also enLer Lhe rolls already engaged ln a counLable acLlvlLy.
Moreover, a number of appllcanLs who have been gulded lnLo [ob search before comlng onLo
Lhe program acLually flnd employmenL, Lhey no longer need cash asslsLance or may be found
ellglble for a smaller granL based on Lhe earnlngs-dlsregard formula. ln Lhese cases, deLermlnlng
lf oLher work supporLs are avallable ls an essenLlal parL of ensurlng LhaL Lhe famlly recelves Lhe
level of work supporLs lL ls enLlLled Lo by Lhe agency.

Subs|d|zed Iobs rogram. Lven ln a less Lhan robusL economy, an evldence-based
sLraLegy for movlng dlsadvanLaged populaLlons lnLo Lhe [ob markeL lncludes a well-deslgned
and flexlble subsldlzed [obs program. Whlle unsubsldlzed full-Llme work should remaln Lhe Lop
prlorlLy, subsldlzed employmenL can be used as a supplemenL Lo [ump sLarL a reclplenL's work
experlence and relnforce a work eLhlc. uurlng 2009 and 2010, when Lhe economy dlpped lnLo a
recesslon, no less Lhan LhlrLy sLaLes creaLed subsldlzed [obs programs, whlch ln a relaLlvely
shorL Lerm proved Lo be cosL effecLlve. 1hey also produced lmpresslve resulLs for placlng large
groups of unemployed lndlvlduals lnLo work raLher qulckly.

Accordlng Lo Lhe CenLer for 8udgeL ollcles and rlorlLles, Lhe followlng advanLages
were demonsLraLed by lmplemenLlng slmpllfled and flexlble subsldlzed [obs programs:
33


33. Lauonna aveLLl, Llz SchoLL, and LllzabeLh Lower-8asch, CreaLlng Subsldlzed LmploymenL
CpporLunlLles for Low-lncome arenLs: 1he Legacy of Lhe 1Anl Lmergency lund," CenLer on
8udgeL and ollcy rlorlLles, lebruary 16, 2011.


110
- lL ls posslble (Lhough challenglng) Lo geL large-scale [ob-creaLlon programs up and
runnlng relaLlvely qulckly and Lo engage Lhe prlvaLe secLor ln creaLlng [ob opporLunlLles.
- Subsldlzed [obs LargeLed Lo dlsadvanLaged lndlvlduals (low-lncome adulLs, ex-offenders,
and youLh) beneflL noL only parLlclpaLlng workers and buslnesses buL also enLlre
communlLles by puLLlng money lnLo Lhe hands of lndlvlduals mosL llkely Lo spend lL.
- Subsldlzed [obs programs can be lmplemenLed aL reasonable cosLs.
- llexlblllLy makes success posslble ln many dlfferenL envlronmenLs.
- new LargeLed fundlng can provlde Lhe caLalysL for lnnovaLlon and lncreased
collaboraLlon.
- rovlde dlrecL and Llmely supporL Lo help buslnesses, nonproflLs, and local governmenLs
weaLher Lhe recesslon.
- rovlde opporLunlLles for low- lncome parenLs and youLh Lo malnLaln a connecLlon Lo
Lhe labor force and bulld new skllls.
- CreaLe new parLnershlps beLween 1Anl agencles, workforce agencles, buslnesses,
foundaLlons, advocaLes, and local nonproflL servlce provlders.
- Pelp sLaLes susLaln work-focused 1Anl programs.


Lessons Learned from Cther States

MosL recenLly (from 2009 Lo presenL), subsldlzed [obs programs have largely been
assoclaLed wlLh Lwo groups: welfare reclplenLs and ex-offenders. As a parL of efforLs Lo shlfL Lhe
focus of Lhelr publlc-asslsLance programs Lo work, some sLaLe and counLy welfare agencles have
used Lhelr regular 1Anl funds Lo creaLe subsldlzed employmenL programs for lndlvlduals who
have noL been successful aL flndlng unsubsldlzed employmenL, oLhers have creaLed work-sLudy
programs Lo help sLudenLs enrolled ln posL-secondary lnsLlLuLlons meeL work requlremenLs
whlle pursulng Lhelr educaLlon. 1he federal governmenL has also provlded fundlng Lo help
sLaLes launch lnlLlaLlves for ex- offenders Lhrough Lhe Serlous and vlolenL Cffender 8eenLry
lnlLlaLlve, Lhe rlsoner 8eenLry lnlLlaLlve, and, mosL recenLly, Lhe Second Chance AcL of 2008.

1he ma[orlLy of sLaLes LhaL operaLed programs dld so as a parL of a broader, mulLl-
pronged sLraLegy Lo serve needy famllles durlng Lhe recesslon. 1he mosL common sLraLegles
used Lo help creaLe [ob opporLunlLles ln dlfflculL economlc envlronmenLs lncluded:

Creat|ng new temporary [obs |n the pr|vate and pub||c sectors. 1he largesL subsldlzed
employmenL programs worked wlLh prlvaLe-secLor buslnesses and governmenL agencles Lo
creaLe new Lemporary [obs LhaL oLherwlse would noL have exlsLed. 1hese [obs usually were
LargeLed Lo [ob-ready lndlvlduals who were someLlmes ellglble for chlld care asslsLance buL dld
noL recelve any oLher speclal supporL. Lmployers were noL requlred Lo hlre lndlvlduals aL Lhe
end of Lhe subsldy perlod buL were encouraged Lo conslder Lhelr subsldlzed employees for any
permanenL poslLlons LhaL became avallable durlng Lhelr Lenure.

ln Lhe Lwo largesL programs of Lhls Lype, operaLed ln llllnols and Los Angeles, all


111
lndlvlduals were pald Lhe same wage: $10 per hour for up Lo forLy hours per week. ln boLh
programs, Lhe ma[orlLy of [obs creaLed were ln Lhe prlvaLe secLor. lndlvlduals were on Lhe
payroll of an lnLermedlary, a nonproflL organlzaLlon, or a Workforce lnvesLmenL 8oard. ln oLher
smaller programs, employers puL workers dlrecLly on Lhelr payrolls and were Lhen relmbursed
for some or all of Lhelr wage-relaLed cosLs.

G|v|ng bus|nesses |ncent|ves to h|re |nd|v|dua|s w|th the |east favorab|e emp|oyment
prospects and the most to |ose from extended unemp|oyment |s effect|ve. Some programs
use subsldles Lo lnfluence employers' hlrlng declslons. 8ecause Lhe programs were LargeLed Lo
low-lncome famllles and youLh, many of whom have lower levels of educaLlon and more llmlLed
[ob hlsLorles, Lhe subsldles provlded an lncenLlve for buslnesses Lo hlre lndlvlduals Lhey mlghL
noL oLherwlse hlre. lor example, SouLh Carollna LargeLed lLs subsldlzed employmenL program
Lo [ob-ready 1Anl appllcanLs. 8y subsldlzlng parL of lndlvlduals' wages, Lhe sLaLe encouraged
chaln grocery and deparLmenL sLores Lo hlre 1Anl appllcanLs, whlch Lhe sLaLe had been unable
Lo accompllsh ln Lhe pasL.

Creat|ng trans|t|ona| [ob opportun|t|es for |nd|v|dua|s who face persona| and fam||y
cha||enges that ||m|t the|r emp|oyment prospects even when the economy |s stronger. A non-
Lrlvlal porLlon of Lhe 1Anl caseload faces slgnlflcanL challenges LhaL llmlL lLs ablllLy Lo work full
Llme ln regular, unsubsldlzed employmenL. CfLen, Lhese lndlvlduals need lnLenslve personal
supporL and a supporLlve work envlronmenL Lo succeed ln Lhe workplace. lor example,
WashlngLon, Cregon, and San lranclsco used funds Lo expand long-sLandlng programs LhaL
serve lndlvlduals wlLh employmenL barrlers. nonproflL organlzaLlons LhaL are able Lo creaLe [ob
opporLunlLles for lndlvlduals wlLh employmenL barrlers (ofLen wlLh oLher nonproflLs) and
provlde supporL Lo lndlvldual parLlclpanLs LhroughouL Lhe program played an lmporLanL role ln
Lhe lmplemenLaLlon of Lhese programs.

Creat|ng career-|adder |n|t|at|ves that |nc|ude a subs|d|zed [obs component |s a|so
va|uab|e. A few sLaLes creaLe or expand programs LhaL help low-lncome lndlvlduals wlLh llmlLed
skllls comblne work and Lralnlng Lo move lnLo hlgher-paylng [obs. lor example, new ?ork
creaLed Lralnlng and employmenL opporLunlLles for green [obs and healLh careers, whlle
Maryland creaLed a career-advancemenL program LhaL uses wage subsldles Lo encourage
employers Lo hlre low-lncome lndlvlduals as Lralnees ln enLry-level [obs LhaL have hlgher
sLarLlng wages (usually beLween $10 and $12 per hour) and Lhe poLenLlal for career growLh.

1he followlng maLrlx offers Lhree sLrucLures used by oLher sLaLes LhaL have admlnlsLered
subsldlzed [obs programs. 1he maLrlx provldes examples of opLlons and declslon polnLs ln
deslgnlng such a program. 1hey are lnLerchangeable based on sLaLe resources and oLher
conslderaLlons relaLed Lo buslness and Lhe economy.



112
CharL 8-3: Subs|d|zed Iobs rogram
Max|mum
wage e||g|b|e
for
re|mbursement
Amount of
wage to be
subs|d|zed
Coverage of payro||
costs: IICA,
unemp|oyment tax
(U1), and workers
compensat|on (WC)
nours per week
e||g|b|e for
re|mbursement
r|mary serv|ce-
de||very structure
Lmp|oyer of
record
No max|mum
hour|y wage
|eve|
100 x 2 mos.,
80 x 2 mos.,
30 x 2 mos.
Lmployer covers
mosL payroll cosLs,
programs cover WC
up Lo 40 hours 1Anl agency Lmployer or
Lemporary
employmenL
agency
512 per hour 80 Lmployee porLlon of
llCA
no weekly
maxlmum
hours, buL no
more Lhan
1,040 hours per
parLlclpanL
CounLy workforce
agencles
1hlrd-parLy
sLafflng
agency
State m|n|mum
wage: 57.S0 per
hour
100 llCA, u1, and WC 23 Lo 40 hours
per week
CollaboraLlon
parLners (1Anl,
AdulL Ld., MuCL
8ureau of
LmploymenL
Servlce)
Lmployer


8u||d|ng an Lffect|ve Subs|d|zed Iobs rogram

CollaboraLlon beLween Malne uPPS, AdulL LducaLlon, and MuCL ls crlLlcal Lo
currenL and fuLure program developmenL.
SLakeholder lnpuL ls vlLal.
Malne ulvlslon of 1ax 8evenue may be a valuable asseL Lo helplng Lhe sLaLe
sLrucLure lLs program. 1he dlvlslon has a unlque relaLlonshlp wlLh prlvaLe-
secLor employers who are parL of LaxaLlon's daLa sysLem - some
slmpllflcaLlons and efflclencles may be posslble.
ldenLlfy fundlng and LargeL groups Lo be engaged and geographlcal areas LhaL
wlll beneflL mosL by a subsldlzed [ob model.
Whenever purchaslng servlces ls an opLlon, develop [olnL-conLracLlng
meLhods wlLh performance-based paymenLs as Lhe rule raLher Lhan Lhe
excepLlon.
lan ln advance and conslder key declslons for sLrucLurlng Lhe program.
ueLermlne who wlll develop placemenLs.
ueLermlne who wlll maLch poLenLlal parLlclpanLs wlLh subsldlzed [obs.
ueLermlne Lhe paperwork requlremenLs.
ueLermlne how Llme and aLLendance wlll be Lracked, monlLored, and bllled.


113
erformance-8ased Contract|ng

AlLhough Malne uPPS has declded Lo uLlllze sLaLe agencles as collaboraLors Lo lncrease
work parLlclpaLlon, lL may also conslder oLher parLners. 1he conLracLlng-ouL of soclal servlces Lo
nonproflL and falLh-based organlzaLlons has been done slnce Lhe Lurn of Lhe LwenLleLh cenLury.
8uL conLracLlng-ouL welfare (1Anl) servlces, especlally welfare-Lo-work servlces, became an
lmporLanL pracLlce afLer Lhe enacLmenL of 8WC8A ln 1996. A small number of sLaLes, llke
Wlsconsln, whose program was Lhe besL known, conLracLed-ouL boLh case managemenL and
ellglblllLy deLermlnaLlon Lo Lhe prlvaLe secLor. 1he ma[orlLy of sLaLes however, kepL mosL
servlces ln-house and focused on conLracLlng-ouL Lhe [obs search and placemenL Lo prlvaLe
enLlLles. Malne could conslder a hybrld approach and leL sLaLe agencles compeLe agalnsL prlvaLe
agencles - and measure performance beLween Lhem. lf Malne followed Lhls approach,
regulaLlons and sLaLe accounLlng sysLems would noL be able Lo faclllLaLe Lhe wlLhholdlng of
funds Lo a sLaLe agency based on performance llke Lhey can Lo a prlvaLe vendor. noneLheless,
performance meLrlcs and benchmarks could sLlll be developed wlLh sLaLe agencles Lo acLually
see who performs more efflclenLly.

erformance-based conLracLlng mlghL enable Malne Lo expand capaclLy and resLrucLure
lLs servlce-dellvery sysLem qulckly wlLh greaLer flexlblllLy and more efflclency and Lruly move
Loward full engagemenL." lull engagemenL drlves performance for all parLlclpanLs - lncludlng
Lhose wlLh barrlers LhaL llmlL Lhelr ablllLy Lo fully parLlclpaLe ln employmenL programs. WlLh full
engagemenL, Lhose wlLh barrlers are engaged Lhrough alLernaLlve acLlvlLles. ConLracLs could be
dlvlded ln Lwo caLegorles:

LmploymenL servlces for appllcanLs of welfare, lncludlng sklll assessmenL and [ob
placemenL, and
LmploymenL servlces for reclplenLs who are consldered employable" or able Lo work.

1he conLracLors (also referred Lo as vendors) may vary ln slze. ConLracLors/vendors work
wlLh reclplenLs/parLlclpanLs on meeLlng boLh placemenL and [ob-reLenLlon goals. 1he sLaLe
should expecL Lhe conLracLors/vendors Lo balance Lhese ob[ecLlves and achleve hlgh
performance for boLh. 1he conLracLors/vendors mlghL lnclude large naLlonal for-proflL
companles and nonproflL organlzaLlons or local for-proflL and nonproflL agencles and
communlLy colleges. A number of conLracLors mlghL also use communlLy- or falLh-based
organlzaLlons as subconLracLors.

ConLracLs should be performance-based and awarded on a negoLlaLed basls Lo each
conLracLor wlLh Lhe unlL prlce negoLlaLed beLween Lhe conLracLor and Lhe sLaLe. 1hls can vary
among Lhe conLracLors. 1he same conLracLor would be responslble for boLh appllcanLs and
reclplenLs - or for Lhe conLracL caLegorles 1 and 2 below. 1he sLaLe should creaLe mllesLones
and negoLlaLe Lhese paymenLs or Lhe unlL prlce wlLh each conLracLor durlng Lhls process.



114
1he deslgn of Lhe conLracL paymenL mllesLones ls crlLlcal for success. ln an era where
Lhe publlc secLor ls focused more lnLensely Lhan ever on performance, Lhe besL leverage polnLs
for achlevlng hlgh performance are embedded ln Lhe deLalls of how mllesLone paymenLs are
consLrucLed. 1he conLracLs should be crafLed wlLh an eye on lncenLlvlzlng paymenLs and how
mllesLone paymenLs are welghLed - all Loward drlvlng performance for vendors around
effecLlveness and efflclency. 1he paymenLs drlve conLracLed vendors Lo achleve Lhe deslred
ouLcomes, slnce Lhelr revenue ls Lled Lo Lhelr ablllLy Lo achleve speclflc ouLcomes. 1he
conLracLors assume Lhe flnanclal rlsk or reward aLLached Lo Lhelr performance. AlLhough
conLracLors can bulld flnanclal models and budgeLs of Lhelr own, sLaLe admlnlsLraLors should
work closely wlLh Lhem.

Contract Category 1. erformance-paymenL conLracLs can be conLlngenL upon meeLlng
Lhe performance mllesLones Lled Lo a reclplenL's assessmenL, engagemenL, [ob placemenL, and
reLenLlon ln employmenL. unlL prlce per conLracL can be dlsLrlbuLed ln Lhe followlng mllesLones:
AssessmenL: 8,
LngagemenL: 22,
lacemenL: 30,
nlneLy-day reLenLlon: 40
A bonus mllesLone for a case closure due Lo earnlngs aL nlneLleLh day.
34


1hls focus wlll alm aL assesslng lndlvldual needs and lnLeresL, provldlng [ob-readlness
skllls, and aLLempL Lo aLLach appllcanLs Lo [obs as qulckly as posslble befote Lhe appllcaLlon for
welfare ls approved. Cn average, a poLenLlal reclplenL can work wlLh Lhe conLracLed vendor for
four Lo slx weeks. lf Lhe lndlvldual ls placed ln a [ob, Lhe case mlghL be re[ecLed or closed, and
Lhe vendor should be expecLed Lo Lrack and asslsL Lhe lndlvldual Lo reLaln employmenL.

Contract Category 2. 1he average unlL prlce for conLracLs for reclplenLs who are
consldered employable" or able Lo work should have mllesLone paymenLs focused on Lhe
reclplenL's employmenL placemenL and reLenLlons. 1he unlL prlce mlghL be sLrucLured as
follows:
!ob placemenL: 30,
90-day reLenLlon: 40,
180-day reLenLlon: 30
A bonus mllesLone for a [ob wlLh hlgh wage aL 90 days and a case closure due Lo
earnlngs aL 180 days.

34. 1he sLaLe needs Lhe opporLunlLy Lo resLrucLure Lhe amounL pald for each mllesLone afLer renewlng
Lhe efflcacy of Lhe conLracLs. lor example, Lhe sLaLe could lncrease Lhe value pald for nlneLy days
of [ob reLenLlon whlle decreaslng Lhe amounL pald for placemenLs. 8onus paymenLs can also be
offered. 1he sLaLe can use Lhls Lype of lncenLlve Lo encourage full-Llme employmenL over parL-
Llme, Lo focus on [obs LhaL pay above mlnlmum wage, Lo promoLe [ob advancemenL, and Lo
encourage placemenLs for a LargeLed populaLlon. Powever, expecLaLlons need Lo be
communlcaLed aL all Llmes.


113
8eclplenLs LhaL do noL secure a [ob durlng Lhe appllcaLlon phase, and Lhose who are
already recelvlng asslsLance, could be randomly asslgned Lo recelve servlces for a few days a
week as a parL of a full-engagemenL model." uurlng Lhe oLher days of Lhe week, Lhe reclplenLs
could be requlred Lo parLlclpaLe ln a work-experlence program (or subsldlzed [obs program). ln
CaLegory 2 conLracLs, reclplenLs mlghL recelve a more lnLenslve mlx of servlces compared Lo
CaLegory 1. 1hese mlghL lnclude all of Lhe followlng: [ob search, [ob-placemenL asslsLance, and
shorL-Lerm Lralnlng such as compuLer Lralnlng and oLher Lralnlngs (for example, worklng as a
cerLlfled nurslng asslsLanL).

1hose reclplenLs who do noL geL a [ob ln Lhe flrsL slx monLhs could be reasslgned Lo
anoLher vendor. Plgher conLracL paymenLs mlghL be reserved for CaLegory 2 conLracLs because
Lhey wlll be servlng Lhose LhaL need more lnLenslve servlces. Also, Lhe hlgher proporLlon of unlL
prlce would be allocaLed Lo [ob placemenL Lo move reclplenLs lnLo employmenL more
expedlLlously. 1he conLracLs could also lnclude addlLlonal bonus mllesLones for a) [ob
placemenL for sancLloned, 2) [ob placemenL for Llme-llmlLed parLlclpanLs, 3) wage galn aL 180
days, and 4) case closure aL nlneLy days. 1hese Lypes of paymenLs could be a small flxed- dollar
amounL. lf conLracLs glve more welghLs Lo a speclflc mllesLone - LhaL ls whaL a conLracLed
vendor wlll focus on. 1hese mllesLone welghLs mlghL vary, dependlng on Lhe phllosophy of
Lhose operaLlng Lhe program. 8uL a focus on full engagemenL, emphaslzlng placemenL and
successful lmplemenLaLlon of employmenL conLracLs would help Malne conLlnue lLs decllne ln
Lhe caseload.

1he use of performance-based conLracLlng can be a valuable Lool ln drlvlng full
employmenL engagemenL lnLo Lhe publlc-welfare sysLem and helplng reclplenLs flnd and reLaln
employmenL. A well deslgned and managed performance-based conLracL can provlde lncenLlves
for conLracLors and Lhe sLaLe Lo ensure LhaL focus ls puL on Lhe reclplenL and hls or her
movemenL up Lhe economlc ladder. Whlle performance-based conLracLlng shlfLs Lhe publlc
secLor lnLo Lhe role of a conLracL manager as opposed Lo a servlce provlder, oLher Lools are
needed Lo asslsL Lhe sLaLe ln lLs quesL Lo move reclplenLs lnLo employmenL, for example, Lhe
need for a Lechnology and managemenL lnfrasLrucLure LhaL works across a whole porLfollo of
conLracLors Lo ensure accuraLe exchange of daLa, flnanclal clalms, and performance lnformaLlon
and a clear seL of performance meLrlcs Lo noL only hold conLracLors accounLable - buL
reclplenLs and sLaLe admlnlsLraLors as well.

As demonsLraLed ln Wlsconsln, new ?ork ClLy, and hlladelphla, performance-based
conLracLlng Lo lncrease employmenL can have poslLlve effecLs on Lhe reclplenLs, sLaLe
lnfrasLrucLure, and program goals. Malne could conslder a hybrld approach whlch uLlllzes lLs
new currenL sysLem and lnlLlaLes ouLslde vendor conLracLs Lo enhance and supplemenL currenL
operaLlons. LlLher way, performance-based conLracLlng mlghL [usL be whaL Malne needs Lo
conLlnue lLs momenLum Lo decrease caseloads, lmprove accounLablllLy across Lhe enLerprlse,
and lncrease economlc opporLunlLy.




116
Needs of 1ANI kec|p|ents w|th D|sab|||t|es

lor some 1Anl reclplenLs, Lhe paLhway Lo work ls encumbered wlLh undlagnosed and
unLreaLed dlsablllLles LhaL lnLerfere wlLh sLeady program parLlclpaLlon and work. MenLal healLh
condlLlons, learnlng dlsablllLles, and physlcal healLh problems are among Lhe mosL prevalenL
dlsablllLles documenLed, accounLlng for a subsLanLlal porLlon of Lhe 1Anl caseload. Whlle Lhe
ma[orlLy of Lhese reclplenLs evenLually may be able Lo flnd and susLaln employmenL, Lhey may
need speclallzed asslsLance and Lake more Llme Lo do so, as a 2008 MaLhemaLlc ollcy 8esearch
reporL explalns.
33


1hls reporL sLrongly urges unlversal engagemenL, meanlng LhaL all reclplenLs are
expecLed Lo parLlclpaLe ln acLlvlLles LhaL wlll prepare Lhem for work, for Lhe followlng reasons:
1) wlLh Llme llmlLs on cash asslsLance, reclplenLs cannoL expecL Lo rely on 1Anl ln Lhe long run,
2) pald employmenL ls Lhe suresL paLh Lo achlevlng self-sufflclency for all, lncludlng reclplenLs
llvlng wlLh a dlsablllLy, 3) Lhe 1Anl sysLem has an employmenL lnfrasLrucLure ln place LhaL can
be expanded and adapLed Lo meeL Lhe needs of reclplenLs who need more lnLenslve servlces
and employmenL accommodaLlons, and 4) 1Anl agencles, llke all publlc agencles, are requlred
by Lhe Amerlcans wlLh ulsablllLles AcL Lo provlde opporLunlLles for reclplenLs llvlng wlLh a
dlsablllLy Lo beneflL from all Lhe programs, servlces, and acLlvlLles Lhey offer.

1he key Lo properly ldenLlfylng lssues of learnlng dlsablllLles resLs ln Lhe use of
speclallzed assessmenL Lools, lncludlng ulsablllLy Screenlng 1ools, sychosoclal AssessmenLs,
Cllnlcal and sychologlcal AssessmenLs, luncLlonal needs AssessmenLs, and vocaLlonal
AssessmenLs.

numerous sLudles have been conducLed LhaL have aLLempLed Lo quanLlfy Lhe porLlon of
1Anl reclplenLs wlLh Lu, and whlle Lhe flndlngs are noL conslsLenL across Lhese sLudles, Lhey all
suggesL LhaL a subsLanLlal porLlon of Lhe 1Anl caseload ls llvlng wlLh a dlsablllLy.

Malne recenLly bullL lnLo Lhe 1Anl assessmenL process a comprehenslve vocaLlonal
assessmenL Lhrough a local medlcal provlder Lo ldenLlfy Lu and oLher condlLlons LhaL may llmlL
parLlclpanL engagemenL wlLh employmenL. 8ecognlzlng Lhe lssues ls Lhe flrsL sLep and
accommodaLlng parLlcular needs Lhrough speclallzed servlce provlders can asslsL Lhls
populaLlon Lo succeed ln a [ob.


Integrat|ng Ind|v|dua|s w|th D|sab|||t|es |nto r|vate-Sector Workforce

When he slgned Lhe Amerlcans wlLh ulsablllLles AcL ln 1990, resldenL Ceorge P. W.
8ush promlsed Lhe leglslaLlon would malnsLream" Amerlcans wlLh dlsablllLles, allowlng Lhem

33. See !acquellne kauff, AsslsLlng 1Anl 8eclplenLs Llvlng wlLh ulsablllLles Lo CbLaln and MalnLaln
LmploymenL," MaLhemaLlca ollcy 8esearch, lebruary 2008.


117
Lo achleve employmenL and llve as lndependenLly as posslble. ?eL, Lhe real-world effecLs of LhaL
landmark leglslaLlon have acLually worked Lo keep many of Lhese Amerlcans ouL of Lhe
workforce. WlLh cosLly lncenLlves embedded lnLo Lhe Medlcald-dellvery sysLem, Lhe law has noL
rewarded clLlzens who seek lndependence from Lhe publlc-welfare sysLem.

1he good news ls LhaL sLaLes, locallLles, and a coallLlon of buslnesses are spearheadlng a
more promlslng alLernaLlve: prlvaLe-secLor employmenL. When dlsabled workers are connecLed
wlLh prlvaLe companles, employers acqulre Lhe hardworklng, skllled employees Lhey need whlle
people wlLh dlsablllLles achleve Lhe flnanclal lndependence Lhey need. AddlLlonally, Lhese
soluLlons reduce Lhe demands placed upon Lhe overburdened welfare sysLem whlle lncreaslng
Lhe number of dlsabled Amerlcans earnlng a paycheck.

Many employers sLlll exclude persons wlLh dlsablllLles - lnLellecLual and physlcal -
from Lhe workplace because of perslsLenL buL unfounded myLhs, fears, and sLereoLypes. Some
employers belleve LhaL workers wlLh dlsablllLles wlll have a hlgher absenLee raLe Lhan
employees wlLhouL dlsablllLles. SLudles show LhaL Lhls ls noL Lrue, workers wlLh lnLellecLual and
physlcal dlsablllLles are absenL no more Lhan oLher workers. AnoLher popular mlspercepLlon ls
LhaL employlng people wlLh dlsablllLles wlll cause lnsurance cosLs Lo skyrockeL. SLudles show,
however, LhaL employlng workers wlLh dlsablllLles wlll noL lead Lo hlgher lnsurance raLes or
more workers' compensaLlon clalms.
36
ln facL, sLudles show LhaL Lhose wlLh dlsablllLles have
hlgh producLlvlLy and ouLpuL, someLlmes even beLLer Lhan Lhelr non-dlsabled counLerparLs.

A growlng number of employers, however, have esLabllshed lnlLlaLlves Lo lncrease Lhe
parLlclpaLlon of employees wlLh dlsablllLles wlLhln Lhelr companles as a componenL of Lhelr
workforce plannlng and dlverslLy sLraLegles. 1hese employers Lyplcally esLabllsh parLnershlps
wlLh sLaLe agencles or workforce and dlsablllLy-servlce organlzaLlons Lo source for LalenL.
CoordlnaLed by a slngle agency (or small number of agencles), employers are provlded
asslsLance and supporL servlces for recrulLmenL, Lralnlng, and [ob reLenLlon of employees wlLh
dlsablllLles. Malne has already begun Lhls efforL - alLhough much more needs Lo be
accompllshed ln order Lo Lruly lnLegraLe Lhose wlLh dlsablllLles lnLo Lhe workforce.

1he success of Lhls soluLlon ls obvlous aL Lowe's reglonal dlsLrlbuLlon cenLer ln Luzerne
CounLy, ennsylvanla. Lowe's, wlLh Lhe help of Lhe Arc of Luzerne CounLy, lmplemenLed a
model, orlglnally formulaLed by Walgreens, for offerlng a new employmenL Lrack, compleLe
wlLh speclal Lralnlng for clLlzens wlLh physlcal and lnLellecLual dlsablllLles. 1he naLlonal
1echnlcal AsslsLance and 8esearch CenLer has acknowledged Lhe Walgreens-Lowe's model as
one of Lhe mosL effecLlve ln Lhe naLlon. 8ecause Lhls buslness-cenLered sLraLegy generaLes
beLLer economlc ouLcomes, oLher ma[or employers around Lhe naLlon are sLepplng up Lo
repllcaLe slmllar programs. As of 2012, Walgreens had more Lhan a Lhousand lndlvlduals
worklng aL lLs sevenLeen dlsLrlbuLlon cenLers ln Lhe unlLed SLaLes.

36. eLer uavld 8lanck, 1be Ametlcoos wltb ulsobllltles Act ooJ tbe metqloq wotkfotce. mploymeot
of leople wltb Meotol ketotJotloo (Amerlcan AssoclaLlon on MenLal 8eLardaLlon, 1998), p. 17.


118
lollowlng Lhe Walgreens-Lowe's model, rocLor & Camble has creaLed opporLunlLles for
people wlLh dlsablllLles Lhrough lLs ulverslLy of AblllLles" lnlLlaLlve aL lLs new packaglng faclllLy
ln Auburn, Malne. ln parLnershlp wlLh Lhe sLaLe's 8ehablllLaLlon Servlces and uPPS, Lhls faclllLy
ls offerlng employmenL opporLunlLles for people wlLh physlcal and/or lnLellecLual dlsablllLles.
37


Malne ls llkewlse sLepplng up Lo Lhe plaLe Lo reach ouL Lo Lhls vlLal populaLlon. ln 2010,
Lhe sLaLe was awarded a $1.3 mllllon federal granL under Lhe lederal ulsablllLy LmploymenL
lnlLlaLlve. 1haL granL was used Lo lncrease access Lo employmenL opporLunlLles for adulLs wlLh
dlsablllLles Lhrough Malne's workforce developmenL sysLem, lncludlng Lhe expanslon of Lhe
Soclal SecurlLy 1lckeL Lo Work program Lhrough Malne's Career CenLer neLwork.

1haL focus, however, as lLs challenges. Accordlng Lo Lhe naLlonal Councll on ulsablllLy:

Many people wlLh dlsablllLles recelve publlc dlsablllLy lncome ln Lhe form of Soclal
SecurlLy ulsablllLy lnsurance (SSul) or SupplemenLal SecurlLy lncome (SSl). Such lncome
ls Lyplcally accompanled by healLh care Lhrough Medlcare or Medlcald. eople wlLh
dlsablllLles are ofLen relucLanL Lo become employed for fear of [eopardlzlng Lhese
beneflLs, and research clearly shows LhaL Lhese beneflLs affecL boLh labor markeL exlLs
and reLurn Lo work.
38


lurLher, many lndlvlduals wlLh dlsablllLles are encouraged noL Lo work full Llme by
governmenL agencles for fear of loslng beneflLs. Moreover, some dlsablllLles requlre exLra Llme
for self-care, Lherapy, and medlcal appolnLmenLs, and LransporLaLlon problems can lnLroduce
an added level of uncerLalnLy ln dally schedules. lor Lhese reasons, some people wlLh
dlsablllLles are noL able Lo accepL LradlLlonal full-Llme [obs, and Lhose who wanL Lo be employed
may be drawn Lo parL-Llme and flexlble work arrangemenLs. Powever, many adulLs wlLh
dlsablllLles can and do overcome Lhese obsLacles. ln facL, Lhey sLrongly prefer prlvaLe-secLor pay
and beneflLs Lo publlc-welfare dependency.

Steps to Ach|ev|ng a 8a|anced Integrat|on: 1he Lmp|oyment I|rst Ma|ne Act of 2013

LnacLed on !une 16, 2013, Lhls law creaLes cusLomlzed employmenL and lnLegraLed
communlLy-based employmenL opporLunlLles ln Lhe general workforce for lndlvlduals wlLh
dlsablllLles. 1he law requlres uPPS and Lhe ueparLmenLs of Labor and LducaLlon - across all
programs - Lo offer, as Lhe flrsL and preferred, employmenL as a servlce. 1he law also charges
Lhe LmploymenL llrsL Malne coallLlon wlLh proposlng and promoLlng such employmenL

37. Shaun Peasley, lncluslve LmploymenL Model Calnlng SLeam," ulsablllLy Scoop," AugusL 4, 2011,
hLLp://www.dlsablllLyscoop.com/2011/08/04/lncluslve-employmenL/13678/.
38. LmpowermenL for Amerlcans wlLh ulsablllLles: 8reaklng 8arrlers Lo Careers and lull
LmploymenL," 8eporL Lo Lhe resldenL Ceorge W. 8ush, naLlonal Councll on ulsablllLy, CcLober
2007.


119
opporLunlLles. 1he followlng sLeps are recommended Lo help Lhe sLaLe achleve Lhe splrlL of Lhe
law and more fully allgn lLs efforLs wlLh Lhe needs of Lhls vlLal populaLlon:

1. 1he sLaLe should adopL Lhe moLLo LhaL lndlvlduals wlLh dlsablllLles wanL Lo work full Llme
and llve lndependenLly.

2. An annual mulLl-day sLaLewlde dlsablllLy employmenL summlL Lo brlng LogeLher
governmenL agencles, pollcymakers, famllles, sLakeholders, and buslnesses Lo dlscuss
how Lo lmprove Lhe dlsablllLy-work cllmaLe and opporLunlLles. 1hls conference would
dlscuss Lhe challenges, opporLunlLles, models or case sLudles of programs of excellence,
advancemenLs ln adapLlve Lechnology, supporLs, and suggesLlons for sysLem
lmprovemenLs. 1hls should be spearheaded by uPPS and MuCL wlLh Lhe asslsLance of
advocacy organlzaLlons llke Lhe Arc.

3. 1he sLaLe should deslgnaLe a small sLaff Lo work excluslvely across sLaLe agencles Lo
breakdown sllos and LerrlLorlal ownershlp so LhaL lL focuses on Lhe people served, noL
Lhe bureaucracy. 1he sLaLe should convene quarLerly meeLlngs of sLaLe and federal
deparLmenL senlor admlnlsLraLors (lncludlng Lhe Covernor's CommlLLee on LmploymenL
of eople wlLh ulsablllLles) LhaL have a role ln Lhls efforL Lo creaLe greaLer coheslon
among leaders and more LargeLed efforLs Lo help Lhe dlsabled achleve Lhelr goals.

4. 1he sLaLe should serve as an lnLermedlary and servlce broker beLween local servlce
provlders, consumers, and buslnesses, Lhereby helplng companles effecLlvely recrulL,
hlre, reLaln, and supporL workers wlLh dlsablllLles. WlLh dual experLlse ln human-caplLal
managemenL, human-resource experLlse, recrulLlng, pollcy and program experLlse, and
vocaLlonal rehablllLaLlon (e.g., [ob coachlng and employmenL neLworks), Lhe sLaLe ls
naLurally sulLed Lo serve as Lhls neuLral convener.

3. Acknowledge LhaL each employmenL opporLunlLy may operaLe dlfferenLly based on Lhe
[ob seeker's needs and ablllLles as well as Lhe needs of Lhe employer. 1he sLaLe's
cenLrallzed unlL (as Lhe lead) would ldenLlfy local servlce provlders LhaL can work wlLh
consumers and buslness Lo ensure LhaL orlenLaLlon and Lralnlng -Lo Lhe flrsL day of
work and beyond - are accompllshed smooLhly. ln oLher words, one slze does noL flL
all. SLraLegles Lo usher lndlvlduals wlLh dlsablllLles lnLo employmenL are as dlverslfled as
Lhe employers seeklng Lhe labor pool. Moreover, performance should be measured, and
each case deLalled, so LhaL Lhe publlc and prlvaLe secLors can learn how Lo conLlnuously
lmprove.

6. Malne malnLalns a llexlble LmploymenL lund, whlch provldes one-Llme, shorL-Lerm
flnanclal asslsLance Lo people wlLh dlsablllLles who are experlenclng barrlers Lo
malnLalnlng or obLalnlng compeLlLlve employmenL. 1he fund ls operaLed by Lhe
ulsablllLy LmploymenL lnlLlaLlve pro[ecL Lhrough Malne Local Workforce lnvesLmenL
8oards 8eglons 1 and 2. llnanclal supporL from Lhe fund, however, ls only avallable Lo
lndlvlduals ln a llmlLed number of counLles. 8y sLreamllnlng programs for abled-bodled


120
lndlvlduals, Lhe sLaLe mlghL be able Lo lncrease Lhe slze of Lhe fund Lo help addlLlonal
lndlvlduals achleve Lhelr dream of economlc lndependence.

7. CovernmenL flnances should be used Lo Lraln lndlvlduals and orlenL Lhem Lo work ln Lhls
new employmenL opporLunlLy. Cnce Lhe lndlvldual ls Lralned and lnLegraLed lnLo Lhe
workforce, Lhe prlvaLe employer should assume Lhe responslblllLy for beneflLs.

8. 1he goal of Lhe sLaLe should be Lo creaLe a person-cenLered sysLem LhaL has as lLs goal
Lhe full lnLegraLlon of parLlclpanLs ln Lhe llfe of Lhe buslness. 1hls means LhaL Lhe new
employee mlghL be LoLally lndependenL of governmenL asslsLance and fully lnLegraLed
lnLo hls/her employmenL.

As !ohn 8. vaughn, chalrman of Lhe naLlonal Councll on ulsablllLy, wroLe Lo resldenL
Ceorge W. 8ush on CcLober 1, 2007:

1here ls a dlrecL beneflL Lo expandlng employmenL opporLunlLles for people wlLh
dlsablllLles. lor employers who are pro[ecLed Lo face labor shorLages as Lhe baby-boom
generaLlon reLlres, non-employed people wlLh dlsablllLles represenL a valuable Lool of
human resources Lo help flll Lhose needs. lor people wlLh dlsablllLles, employmenL has
noL [usL economlc value, buL lmporLanL soclal and psychologlcal value as well. lor
governmenL, lncreased employmenL of people wlLh dlsablllLles helps lncrease Lax
recelpLs and decrease soclal expendlLures. llnally, as recognlzed ln Lhe passage of Lhe
Amerlcans wlLh ulsablllLles AcL, Lhere are socleLal beneflLs from greaLer lncluslveness ln
malnsLream socleLy as Lhe barrlers faclng people wlLh dlsablllLles are dlsmanLled.
39


A 1990 uuonL sLudy of 811 employees wlLh dlsablllLles found LhaL 90 of Lhese
workers raLed an average or beLLer ln [ob performance, relaLlve Lo 93 or employees wlLhouL
dlsablllLles. A 2007 ueaul unlverslLy Lconomlc lmpacL SLudy of LwenLy-flve buslnesses from
Lhe healLh-care, reLall, and hosplLallLy secLors - and 314 employees - concluded LhaL workers
wlLh dlsablllLles had fewer scheduled absences Lhan employees wlLhouL dlsablllLles and nearly
ldenLlcal [ob performance raLlngs. lurLher, workers wlLh dlsablllLles Lend Lo remaln wlLh Lhelr
employer for longer Lenures, reduclng Lurnover.
40


ollcy soluLlons LhaL focus on movlng dlsabled reclplenLs lnLo Lhe workforce make good
economlc sense. MosL lmporLanLly, Lhey remaln Lhe cholce for all Amerlcans (and Malners) wlLh
dlsablllLles and Lhelr famllles, raLher Lhan Lhe anLlquaLed, Lop-down dlsablllLy pollcles offered by
Lhe federal governmenL. 8y offerlng progress on Lhe paLh Lo lndependence - free from labels
- Lhey can dellver whaL all clLlzens wanL: a chance Lo achleve Lhe Amerlcan dream.

39. !ohn 8. vaughn Lo Ceorge W. 8ush, CcLober 1, 2007,
hLLp://www.ncd.gov/publlcaLlons/2007/CcL2007.
40. 2007 ueaul unlverslLy Lconomlc lmpacL SLudy.


121
Ach|ev|ng 1ANI Work art|c|pat|on kates

Achlevlng Lhe federally mandaLed work parLlclpaLlon raLes ln 1Anl, perhaps Lhe mosL
pracLlcal measure of success, remalns challenglng for mosL sLaLes. lndeed, falllng Lo achleve
Lhese raLes lmposes severe rlsks of flscal penalLles, a consequence LhaL drlves almosL all 1Anl
program deslgns and sLraLegles LhroughouL Lhe counLry. 1he ldeas offered hereln for Malne are
no dlfferenL, buL Lhey Lake lnLo conslderaLlon Lhe lnLeresLs of all parLles, mosL of all Lhe low-
lncome famllles who need help Lo become self-sufflclenL.

1o lmprove Lhe sLaLe's success, uPPS has sollclLed help Lo resLrucLure, reflne, and
revamp servlces and pollcles. ueveloplng parLners Lo achleve Lhe deslred ouLcomes ls no small
facLor buL by sharlng responslblllLles, Lhe deparLmenL can overcome Lhe challenges. Moreover,
acknowledglng Lhe role of all sLakeholders ls one of Lhe mosL valuable sLraLegles of all.

CharL 8-4: 1ANI Work art|c|pat|on Stakeho|ders

3,:. 6DKO8
9>KE@F@G>E@DH
2>EBC
7.0 ,59024
4-0P0Q0-031
,:R L,54
672S425
/R7-
4/9-71/4:3
542T0L4
594L0,-0535
,--
L7:32,L34R
U7Q
9249,2,307:
,:R 9-,L4/4:3
542T0L4
927T0R425
,5902483,:.
927P2,/
9,230L09,:35


122
Measurlng success ls anoLher Lool LhaL has emerged from Lhe research presenLed ln Lhls
reporL. A faulL of 1Anl ls lL focuses on parLlclpaLlon and lgnores famlly ouLcomes. uPPS and lLs
collaboraLlve parLners can and should expecL much more ln Lerms of ouLcomes. CharL 8-3
ldenLlfles baslc measures LhaL are llkely Lo provlde Lhe lnformaLlon needed Lo evaluaLe program
cosLs and effecLlveness as well as Lhe well-belng of Lhe 1Anl caseload.

CharL 8-3: 1ANI Goa|s and Measures Lach rogram ear
erformance Goa|s erformance Measures
lncrease number of parLlclpanLs who meeL
work parLlclpaLlon raLes
8aLe aL whlch parLlclpanLs are acLlvely
engaged ln approved work acLlvlLles for
requlred number of hours per week
lncrease Lhe number of parLlclpanLs who
overcome educaLlonal and sklll barrlers Lo
become employable
8aLe aL whlch parLlclpanLs compleLe
educaLlon/Lralnlng programs ln Lhelr
approved employmenL plans
lncrease number of parLlclpanLs who secure
full-Llme, hlgh-wage [obs
Wage 8aLes and Weekly Work Pours of Lhose
who were approved for posL secondary
educaLlon or [ob placemenL servlce provlders
lncrease number of parLlclpanLs who galn
employmenL
!ob lacemenL raLe for all parLlclpanLs boLh
Lhose who were asslgned Lo provlders of
employmenL relaLed servlces and Lhose who
flnd and enLer employmenL Lhrough
lndlvldual [ob search acLlvlLles
lncrease number of parLlclpanLs who close
due Lo employmenL
8aLe of hourly wages above ellglblllLy
maxlmum for famlly slze
Measure number of famllles who close Lo
cash asslsLance wlLh 1ranslLlonal Chlld Care
and healLh care
8aLe of parLlclpanLs who are helped wlLh
work supporLs and Lhe lengLh of Llme Lhe
work supporLs are needed


A [ob ls crlLlcal, buL oLher lnlLlaLlves may be needed Lo help escape poverLy. 1he
followlng concepLs are offered by 8oberL l. Lerman of Lhe urban lnsLlLuLe ln hls paper enLlLled,
1he 1wo Worlds of ersonal llnance: lmpllcaLlons for romoLlng Lhe Lconomlc Well-8elng of
Low- and ModeraLe-lncome lamllles." lncludlng any one or comblnaLlon of Lhese sLraLegles wlll
enhance Lhe flnanclal llLeracy levels of lndlvlduals who aLLend ASl8L-funded programs and wlll
also lmprove Lhe overall success of welfare-Lo-work programs.


123



Coord|nat|on and Co||aborat|on at the Serv|ce-De||very Leve|

llnally, a lesson learned over years of runnlng 1Anl, SnA food sLamps, and oLher
publlc-welfare programs ls faclllLaLlng reclplenL compllance wlLh program requlremenLs.

I|ve Strateg|es to Improve the Lconom|c We||-8e|ng
of Low- and Moderate-Income Work|ng Iam|||es

1. Ind|v|dua| Deve|opment Accounts (IDAs) are models, whlch comblne a flnanclal llLeracy
program wlLh maLched savlngs. 1o low-lncome quallfled lndlvlduals, luAs provlde
lncenLlves Lo open a savlngs accounL, whlch can be maLched by Lhe program Lo Lhe
parLlclpanL's savlngs. Assumlng Lhe purpose of Lhe savlngs ls ln llne wlLh Lhe goals of Lhe
luA program, such as placlng a down paymenL on a home, paylng LulLlon, or sLarLlng a
buslness, Lhese sLraLegles can be llfe changlng. Lxample of luAs: parLlclpanL saves
$1,000 ln her/hls luA accounL, whlch ls Lhen maLched aL a 3:1 raLlo, LhaL parLlclpanL wlll
acLually have $4,000 Lo puL Loward a house, LulLlon, or a new buslness sLarLup. noLe:
1Anl funds may be used for luAs.
2. Lducat|ng |ower-|ncome workers abouL Lhe lmporLance of Soclal SecurlLy lncome. Many
parenLs, who have been Lled Lo welfare over one or Lwo generaLlons, do noL reallze LhaL
Lhelr long-Lerm Lra[ecLory ouL of poverLy ls based on paylng lnLo Soclal SecurlLy whlle
Lhey are young and havlng Lhls baslc supporL bullL up for Lhe Llme Lhey may no longer be
able Lo work and earn.
3. Shar|ng |nformat|on abouL Lhe deLrlmenLal effecLs of hlgh-cosL flnanclal servlce
producLs (credlL cards, hlgh-level educaLlonal loans, auLo loans, Lo name a few). Slgnlng
on Lhe boLLom llne" can lead Lo bankrupLcy down Lhe road and ln a perverse way, can
lock a famlly lnLo Lhe very low-lncome/no-lncome slLuaLlon Lhey hoped Lo have escaped.
4. Structured d|scuss|ons w|th know|edgeab|e experts can he|p gu|de non-custod|a|
parents through ch||d-support |ssues and ob||gat|ons. lor low-lncome men ln
parLlcular, Lhe bulldup of arrearages ln chlld supporL, ofLen aL hlgh-lnLeresL raLes, ls
anoLher lssue LhaL Lends Lo be lgnored when dlscusslng flnanclal maLLers.
S. L|v|ng w|th|n a budget, ln some clrcles referred Lo as behavloral economlcs, ls an
lmporLanL llfe sklll Lo Leach famllles Lo help Lhem galn ground on flnanclal securlLy. 1hls
may noL be clearly undersLood by some low- and moderaLe-lncome households, buL
wlLhouL such skllls, sLablllLy of flnances and securlLy for Lhe fuLure are unllkely.


124
lndeed, aLLenLlon Lo program requlremenLs wlll relnforce Lhe efforLs of welfare reclplenLs noL
only Lo prepare for and flnd a [ob buL also Lo aLLach Lhemselves Lo Lhe labor markeL as opposed
Lo conLlnulng an aLLachmenL Lo Lhe welfare sysLem. ComponenLs of such an approach lnclude:

- 8eferrals Lo Lhe labor sysLem need Lo be done as slmply as posslble,

- 8ecerLlflcaLlons and renewals for SnA, chlld care, MA, and oLher beneflLs should occur
Lhrough lnLegraLed Lechnology and communlcaLlon, requlrlng offlce appolnLmenLs wlLh
Cll should be mlnlmlzed as opposed Lo havlng reclplenLs Lravel back and forLh beLween
Lhe Lwo ma[or program offlces,

- Lxpandlng Lhe role of MuCL employmenL servlces sLaff who work wlLh uPPS
populaLlons Lo allow ease of approval of changes, reporLlng of reclplenL engagemenL,
and Lracklng reclplenL acLlvlLles,

- LsLabllshlng a unlque role of a work parLlclpaLlon speclallsL Lo funcLlon across agency
sLaff. 1hls speclallsL would Lrack and monlLor Lhe work parLlclpaLlon level by offlce and
reporL monLhly on how well Lhe new programs are worklng.


1he Malne uPPS-Cll has already lmplemenLed some pollcy reforms LhaL are helplng Lhe
ASl8L-1Anl program Lo beLLer achleve programmaLlc goals, however a number of addlLlonal
reforms LhaL have greaLer emphasls on unlversal engagemenL and work acLlvlLles for all wlll
enhance Lhe performance measures of Lhe program and wlll lmprove Lhe economlc poLenLlal of
all famllles who parLlclpaLe ln ASl8L-1Anl welfare-Lo-work programs.


123






A81 ll: MAlnL'S WLLlA8L AuMlnlS18A1lvL S?S1LMS

9. L||g|b|||ty and Serv|ce-De||very System


Malne's uPPS-Cll compuLer sysLem has lnLegraLed vlrLually all of Lhe ellglblllLy
processlng for publlc-asslsLance programs Lhrough a slngle AuLomaLed CllenL LllglblllLy SysLem
(ACLS). WlLh Lhe excepLlon of ellglblllLy for long-Lerm-care servlces, whlch ls done Lhrough a
cenLrallzed unlL ln AugusLa, ACLS has enabled Cll admlnlsLraLlon Lo rely on a unlversally Lralned
ellglblllLy sLaff Lo handle all ma[or asslsLance programs offered Lo low-lncome lndlvlduals and
famllles LhroughouL Lhe sLaLe of Malne. 1hese ma[or programs lnclude SnA, ASl8L-1Anl/aS,
AlLernaLlve Ald AsslsLance, uSL8, 1ranslLlonal Chlld Care, 1ranslLlonal 1ransporLaLlon and oLher
supporLlve servlces for famllles who close Lo 1Anl or aS due Lo lncreased earnlngs, Chlld Care
uevelopmenL lund for non-cash worklng famllles, ulsablllLy ueLermlnaLlon Servlces, SSl SLaLe
SupplemenL, Lmergency AsslsLance, MalneCare, Medlcal AsslsLance, Ceneral AsslsLance,
8efugee Cash AsslsLance, and SLaLe lood SupplemenLal 8eneflLs for legal non-clLlzens, and
several smaller programs avallable Lo ellglble famllles. 1he Long-1erm Care rogram has Lhe
only unlque ellglblllLy deLermlnaLlon funcLlon LhaL operaLes separaLely from Lhe Cll ellglblllLy
speclallsLs locaLed ln speclflc fleld offlces.

Access Lo Lhese servlces ls avallable Lhrough slxLeen reglonal offlces locaLed wlLhln Lhe
followlng counLles: Androscoggln, AroosLook, Cumberland, lranklln, Pancock, kennebec, knox,
Llncoln, Cxford, enobscoL, lscaLaquls, Sagadahoc, SomerseL, Waldo, WashlngLon, and ?ork.

ACLS ls deslgned Lo operaLe a fully lnLegraLed ellglblllLy deLermlnaLlon process, one ln
whlch Cll ellglblllLy speclallsLs funcLlon as Lhe gaLeway Lo vlrLually all programs offered aL Lhe
reglonal cenLers. All sLaLes have sysLems Lo handle mulLlple programs, however ofLen Lhe
sLafflng sLrucLure dlvldes up lnLo program-speclflc enLry polnLs, Lhe unlversal ellglblllLy-
speclallsL role has been challenglng for many sLaLes Lo lmplemenL and susLaln. Cne example
relaLes Lo chlld care access, whlch ls ofLen compleLely dls[olned from 1Anl, SnA, and/or
medlcal asslsLance ellglblllLy. Lven lf Lhe sysLem can handle all programs, Lhe process may geL
dlvlded by worker roles, ofLen creaLlng confuslon and breakdown ln communlcaLlon among and
beLween program speclallsLs. CLher sLaLes have noL aLLempLed Lo merge ellglblllLy for SSl and
Ceneral AsslsLance Lhrough one worker/one sysLem. 8ecause Lhe Cll ellglblllLy speclallsL ls Lhe
slngle polnL of enLry onLo all forms of publlc asslsLance, Malne's sysLem ls able Lo coordlnaLe
recerLlflcaLlon daLes for more Lhan one program. 1hls provldes efflclencles for famllles and for
Lhe sysLem, avoldlng unnecessary lnLerrupLlons of beneflLs and servlces because Lhere ls a


126
conslsLency of lnformaLlon gaLhered and recorded wlLhln Lhe reclplenLs' elecLronlc records by
one worker as opposed Lo several workers.

Some sLudles of publlc-asslsLance programs are recommendlng coordlnaLlon of
recerLlflcaLlon daLes for chlld care and MA, or chlld care and SnA as lnnovaLlve for
beneflclarles and bureaucracles allke." Malne deserves credlL for bulldlng a sysLem and a
sLafflng sLrucLure LhaL Lruly serves an enLlre range of needs Lhrough a slngle access polnL.

CharL 9-1: Cff|ce of Iam||y Ass|stance Staff|ng Leve|s, 2013
Locat|on 1ota| os|t|ons
A||ocated
1ota| Number
I|||ed
1ota| Number
Vacanc|es
Vacancy
kate
orLland* 87 77 10 11.4
8lddlford & Sanford 38 33 3 9.0
LewlsLon & SouLh arls 84 73 9 10.7
AugusLa & 8ockland 88 81 7 7.9
Skowhegan, larmlngLon & AugusLa* 81 71 10 12.0
PoulLon, Carlbou & lorL kenL* 47 41 6 12.7
8angor 79 73 6 7.3
LllsworLh, Machlas & Calals 46 38 8 17.3
AdmlnlsLraLlon (CenLral Cfflce) 102 94 8 7.8
Source: uPPS-Cll SLafflng CharLs, CcLober 2013.
*Long-Lerm care (L1C) sLaff locaLed ln Lhese offlces - elLher L1C supervlsor and/or ellglblllLy speclallsLs.

ln CcLober 2013, Lhe average vacancy raLe ln fleld operaLlons was approxlmaLely
11.06. A ma[orlLy of vacancles were ln Lhe ellglblllLy speclallsL caLegory. ulscusslons wlLh
uPPS-Cll admlnlsLraLlon revealed LhaL by and large, vacancles are only a problem because
Lhere ls a lack of Lhe approprlaLe sklll seL among [ob seekers. llndlng a [ob-ready pool of
knowledgeable appllcanLs who can adapL and perform Lhe mulLl-faceLed Lasks requlred of an
ellglblllLy speclallsL ls challenglng. 1here ls general agreemenL among admlnlsLraLlve sLaff LhaL lf
Lhe approprlaLe candldaLes can be found, refllllng vacanL poslLlons ls Lyplcally efflclenL and well
supporLed by Lhe sLaLe's Cfflce of Puman 8esources. 1ralnlng ls anoLher challenge LhaL musL be
consldered.



127
CharL 9-2: Source of App||cat|ons for A|| rograms

Source: uPPS-Cll ACLS daLa counLs for C? 2013.


1he ma[orlLy of program appllcanLs conLlnue Lo prefer Lhe face-Lo-face opLlon Lo elLher
Lhe mall-ln or on-llne appllcaLlon opLlons. Maklng cerLaln LhaL Lhe Lechnology and Lhe paper
appllcaLlon forms are as user-frlendly as posslble ls an endurlng goal of all sLaLe welfare
admlnlsLraLlons, Malne ls no dlfferenL.


1ANI App||cat|on 1rends

8eLween !anuary 1 and uecember 31, 2013, Lhe number of 1Anl appllcaLlons was
11,899, wlLh 7,239 accepLances and 16,739 closures. Closures more Lhan doubled Lhe
accepLances ln 2013, of whlch no slngle monLh of appllcaLlons or accepLances exceeded
closures. 1hls represenLs a decrease ln Lhe sLaLewlde 1Anl caseload. 1he average monLhly
appllcaLlons were 992, wlLh 603 accepLances and 1,373 closures, Lhls Lrend creaLed a gap aL Lhe
early parL of Lhe year, alLhough Lhe gap closed by approxlmaLely 9 aL Lhe end of Lhe year.

uurlng LhaL same calendar year, boLh ASl8L and non-ASl8L accepLances were slmllar
and followed Lhe same paLLern. 1he closure Lrend was conslsLenL, alLhough Lhe ASl8L closures
averaged nearly flve hundred less LhroughouL Lhe year. 1hls would be aLLrlbuLable Lo Lhe
dramaLlc number of Llme-llmlLed case closures LhaL occurred aL Lhe beglnnlng of
lmplemenLaLlon of Lhe slxLy-monLh Llme-llmlL.

:+0. *( :+0.
FF#
:+?
4#
@+%- R&
J!#
D(5*+-
!F#
1ota| App||canons kece|ved |n 2013: 49,41S


128
CharL 9-3: 1ANI App||cat|on 1rends

Source: uPPS Cll, uecember 2013.


CharL 9-4: ASIkL-1ANI App||cat|on 1rends

Source: uPPS Cll, uecember 2013.


129
ort|and and Iarm|ngton Cff|ces

8y far one of Lhe hlghesL volume servlce cenLers ln Lhe sLaLe, orLland provldes lnlLlal
ellglblllLy, ongolng ellglblllLy, and supporL for all publlc asslsLance avallable for needy lndlvlduals
and famllles. SLaffers are frlendly, knowledgeable, and dedlcaLed Lo helplng all appllcanLs and
reclplenLs of uPPS servlces. 1hls offlce enables reclplenLs Lo obLaln sLaLus lnformaLlon on Lhelr
cases, and handles reporLlng of changes, and program recerLlflcaLlons. lor ASl8L-1Anl/aS
famllles, Lhe offlce provldes supporLlve case managemenL from program speclallsLs who are
lnvolved ln asslsLlng parenLs Lo develop and carry ouL case plans. 8ecause Lhls offlce ls shared
by oLher Malne human-servlce agencles, menLal-healLh servlces, and dlsablllLy deLermlnaLlon
speclallsLs, Malne's ueparLmenL of AdmlnlsLraLlon has asslgned a recepLlonlsL Lo Lhe cenLer
who supporLs Lhe overall operaLlon.

1he larmlngLon offlce has a vlrLually ldeal physlcal space, whlch provldes appllcanLs and
reclplenLs a welcomlng, well organlzed, servlce frlendly place. WalLlng area equlpped wlLh
Lelevlslon monlLors provldlng lnformaLlonal vldeos LhaL are perLlnenL Lo lssues and lnLeresLs of
people needlng servlces. As wlLh Lhe orLland offlce, ellglblllLy and program-speclflc sLaffers
were very knowledgeable, responslve, and very dedlcaLed Lo dolng Lhelr [ob wlLh compeLence
and efflclency. uocumenLs and lnformaLlonal handouLs were avallable and shared wlLh
reclplenLs and beneflLs and program requlremenLs were rouLlnely explalned Lo reclplenLs.

larmlngLon offlce managemenL and sLaff have been preparlng Lo assume responslblllLy
for a sLaLewlde uocumenL lmaglng CenLer Lo scan paper documenLs lnLo lndlvldual elecLronlc
records of all reclplenLs LhroughouL Lhe sLaLe. 1he cenLer wlll accepL malllngs from all parLs of
Lhe sLaLe and process documenLs submlLLed Lhrough Lhe mall-ln sysLem. 1he expecLaLlon ls LhaL
more Lhan Lhree Lhousand documenLs can be processed per day.


kecent Changes and Cngo|ng Improvements

- lnsLallaLlon of mulLlple cllenL-cenLered klosks ln orLland LhaL help appllcanLs and
reclplenLs Lo enLer Lhelr own daLa lnLo Lhe sysLem, as approprlaLe
- new sLaLewlde Lelephone sysLem enabllng a new call-cenLer capablllLy (offlce-based
and/or sLaLewlde)
- new sLaLewlde uocumenL lmaglng CenLer ln Lhe larmlngLon offlce
- CenLrallzed Lhe mall cenLer ln Lhe larmlngLon offlce (lmplemenLaLlon underway)
- 8eorganlzed work flow and work asslgnmenLs resulLlng from new Lechnology
- ColocaLlon wlLh MuCL whlch wlll beneflL Lhose seeklng employmenL




130
Lnhanc|ng rogram-Integr|ty In|t|at|ves

1he AC has made basellne observaLlons of Lwo fleld slLes as lllusLraLlve of Lhe ellglblllLy
sysLem. Accuracy and program lnLegrlLy are clearly lmporLanL Lo sLaff. Powever, wlLhouL
deLalled daLa LhaL can only be obLalned Lhrough sampllng of case records, areas of agency
vulnerablllLy cannoL be ldenLlfled. ln Lhe near fuLure, AC wlll revlew sample records (LwenLy-
flve Lo LhlrLy) of cerLaln publlc-asslsLance programs. CaLherlng of lnformaLlon based on pollcy
and procedures wlll help Lhe agency Lo verlfy accuracy of paymenLs made ln behalf of ellglble
households, and wlll produce useful evldence Lo deLermlne how Lhe Lypes of program supporLs
affecL Lhe range of parLlclpanL ouLcomes over Llme.

lor ASl8L/aS and Lhe SnA employmenL-and-Lralnlng parLlclpanLs, a revlew of
employmenL ouLcomes wlll be recorded, lf employed, LhaL revlew would Lrack how long
parLlclpanLs reLalned Lhelr [ob(s) and, lf avallable, wage lnformaLlon, full- or parL-Llme sLaLus,
and poslLlon LlLles. 1hls lnformaLlon wlll help Lo deLermlne lf Lhese parenLs/parLlclpanLs
demonsLraLe a capaclLy Lo work and remalned employed over measurable Llme perlods.
AddlLlonally, lndlcaLlons of famlly sLablllLy could be assessed.



131





10. Ma|ne's ub||c-We|fare Data Systems

Malne operaLes nlne publlc-welfare daLa sysLems elLher dlrecLly or Lhrough a serles of
conLracLs. 1he sysLems each operaLe wlLhln Lhelr own envlronmenL and are physlcally housed
LhroughouL varlous offlces ln Lhe AugusLa area. 1hose sysLems lnclude Lhe Malne Chlld Welfare
lnformaLlon SysLem (MACWlS), Malne AdulL roLecLlve Servlces lnformaLlon SysLem (MASlS),
MalneCare, Malne's lnLegraLed PealLh ManagemenL SoluLlon (MlPMS), Malne olnL of
urchase SysLem (MLCS), AuLomaLed CllenL LllglblllLy SysLem (ACLS), LnLerprlse lnformaLlon
SysLem (LlS), and Lhe uaLaPub.

When a Malne clLlzen applles for welfare servlces, ACLS ls Lhe flrsL sLop ln Lerms of Lhe
lnformaLlon exchanges. 1hls sysLem was developed ln con[uncLlon wlLh keane lnc. Lo supporL
Lhe operaLlonal needs of Lhe Cfflce for lamlly lndependence (Cll) and was deployed ln 2002.
1he web-based sysLem ls used sLaLewlde Lo supporL slxLeen dlsLrlcL offlces and a cenLral offlce.
1he sysLem was bullL Lo supporL Lhe numerous buslness requlremenLs of Cll, whlch lnclude Lhe
admlnlsLraLlon of numerous sLaLe and federal welfare programs. 1hus Lhe sysLem malnLalns and
provldes reclplenL lnformaLlon, deLermlnaLlon of ellglblllLy for mulLlple programs, and beneflL
lnformaLlon for several programs. ACLS currenLly lnLerfaces wlLh several sLaLe and federal
agencles Lo collecL lnformaLlon LhaL ls used for verlflcaLlon and deLermlnaLlon of beneflLs where
appllcable. 1he program also supporLs oLher funcLlons such as fraud lnvesLlgaLlon and recovery,
medlcal revlew Leam, quallLy assurance, and Lhe chlld care subsldy program.

MACWlS houses chlld-welfare lnformaLlon. 1he sysLem collecLs ellglblllLy daLa and case
managemenL records. 1he sysLem was developed ln-house, lLs fronL-end or user access was
bullL uslng Sybase ower8ullder ln con[uncLlon wlLh an Cracle daLabase. MalnLalned by Lhe
sLaLe, Lhls sysLem prlmarlly serves Lhe Cfflce of Chlld and lamlly Servlces (CClS). 1haL offlce
uses Lhls sysLem prlmarlly as Lhe case managemenL sysLem for casework sLaff, 1lLle lv-L
ellglblllLy deLermlnaLlon for chlldren ln uPPS care, as well as llcenslng funcLlons for fosLer-care
placemenL servlces, placemenL-servlces paymenL processes for chlldren ln uPPS' care,
mlscellaneous bllls processlng, and lnLake and assessmenL processes for chlld abuse-and-
neglecL reporLlng and mandaLory federal reporLlng. 1he sysLem also conLalns all Lhe offlce's
llcenslng, 1lLle lv-L ellglblllLy deLermlnaLlons, mlscellaneous bllls and chlld-welfare paymenLs,
resource managemenL, chlld-welfare conLracLs, cenLral lnLake work, and Lhe processlng of
auLhorlzaLlons for medlcal servlces or servlces provlded by non-Medlcald provlders. MACWlS
also supporLs Lhe admlnlsLraLlon of Lhe Larly Chlldhood ulvlslon's Chlld Care Subsldy rogram,
whlch admlnlsLers fundlng Lo elghLeen hundred famllles recelvlng supporL under Lhe federal
CCul. MACWlS provldes supporL for Lhe ellglblllLy deLermlnaLlon, case managemenL, flnanclal
reporLlng, and provlder paymenL. MACWlS ls also used by Lhe ulvlslon of Llcenslng and


132
8egulaLory Servlces Lo manage Lhe llcenslng of chlldren's resldenLlal faclllLles and chlld care
resources across Lhe sLaLe. 1he MACWlS flnance module lnLerfaces wlLh Malne's sLaLewlde
flnanclal sysLem sofLware (AdvanLage) for Lhe processlng of uPPS paymenLs Lo servlce
provlders, chlld-welfare payroll, reclplenL-speclflc lnvolces, Lhe Mlscellaneous 8llls ayroll, and
paymenLs Lo agencles wlLh conLracLs/agreemenLs wlLh uPPS. 1he sysLem serves more Lhan
elghL hundred users ln Lhe CClS, 8ureau of Chlldren's 8ehavloral PealLh Servlces, Lhe ALLorney
Ceneral's offlce, ASl8L and reglonal operaLlons, and flnanclal servlces sLaff.

MASlS ls a browser-based case-managemenL sysLem. lL supporLs Lhe mlsslon, sLraLeglc
plan, and lnlLlaLlves of Lhe Cfflce of Aglng and uevelopmenLal Servlces by provldlng case-
managemenL funcLlonallLy LhaL enables sLaff Lo perform and record all reclplenL supporL
lnLeracLlons ln an efflclenL manner. 1he sysLem allows for Lracklng reclplenLs daLa from lnlLlal
referral Lhrough Lo Lhe compleLlon of case-managemenL acLlvlLy, and enables users Lo manage
daLa on all relevanL aspecLs of reclplenL care. 1he daLa sysLem lnLerfaces wlLh several oLher
sysLems ln Lhe dellverance and paymenL of servlces.

LlS ls a LreaLmenL daLa-collecLlon sysLem LhaL allows for Lhe gaLherlng of reclplenL- and
provlder-speclflc lnformaLlon on behavloral healLh/adulL menLal healLh servlces, adulL
developmenLal servlces, and chlld menLal-healLh servlces. 1he sysLem also conLalns Lhe
deparLmenL's agreemenL managemenL funcLlons Lo Lrack provlder conLracLs. 1he sysLem serves
users noL [usL ln uPPS behavloral healLh buL also ln CClS and Lhe sLaLe psychlaLrlc hosplLals. LlS
ls operaLlonal LwenLy-four hours a day, seven days a week. LlS supporLs Lhese buslness areas
wlLh plannlng, managemenL, lncldenL reporLlng, and quallLy lmprovemenL for behavloral and
developmenLal servlces ln Malne. lL ls a generlc, conflgurable sysLem LhaL can be cusLomlzed as
program, sysLem, and pollcy needs change, helplng Lo mlnlmlze exLernal resources requlred.

1he uaLaPub consolldaLes/lnLegraLes ellglblllLy and demographlc lnformaLlon from
mulLlple source sysLems and provlde LhaL lnformaLlon malnly Lo supporL clalms processlng.

MlPMS ls used for paylng Medlcald clalms. lL ls a compleLe sulLe lmplemenLed and
malnLalned by Mollna (sLaLe flscal agency) and lLs subconLracLor 1ruven. 1he sysLem loads
flnanclal ellglblllLy lnformaLlon from Lhe uaLaPub, medlcal/classlflcaLlon (coverage-code)
ellglblllLy lnformaLlon malnly Lhrough manual user enLry, prlor auLhorlzaLlons Lhrough
elecLronlc-flle submlsslon and manual enLry, and 1L lnformaLlon malnly Lhrough elecLronlc
feed. 8eneflL packages (servlces LhaL are covered) are assoclaLed wlLh Lhe loaded lnformaLlon.
MlPMS processes medlcal/denLal clalms submlLLed by provlders malnly Lhrough an elecLronlc-
daLa process uslng all of Lhe above lnformaLlon. harmacy clalms are ad[udlcaLed by MLCS
uslng slmllar Lechnlques, buL are submlLLed Lo and Lhrough MlPMS for flnanclal/accounLlng
purposes. aymenLs Lo provlders are made Lhrough elecLronlc feed from MlPMS Lo AdvanLage.

MLCS processes Medlcald prescrlpLlon-drug clalms by assesslng a number of facLors
lncludlng ellglblllLy. 1he sysLem ls malnLalned by Coold PealLh SysLems, Lhe sLaLe pharmacy
beneflLs manager.



133
!"#"$ %$&'$("
!"#$% &'('
)%*+,$- '.(/
0%1 3"+456#*% '7(8
96,:% ;5<"$: '=(=
>,$$%?-#?@- ''(/
!"55"?6@5%--5 'A(&
)$*+'#+* -./$(*+"0&$1 #1 #
%$&'$(" 23 42"#5 -./$(*+"0&$1
678!9: ;<=>?





A81 lll: MAlnLCA8L

11. Ma|neCare Cverv|ew


Medlcald ls Lhe slngle largesL llne lLem ln mosL sLaLe budgeLs, represenLlng 24.4 of
LoLal sLaLe spendlng ln flscal 2013. ln Malne, MalneCare spendlng ln Sl? 2013 represenLed
24.8 of LoLal general-fund spendlng, or $767 mllllon (MalneCare CMS AnalyLlcs, november
2013). 1hls excludes admlnlsLraLlve cosLs of $20.9 mllllon, represenLlng salary and beneflLs for
MalneCare personnel as well as ouLsourced servlces. When Medlcald Lax revenue ls lncluded,
LoLal non-federal spendlng as a percenL of LoLal non-federal revenue rlses Lo 30.6. Accordlng
Lo analysls by Lhe naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers (nAS8C), ln Sl? 2013, Malne
ranked hlghesL ln new Lngland for Medlcald sLaLe spendlng as a percenL of LoLal sLaLe
expendlLures and Lhe flfLh hlghesL among all sLaLes.
41


CharL 11-1: Med|ca|d Lxpend|tures
Malne All lunds" Medlcald expendlLures
grew aL an average raLe of 3.3 from l? 2000 Lo
l? 2012, or double Lhe l? 2000 level. ln
comparlson, sLaLe revenue growLh ls pro[ecLed Lo
lncrease by 3.2 per year (Malne Cfflce of
8evenue Servlces). As a resulL, MalneCare general-
fund spendlng by lLself wlll accounL for more Lhan
40 cenLs of each addlLlonal Lax dollar (per Lhe
hlsLorlcal Lrend LhaL ls lower Lhan CMS acLuarlal
pro[ecLlons of 6.3). As growLh raLes ln MalneCare
spendlng ouLpace revenue growLh, all oLher
leglslaLlve prlorlLles wlll llkely face dlmlnlshed
resources. WlLhouL a planned resLrucLurlng of
currenL Medlcald cosLs, Lhere wlll llkely be
lncreaslng pressure Lo lmplemenL arblLrary across-
Lhe-board cuLs ln all programs, as reflecLed by commenLs from Lhe naLlonal Covernors
AssoclaLlon (nCA): WlLh Lhe growLh of Medlcald expendlLures, spendlng prlorlLles wlll agaln
face compeLlLlon for sLaLe budgeL dollars Lhls flscal year," sald nCA LxecuLlve ulrecLor uan

41. naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers, SLaLe LxpendlLures 8eporL: Lxamlnlng llscal 2011-
2013 SLaLe Spendlng," 2013.


134
Crlppen. SLaLes have underLaken numerous acLlons Lo conLaln Medlcald cosLs, lncludlng
reduclng provlder paymenLs, cuLLlng prescrlpLlon drug beneflLs, llmlLlng beneflLs, reformlng
dellvery sysLems, expandlng managed care and enhanclng program lnLegrlLy efforLs. 1hese
efforLs alone, however, cannoL sLop Lhe growLh of Medlcald."
42


CharL 11-2: Ma|neCare Spend|ng by Serv|ce Categor|es, 2008-13
Lxpend|ture Category SI 2008 SI 2013
ercentage of
SI 1ota|
ercent
Change
PosplLal $317,370,632 $617,937,232 24.11 19.4
8esldenLlal 1oLal 349,398,932 330,699,683 20.71 -3.4
PC8S Walvers 1oLal 304,381,836 319,031,373 12.43 4.7
SSA PealLh lnsurance 127,063,713 163,217,888 6.43 30.0
harmacy 1oLal 139,643,382 133,173,033 3.20 -16.6
ueducL. & Co-lns for uuals 339 124,397,390 4.83 23098943.6
Medlcal rofesslonals 88,944,843 143,202,229 3.39 61.0
8ehavloral PealLh Cllnlclan 78,389,464 128,163,814 3.00 63.3
Cllnlc 1oLal 61,307,637 123,243,609 4.89 104.3
8ehab Servlces 1oLal 30,314,814 68,438,329 2.67 33.3
1ransporLaLlon 43,038,669 44,424,676 1.73 3.2
Case ManagemenL 64,160,916 42,876,277 1.67 -33.2
uenLlsLry 23,300,363 32,416,338 1.26 27.1
LaboraLory Servlces 9,284,431 10,831,327 0.42 16.9
Pome PealLh 11,417,870 10,361,997 0.40 -9.2
lnsurance 333,099 1,868,632 0.07 236.6
CLher 37,819,033 26,280,288 1.03 -30.3
School-8ased Servlces 37,064,213 38,316,362 1.30 -32.9
Grand 1ota| 52,186,060,631 52,S62,944,328 100.00 17.2
Source: uPPS Cfflce of MalneCare Servlces, november 2013.




42. naLlonal Covernor's AssoclaLlon and naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers, llscal Survey
of SLaLes, 2013."


133
1he Doub||ng of the Ma|neCare Case|oad

MalneCare caseloads more Lhan doubled from !une 2000 Lo !une 2012 (uPPS AnalyLlcs).
8ased on daLa from Lhe Medlcald SLaLlsLlcal lnformaLlon SysLem for ll? 2010, and populaLlon
esLlmaLes for sLaLes from Lhe u.S. Census 8ureau for 2010, Malne Medlcald enrollmenL as
percenL of LoLal populaLlon was 31 (based on unlque users) exceedlng every sLaLe excepL
Callfornla and Lhe ulsLrlcL of Columbla (kalser lamlly loundaLlon, SLaLe PealLh lacLs 2010).

CharL 11-3: Ma|neCare Case|oad Growth

Source: uPPS-CMS AnalyLlcs

Malne has elecLed Lo cover more persons and servlces under MalneCare Lhan requlred
by federal regulaLlon Lhrough elLher a sLaLe plan amendmenL or CMS-approved walvers.
MalneCare enrollees lnclude mandaLory and opLlonal populaLlons covered Lhrough expanslons
LhaL exLend coverage Lo chlldren under Lhe SLaLe Chlldren's PealLh lnsurance rogram (SCPl),
commonly known ln Malne as CubCare, parenLs and legal guardlans of mlnor chlldren, as well
as walver programs for persons wlLh developmenLal dlsablllLles recelvlng home- and
communlLy-based care, persons wlLh Plv/AluS, women wlLh breasL and cervlcal cancer, and
persons wlLh dlsablllLles recelvlng care aL home under Lhe consumer-dlrecLed home-care
program.

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136
CharL 11-4: Med|ca|d and SCnI L||g|b|||ty Leve|s |n New Lng|and
As ercenLage of lederal overLy Level, !uly 1, 2012



State Infants Ch||dren, 1-S Ch||dren, 6-19 regnant
Women
arents of
Med|ca|d-
L||g|b|e Ch||dren
Ch||d|ess
Adu|ts
Iedera|
M|n|mum |eve|
133 133 100 133 n/A n/A
Connect|cut 183 M
300 C
183 M
300 C
183 M
300 C
230 191 SLaLe only
fundlng
Ma|ne 200 M 130 M
200 C
130 M
200 C
200 133 100
(closed)
Massachusetts 200 M
300 C
130 M
300 C
130 M
300 C
200 133 *
New nampsh|re 300 M 183 M
300 C
183 M
300 C
183 47
khode Is|and 230 M+ 230 M+ 230 M+ 230 173
Vermont 223 M
300 C
223 M
300 C
223 M
300 C
191 183 llmlLed
program
130 llmlLed
program
Source: kalser SLaLe PealLh lacLs, Accessed uecember 18, 2013.

M Medlcald offers coverage Lo chlldren up Lo Lhls percenLage of Lhe federal poverLy
guldellnes.
M+ sLaLe's Medlcald program has a SCPl expanslon.
C sLaLe has a separaLe SCPl program LhaL offers coverage Lo chlldren up Lo Lhls percenL
of Lhe federal poverLy level.

*ln MassachuseLLs, chlldless adulLs who are long-Lerm unemployed or a cllenL of Lhe
ueparLmenL of MenLal PealLh wlLh lncome below 100 lL can recelve more llmlLed
beneflLs under Lhe MassPealLh walver program Lhrough MassPealLh baslc or essenLlal
plans. AddlLlonally, adulLs up Lo 300 lL are ellglble for more llmlLed subsldlzed
coverage under Lhe CommonwealLh Care walver program.



137
CharL 11-3: Ma|neCare L||g|b|||ty Groups
Mandatory Cpt|ona|
Chlldren under age 6, below 133 lL Low-lncome chlldren above 100 lL, noL
mandaLory by age
Low-lncome parenLs wlLh lncome aL or
below 1996 AluC level
arenLs below 133 lL (reduced Lo 100 lL as of
!anuary 2014)
regnanL women aL or below 133 lL regnanL women up Lo 200 lL
Llderly and dlsabled SSl beneflclarles aL
or below 77 lL
Llderly and dlsabled above SSl level buL below 100
lL
CerLaln worklng dlsabled adulLs CerLaln worklng dlsabled
Medlcare buy-ln groups (CM8, SLM8,
Cl) aL or below 133 lL
8uy-ln groups up Lo 173 lL
Medlcally needy
nurslng home resldenLs above SSl levels buL below
300 SSl
ersons aL rlsk of needlng nurslng home or lCl- M8
care
non-caLegorlcal adulLs below 100 lL (ellmlnaLed
as of uecember 31, 2013).
Source: uPPS and Malne Lqual !usLlce arLners, MalneCare LllglblllLy Culde," !uly 16, 2013.

CharL 11-6 shows Lhe MalneCare caseload and monLhly cosLs by populaLlon for Sl? 2012
and Sl? 2013. noLe LhaL Lhe charL does noL lnclude enrollees ellglble for a llmlLed seL of
beneflLs. 1hese elderly and dlsabled enrollees quallfy only for asslsLance wlLh Lhelr Medlcare
premlums and colnsurance. ln l? 2013, MalneCare served 44,290 of Lhese lndlvlduals aL a LoLal
cosL of $84.9 mllllon and a MM cosL of $160 (uPPS Cfflce MalneCare Servlces). Malne
currenLly covers lndlvlduals ln Lhls caLegory up Lo 173 lL, hlgher Lhan all oLher sLaLes.




138
CharL 11-6: Ma|neCare Case|oad and MM 8reakdown


MalneCare spendlng, by caLegory of member served, has generally followed naLlonal
Lrends. ln Sl? 2013, chlldren and famllles comprlsed 74.2 of Lhe MalneCare populaLlon buL
accounLed for [usL 38.6 of Lhe spendlng, elderly adulLs comprlsed 7.9 of Lhe populaLlon and
accounLed for 18.3 of spendlng, and persons wlLh dlsablllLles comprlsed 18 of Lhe
populaLlon and accounLed for 43 of all expendlLures. Whlle seemlngly dlsproporLlonal, Lhe
hlgh cosL of servlng Lhe elderly and persons wlLh dlsablllLles reflecLs Lhe hlgher expenses of
long-Lerm care, especlally ln resldenLlal seLLlngs. Medlcald pays Lhe ma[orlLy of cosLs for
enrolled famllles, whlle many aged or dlsabled members are also enrolled ln Medlcare, Lhe
prlmary payer.

1hls ls crlLlcal for Malne, where servlces for lndlvlduals wlLh lnLellecLual dlsablllLles rely
heavlly on resldenLlal seLLlngs. As a resulL, Malne spends an average of $90,178 annually on
servlces for adulLs wlLh developmenLal dlsablllLles, ranklng Lhe sLaLe number 3 ln spendlng per
member. A comparlson Lo Lhe average spendlng by populaLlon for all sLaLe Medlcald programs
ls shown ln CharL 11-7 on Lhe nexL page. Spendlng on chlldren and famllles consLlLuLed 73 of
enrollmenL ln boLh Malne and Lhe unlLed SLaLes. Powever, MalneCare spends more on famllles
Lhan Lhe u.S. average, as shown by Lhelr hlgher share of LoLal expendlLures. ln Sl? 2003,
MalneCare famllles represenLed 72 of members and 34 of expendlLures.
43
8ecenL
MalneCare Laskforces have concenLraLed on hlgh-cosL use among Lhe dlsabled caLegorles.

43. 1he kalser Commlsslon on Medlcald and Lhe unlnsured, MalneCare and lLs 8ole ln Malne's
PealLhcare SysLem," 2003.
!"#$"%& '!'! !"#$"%& '!'!
(%)*+,+-.)/ !)+."1)%"
"#$% &&'()& *+',-& &&'--. *+'/&-
0123% 45 627891$% /+'.:; *+'/-( /&':+/ *+'//)
<=21%5$3 >+::? @AB ++:'-)& *)+& +:-')+& *)&+
A85$3C7 >+::? @AB /:',(, *)(& ,.'.,. *)(&
A5$#383DE +'.(/ *..- +'(&& *(+&
FC8C$ G31E +';.( *&'&&; -;- *+'-.;
GC=$5 H58%2C24381 +:'..( *&;- +&'-/, *&/,
(-,)/ (%)*+,+-.)/ !)+."1)%" 2345678 9:;; 26<57=: 9:;2
>,?"% @%-AB&
<=21%1$77 "%I1C J82K$5 +;':.; *,/. +:';.( */+,
<=21%5$3 L +::? @AB +;');) *&+, +,'+-. *&&&
A85$3C7 M+::?N+/:? @ABO &&'+/- *&.: +('-:& *&-+
(-,)/ >,?"% 365<4: 97;2 6653<= 97;6
@%).* (-,)/& 7435463 9<7= 2=45=<3 9<3;
!)+."1)%" C.%-//#"., ).* '"% !"#$"% '"% !-.,? D'!'!E 1-&,&
1),"F-%G
HIJ 24;;K;2 HIJ 24;2K;7


139
Clven Lhe hlgh relaLlve share of cosLs drlven by chlldren and famlly members, Lhere may also be
opporLunlLy Lo sLeer Lhese expenses closer Lo naLlonal averages.

CharL 11-7: Ma|neCare Lnro||ment & Lxpend|tures by L||g|b|||ty Group

Source: 2011 CMS AcLuarlal 8eporL on Lhe llnanclal CuLlook for Medlcald

CharL 11-8: U.S. Med|ca|d Lnro||ment & Lxpend|tures by L||g|b|||ty Group

Source: uPPS-CMS AnalyLlcs, 2013.
1he famlly group ln boLh charLs lncludes parenLs, chlldren, and chlldless adulLs.


+Q.6
3K# +Q.6M K#
6%2+,-.6
FJ#
6%2+,-.6
3K#
7+9%-X
JH#
7+9%-X
I"#
>?E.&6%*)5.2 >&5(--9.&*
Ma|neCare Lnro||ment and
Lxpend|tures by L||g|b|||ty Group
as Share of 1ota|, SI 2013
+Q.6
!4# +Q.6M H#
6%2+,-.6
FF#
6%2+,-.6
3I#
7+9%-X
J"#
7+9%-X
IF#
>?E.&6%*)5.2 >&5(--9.&*
U.S. Med|ca|d Lnro||ment and
Lxpend|tures by L||g|b|||ty Group
as Share of 1ota|, II 2011


140
Iedera| Med|ca| Ass|stance ercentage (IMA)

SomeLlmes an lncrease ln federal funds can help offseL Lhe budgeLary demand for
publlc-welfare spendlng, buL recenL hlsLory shows oLherwlse. Malne has been faclng decllnlng
lMA, l.e., Lhe share of Lhe Medlcald program pald for by Lhe federal governmenL. Slnce 2000,
Lhe raLe has fallen from 66.12 Lo Lhe currenL 61.33. Lach percenLage-polnL drop ln lMA shlfLs
approxlmaLely $23 mllllon ln federal Medlcald expenses Lo Lhe general fund. WlLhouL a
comprehenslve reform of Lhe MalneCare program, lL wlll conLlnue Lo be a flnanclal burden on
Lhe sLaLe. When conslderlng Lhe flscal problems of Lhe federal governmenL, Lhe susLalnablllLy of
currenL MalneCare fundlng sources are even more Lenuous.

Malne's decllnlng lMA resulLs from a formula LhaL compares per-caplLa lncome for
each sLaLe relaLlve Lo oLher sLaLes. AlLhough Lhe sLaLuLory formula has noL changed, Lhe hlghesL
lMA has decllned, and Lhe average lMA has decllned over four decades whlle Lhe lowesL
lMA has remalned unchanged, shrlnklng Lhe dlsLance beLween Lhe hlghesL and lowesL lMAs.
A reporL by Lhe kalser Commlsslon on Medlcald summarlzes Lhe ma[or conLrlbuLlng facLors:

er caplLa personal lncome ln sLaLes LhaL were relaLlvely wealLhy ln 1969-1970 (and
Lherefore had Lhe lowesL lMAs) grew more slowly over Lhe four decades Lhan per
caplLa personal lncome ln sLaLes LhaL were relaLlvely poor. 1he relaLlvely slow per caplLa
lncome growLh ln Lhese sLaLes meanL slow growLh ln Lhe naLlonal average per caplLa
lncome. 8ecause a sLaLe's lMA ls calculaLed by comparlng lLs per caplLa lncome Lo Lhe
naLlonal average, Lhe fasLer lncome growLh of Lhe poorer sLaLes relaLlve Lo Lhe naLlonal
average per caplLa lncome has reduced Lhelr lMAs over Llme.
44




44. kalser Commlsslon, An Cvervlew of Changes ln Lhe lederal Medlcal AsslsLance ercenLages
(lMAs) for Medlcald," !uly 2011.


141





12. Ma|neCare rograms and Wa|vers


Ma|neCare for Ab|e-8od|ed Adu|ts of Work|ng Age

Slnce 1998, Malne has adopLed a number of pollcles Lo reduce Lhe number of people
wlLhouL healLh lnsurance and curb uncompensaLed care cosLs. ln 2002, Malne applled for and
recelved a SecLlon-1113(a) demonsLraLlon walver LhaL allows chlldless adulLs wlLh lncome aL or
below 100 of lL Lo recelve a comprehenslve beneflL package.
43
CMS allowed Lhe sLaLe Lo Lap
unused dlsproporLlonaLe-share-hosplLal (uSP) alloLmenLs Lo make up Lhe federal share of Lhe
sLaLe's walver. revlously, a porLlon of Lhe uSP allocaLlon had been dlvlded up among
psychlaLrlc hosplLals and communlLy hosplLals, nelLher of whlch LradlLlonally meL Lhelr uSP
llmlL. 1he uSP allocaLlon, currenLly aL $83 mllllon (sLaLe and federal) became Lhe upper llmlL for
Lhe program. ln Lhe walver proposal, Lhe sLaLe esLlmaLed LhaL eleven Lhousand new members
would enroll ln Lhe flrsL year. Powever, by CcLober 2003, fourLeen monLhs afLer
lmplemenLaLlon, 16,834 newly ellglble chlldless adulLs had enrolled ln MalneCare.

CharL 12-1: Ma|ne's Un|nsured opu|at|on

uue Lo Lhe subsequenL sLaLe budgeL shorLfalls and Lhe rlsk of exceedlng Lhe walver cosL-
neuLrallLy Lerms, Malne requesLed Lo amend Lhe walver by reduclng Lhe currenL demonsLraLlon
beneflL package and ellmlnaLlng reLroacLlve coverage for demonsLraLlon populaLlons. 1hese
amendmenLs were approved on SepLember 6, 2003, shorLly afLer enrollmenL was Lemporarlly
capped. SubsequenLly, enrollmenL caps were used Lo conLrol spendlng and, by 2013, Lhe cap
reduced Lhe program's spendlng Lo approxlmaLely $40 mllllon ln comblned annual federal and
sLaLe spendlng. As of SepLember 2013, Lhere were less Lhan elghLy-flve hundred enrolled
chlldless adulLs. 1he walver Lo cover Lhese lndlvlduals explred on uecember 31, 2013.

Whlle Lhese pollcles dld resulL ln small and Lemporary decreases ln Lhe number of

43. CMS, Walver lnformaLlon, hLLp://www.medlcald.gov/Medlcald-CPl-rogram- lnformaLlon/8y-
1oplcs/Walvers/1113/downloads/me/me-chlldless-adulLs-fs.pdf.
!""# !""$ !""% !""& !""' !""( !"") !"*" !"**
!" !# !" !! !# !" !" !! !!
!" $%&'(' )(*%+(
+,-./ 1.234,.5/ 678/4,9/ :74 1.;-8-;3,<2 3.;/4 &% =/,42 ><;
?/45/.@ A.-.234/;


142
unlnsured clLlzens, lL proved noL Lo be a long-Lerm soluLlon ln reduclng Lhe number of
unlnsured clLlzens. 1haL number has remalned falrly consLanL on an annual basls as a
percenLage of all lndlvlduals under 63 years of age, as seen ln CharL 12-1. Cver Lhe same Llme,
from Sl? 1999-2000 Lo Sl? 2012-13, Lhe LoLal MalneCare budgeL, lncludlng boLh sLaLe and
federal funds, rose from $1.2 bllllon Lo almosL $2.3 bllllon, an lncrease of 109. ln Lerms of
sLaLe funds, Lhe lncrease was even greaLer. lL grew from $403 mllllon Lo $992 mllllon, an
lncrease of 146.

Malne's experlence ln expandlng ellglblllLy for MalneCare dld noL resulL ln a noLlceable
reducLlon ln uncompensaLed care. LaLesL esLlmaLes by Lhe Malne PosplLal AssoclaLlon place
charlLy care aL approxlmaLely $200 mllllon. !usL llke enrollmenL and Lhe MalneCare budgeL,
hosplLal charlLy care also exceeded budgeL LargeLs, as lL grew by more Lhan 200 from 2000 Lo
2013. As Lhese numbers lndlcaLe, desplLe efforLs Lo expand healLh coverage ln order Lo reduce
Lhe number of unlnsured clLlzens and curb uncompensaLed care, boLh lssues remaln unsolved.

1hls lack of evldence llnklng Medlcald ellglblllLy expanslons wlLh reducLlons ln
uncompensaLed care cosLs may be explalned by Lhe resulLs of several sLudles, lncludlng one by
!onaLhan Cruber and Slmon kosall LhaL found:

ConLlnued lnLeresL ln publlc lnsurance expanslons as a means of coverlng Lhe unlnsured
hlghllghLs Lhe lmporLance of esLlmaLes of crowd-ouL," or Lhe exLenL Lo whlch such
expanslons reduce prlvaLe lnsurance coverage. Cur resulLs clearly show LhaL crowd-ouL
ls slgnlflcanL, Lhe cenLral Lendency ln our resulLs ls a crowd-ouL raLe of abouL 60.
46


8ecenL evldence from employer-sponsored lnsurance (LSl) supporL LhaL research. lrom
2000 Lo 2011, LSl coverage ln Malne for Lhe under-63 populaLlon fell from 69.6 Lo 61.3.


Ma|ne r|vate nea|th Insurance rem|um rogram (nI)

SLaLes have pursued a number of sLraLegles Lo leverage fundlng and sLreLch Lhelr healLh-
care dollars ln order Lo avold cuLLlng ellglblllLy. AuLhorlzed under SecLlon 1906 of Lhe Soclal
SecurlLy AcL, PealLh lnsurance remlum aymenL (Pl) programs subsldlze enrollmenL ln
employer-sponsored healLh lnsurance for Medlcald-ellglble lndlvlduals - and Lhelr famllles -
who have access Lo such coverage and for whom lL ls cosL-effecLlve. When an adulL ls ldenLlfled
as havlng oLher prlvaLe lnsurance coverage, Lhe member's commerclal lnsurance or LSl
becomes prlmary and Medlcald fee-for-servlce ls secondary.


46. !onaLhan Cruber and Slmon kosall, Crowd-CuL 1en ?ears LaLer: Pave 8ecenL ubllc lnsurance
Lxpanslons Crowded CuL rlvaLe PealLh lnsurance," naLlonal 8ureau of Lconomlc 8esearch
Worklng aper, !anuary 2007.


143

Malne has Lhe Lhlrd-mosL aged
populaLlon ln Lhe counLry, and as of
2012, 17 of Malne's populaLlon was
age 63 or older.
1he Malne Pl program was seL up ln 1993. LnrollmenL ln Pl ls volunLary ln Malne.
1o ldenLlfy MalneCare members who are worklng and who may have access Lo LSl, Pl
program admlnlsLraLors send leLLers Lo MalneCare enrollees LhaL are employed for LhlrLy-Lwo
hours or more per week (approxlmaLely LhlrLeen Lhousand households) and dlsLrlbuLed
brochures aL reglonal lnLake offlces and oLher locaLlons. Powever, unllke Lhe 8hode lsland,
lowa, and ennsylvanla programs, Lhe Malne Pl program has shown low enrollmenL and
mlnlmal cosL-savlngs. CurrenLly, 400 MalneCare households and 1,343 lndlvlduals represenLlng
less Lhan 1 of LoLal MalneCare worklng-age famllles parLlclpaLe ln Pl.

8hode lsland began wlLh low enrollmenL under a volunLary program buL was able Lo
reach more Lhan 6 of cases when enrollmenL ln Pl was mandaLed. MalneCare requlres
members Lo conLacL Lhe Pl admlnlsLraLor ln order Lo be enrolled. 8hode lsland also passed
leglslaLlon Lo requlre Medlcald provlders Lo submlL lnformaLlon on employer-sponsored healLh
lnsurance (LSl) as a condlLlon for enrollmenL. ln addlLlon, all oLher employers were requlred Lo
submlL Llmely flllngs on LSl (8lCL 40-6-9.1).


Long-1erm Care Systems Support

MalneCare covers a range of long-Lerm care
(L1C) ln home- and faclllLy-based seLLlngs LhaL
lnclude skllled nurslng, home healLh, asslsLance wlLh
home chores and personal care, adulL day- cenLer
servlces, and resldenLlal care. 1hese servlces are
drlven by Malne's oldesL ln Lhe naLlon sLaLus," as
Lhe sLaLe's populaLlon has a medlan age of 43.3
years (2012 CurrenL opulaLlon Survey, u.S. Census
8ureau) whlle 17 of Lhe sLaLe's populaLlon ls over
age 63, Lhe sevenLh hlghesL percenLage ln Lhe counLry. As Lhe over-age-63 populaLlon grows
fasLer Lhan all oLher Malne age groups (2012 Malne SLaLe roflle, Woods and oole) over Lhe
nexL few decades, a smaller percenLage of worklng-age Malners wlll be flnanclng a larger
percenLage of low-lncome elderly MalneCare enrollees. 1hls ls lmporLanL as LradlLlonal long-
Lerm care expenses for elderly and physlcally dlsabled lndlvlduals represenLed 34 of LoLal
MalneCare servlces ln Sl? 2013.

Malne has recelved approval of Lhe 8alanclng lncenLlve rogram (8l) (awarded
effecLlve !uly 1, 2012) Lo furLher develop Malne's sysLems of communlLy-based long-Lerm
servlces and supporLs (L1SS). 1he 8l appllcaLlon shows Malne spendlng 49.1 of lLs L1SS
spendlng on communlLy L1SS. As parL of lLs parLlclpaLlon ln Lhls lnlLlaLlve, Malne commlLs Lo
meeLlng Lhe 30 spendlng benchmark for communlLy L1SS as requlred by Lhe 8l no laLer Lhan
SepLember 30, 2013. Powever, Lhe benchmark lncludes spendlng on lndlvlduals wlLh
developmenLal dlsablllLles. Lxcludlng Lhese servlces Lhe share of lnsLlLuLlonal spendlng
(excludlng prlvaLe non-medlcal lnsLlLuLlons, or nMl) rlses Lo approxlmaLely Lwo-Lhlrds. 1he


144
share of L1SS for all resldenLlal cosLs lncludlng nMl personal-care servlces exceeds 87 (uPPS
AnalyLlcs).

Malne lnlLlaLed several reforms Lo LargeL nurslng faclllLy admlsslons Lo Lhose mosL ln
need by esLabllshlng sLrlcLer medlcal-ellglblllLy crlLerla and requlrlng LhaL anyone seeklng
admlsslon Lo a nurslng faclllLy, regardless of paymenL source, be assessed for medlcal ellglblllLy
and provlded an advlsory communlLy plan of care. As a resulL, Lhe sLaLe has one of Lhe hlghesL
aculLy levels for nurslng-home resldenLs.

Malne has also been LranslLlonlng chlldren needlng nurslng faclllLy level-of-care Lo
home- and communlLy-based servlces Lhrough Lhe kaLle 8eckeLL ellglblllLy opLlon. As a resulL of
Lhese reforms, Malne has reduced lLs uLlllzaLlon of large lnsLlLuLlonal servlces for many
lndlvlduals needlng L1SS.


nome- and Commun|ty-8ased Serv|ces (nC8S) Wa|vers

ln addlLlon Lo mandaLory and opLlonal Medlcald sLaLe-plan servlces, Lhere are currenLly
slx approved home- and communlLy-based walvers LhaL serve elders, adulLs wlLh physlcal and
lnLellecLual dlsablllLles, and chlldren as descrlbed ln CharL 12-2.

CharL 12-2: Se|ected Sect|on 191S-Wa|ver opu|at|ons
Wa|ver 1arget opu|at|on and 8as|c Descr|pt|on
Aged and d|sab|ed lndlvlduals (age 18 or older) who meeL nurslng faclllLy level-of-care
requlremenLs buL choose Lo remaln aL home. Servlces lnclude: care
coordlnaLlon, personal supporL servlces, home-healLh servlces,
adulL day healLh servlces, LransporLaLlon, emergency-response
sysLem, envlronmenLal modlflcaLlons, and resplLe servlces. 1he
program rules are ln SecLlon 19 of Lhe MalneCare 8eneflLs Manual
(10-144 CM8 ChapLer 101). As of lebruary 2013, 1,331 members
were belng served.
Commun|ty support
benef|ts for members
w|th deve|opmenta|
d|sab|||t|es
rovldes supporL servlces Lo members who mosL commonly llve on
Lhelr own or wlLh famllles, Lhere are occaslonally lndlvlduals llvlng
ln group homes who are also ellglble. 1he ma[or servlces are
communlLy supporL and work supporL. 1hls walver does noL provlde
any resldenLlal servlces. 1he program rules are ln Lhe MalneCare
8eneflLs Manual, SecLlon 29. 1he enrollmenL llmlL ls 1,430 persons.
nome and commun|ty
benef|ts for the
phys|ca||y d|sab|ed (se|f-
d|rected)
lndlvlduals wlLh physlcal dlsablllLles, age 18 or older. lndlvlduals ln
Lhls program choose Lo manage and dlrecL Lhelr own personal-care
aLLendanL. Some servlces provlded are: supporLs brokerage
funcLlons, personal-care aLLendanL servlces, and Lhe emergency-
response sysLem. 1he program rules are ln Lhe MalneCare 8eneflLs
Manual, SecLlon 22. Serves 126 members.


143
nome and commun|ty
benef|ts for members
w|th |nte||ectua|
d|sab|||t|es or aut|st|c
d|sorder wa|ver
Cffers a comprehenslve mlx of servlces Lo members, age 18 or
older. 1he ma[or servlces offered are: home supporL - lncludlng
supporL Lo llve alone or ln seLLlngs wlLh oLhers (l.e. group homes),
communlLy supporL, and work supporL. 1he program rules are ln
Lhe MalneCare 8eneflLs Manual, SecLlon 21. 1hese lndlvlduals are
resldlng ln Lhe communlLy and have been classlfled as needlng
nurslng faclllLy level-of-care requlremenLs or meeLlng Lhe lCl-M8
level of care. 1hls walver was servlng 2,833 members as of lebruary
23, 2013.
Ch||dren w|th |nte||ectua|
d|sab|||t|es and]or
pervas|ve deve|opmenta|
d|sorders
1hls walver provldes an alLernaLlve Lo lnsLlLuLlonal care Lo chlldren,
ages 3 Lhrough 20, wlLh lnLellecLual dlsablllLles and/or pervaslve
developmenLal dlsorders who would oLherwlse requlre servlces ln
an lCl/M8 or psychlaLrlc hosplLal. 1he servlces offered and program
rules are speclfled ln Lhe MalneCare 8eneflLs Manual, SecLlon 32.
lmplemenLed november 2013. 1he walver wlll serve up Lo 80
chlldren.
Cther re|ated cond|t|ons Serves adulLs, ages 21 or older, who meeL lnsLlLuLlonal level of care
and choose Lo llve ln Lhe communlLy. 1hls walver ls deslgned Lo
maxlmlze opporLunlLles for members wlLh several condlLlons
lncludlng cerebral palsy and epllepsy. lL became effecLlve !uly 1,
2013, and wlll serve up Lo 70 lndlvlduals.
CharL lncludes only Lhe walvers and does noL lnclude amendmenLs Lo Lhe Medlcald sLaLe plan.


Med|ca|d Lstate-kecovery rogram

1he Medlcald LsLaLe-8ecovery rogram ls a federal-sLaLe program deslgned Lo recover
Medlcald-funded medlcal cosLs from Lhe esLaLes of Medlcald reclplenLs, lncludlng nurslng-home
resldenLs whose cosLs of care were covered by Medlcald. A clalm may noL be flled where Lhe
reclplenL ls under Lhe age of 33, or where Lhere ls a survlvlng spouse, mlnor chlld, or
bllnd/dlsabled chlld. 1he currenL law allows MalneCare Lo flle a clalm ln probaLe courL, flle llens
on properLy of Lhe probaLe esLaLe, and recover up Lo Lhe amounL of Medlcald expendlLures pald
on behalf of a deceased reclplenL. ln addlLlon, cerLaln Lransfers of asseLs prlor Lo or afLer
becomlng ellglble are prohlblLedG

Several facLors make maxlmlzlng nurslng-home recoverles lmporLanL for Malne. Malne
ranks elghLh hlghesL among sLaLes for elders 83 years or older, Lhe age cohorL mosL llkely Lo
requlre long-Lerm care. Malne also has Lhe hlghesL proporLlon of nurslng-home resldenLs wlLh
demenLla of any sLaLe (33) and Lhe second lowesL percenLage of resldenLs wlLh low-care
needs (2)G
FI


47. Arl Pouser, Wendy lox-Crage, and kaLhleen u[varl, Actoss tbe 5totes. ltoflles of looq-1etm
5etvlces ooJ 5oppotts, nlnLh LdlLlon, 2012.


146
MalneCare relmbursemenL Lo prlvaLe nurslng homes currenLly exceeds $230 mllllon
(uPPS Cfflce of MalneCare Servlces). AlLhough Malne has ranked abouL average of sLaLes,
collecLlng 1 Lo 2.3 (sLaLes range from 0 Lo 10.4) of nurslng-home spendlng or an annual
amounL of approxlmaLely $2.7 mllllon (uPPS uashboard Sl? 2010, accessed on 12/20/13) Lo $6
mllllon over Lhe pasL few years, Lhere remalns opporLunlLy Lo lncrease recoverles by uLlllzlng
besL pracLlces among sLaLes wlLh a hlgher percenLage of collecLlons.
48
1he scope of pollcy
opLlons for esLaLe recovery should be enhanced Lo lnclude ellmlnaLlng Lhe value of asseLs
exempL from recovery, pursulng spousal recoverles, lmposlng addlLlonal llens on ellglble
properLles, and hlrlng professlonal sLaff Lo pursue Lhe lncrease ln Lhe lnvenLory of probaLed
properLy.


48. ueparLmenL of PealLh & Puman Servlces Medlcald LllglblllLy for Long-1erm Care 8eneflLs Cfflce of
AsslsLanL SecreLary for ollcy & LvaluaLlon ollcy 8rlef #6, conLracL #PPS-100-03-0022.


147





13. Care Management]Va|ue-8ased urchas|ng In|t|at|ves


AlLhough MalneCare servlces have been dellvered prlmarlly Lhrough fee-for-servlce
provlder relmbursemenLs, slnce 2003, MalneCare has underLaken a number of care-
managemenL lnlLlaLlves Lhrough plloL programs and sLaLe plans under Lhe ACA.


r|mary-Care Case Management (CCM)

Malne lmplemenLed a prlmary-care case-managemenL (CCM) program ln 2004 when
approxlmaLely 163,000 MalneCare members were enrolled ln CCM wlLh Lhe hope of lncreaslng
access Lo prlmary care, promoLlng prevenLlve care, reduclng eplsodlc care, conLrolllng chronlc
condlLlons, and reduclng healLh-care cosLs. ApproxlmaLely 180,000 persons, or 73 of Lhe
ellglble MalneCare caseload, are currenLly parLlclpaLlng. MalneCare members on Medlcare and
home- and communlLy-based walvers, and chlldren wlLh speclal healLh-care needs, are noL
ellglble for CCM servlces. 1haL feaLure ls unllke mosL sLaLe Medlcald programs ln whlch some
or all elderly and dlsabled Medlcald reclplenLs are enrolled ln a LradlLlonal manage-care
organlzaLlon (MCC) or a care-managemenL program slmllar Lo Malne's CCM.

under Lhe CCM program, Lhe MalneCare enrollee has a prlmary-care physlclan (C)
who provldes a medlcal home" and manages and coordlnaLes care for Lhe member.
MalneCare pays parLlclpaLlng Cs a per-member per-monLh fee of $3.30 for Lhelr case-
managemenL responslblllLles. 1he CCM program also lncludes a pay-for-performance
componenL, Lhe rlmary Care hyslclan lncenLlve rogram (Cl). under Cl, parLlclpaLlng
Cs are Lracked for quallLy lndlcaLors and recelve regular performance reporLs, and MalneCare
pays an lncenLlve paymenL Lo Lhose Cs ranked above Lhe LwenLleLh percenLlle on speclfled
performance measures wlLhln Lhelr prlmary-care speclalLy. Lxamples of performance crlLerla
lnclude emergency-room uLlllzaLlon raLes, admlsslon raLes for avoldable hosplLallzaLlons, lead-
screenlng raLes, and mammogram raLes.


at|ent-Centered Med|ca| nomes (CMn)

ln 2010, Malne lnLroduced Lhe CMP model ln prlmary care for all ma[or payers
lncludlng MalneCare. 1he plloL program was a Lhree-year efforL lmplemenLlng a seL of Len Core
LxpecLaLlons." hyslclan pracLlces recelve a per-member paymenL for coordlnaLlon wlLh
communlLy-care Leams (CC1) LhaL also recelve paymenL from Lhe ma[or healLh-care payers.


148
State Innovat|on Mode| (SIM)

Malne has been selecLed by Lhe CenLer for Medlcare and Medlcald lnnovaLlon as one of
slx sLaLes Lo recelve a sLaLe lnnovaLlon model (SlM) award. 1hls federal award ls deslgned Lo
LesL a seL of bold changes Lo allgn lmprovemenL efforLs ln Lhe sLaLe and Lransform healLh-care
dellvery and paymenL sysLems. 1he $33 mllllon, Lhree-year award was made Lo Lhe governor's
offlce and ls led by uPPS and MalneCare, ln parLnershlp wlLh provlders, reclplenLs, and several
oLher organlzaLlons encompasslng a mulLl-payer neLwork.

1he overarchlng goal of Lhe Malne SlM lnlLlaLlve ls Lo achleve Lhe Lrlple alm" of
lmprovemenL: lmprove healLh-care quallLy and populaLlon healLh, lmprove paLlenL experlence
of care, and reduce healLh-care cosLs. 1hrough lLs SlM-funded efforLs, Lhe sLaLe ls worklng Lo
brlng LogeLher prlvaLe-publlc parLnershlps and allgn lmprovemenL efforLs across payers and
provlder groups, wlLh a sLrong focus on expandlng new paymenL models such as Lhe paLlenL-
cenLered medlcal home (CMP) and accounLable-care organlzaLlon (ACC) models.


nea|th nomes

MalneCare ls now uslng Lhe Llme-llmlLed enhanced nlneLy-Len maLch raLe lncluded ln
SecLlon 2703 of Lhe ACA Lo dellver coordlnaLlon and prevenLlve servlces for persons requlrlng
chronlc dlsease managemenL and long-Lerm care sysLem supporLs. 1he flrsL sLage began ln
!anuary 2013, wlLh MalneCare paymenLs Lo pracLlces quallfylng as healLh homes and CC1s. 8oLh
chlldren and adulL pracLlces are lncluded. SLage 8 wlll begln ln Sprlng 2014, as quallfled
communlLy menLal-healLh cenLers parLner wlLh prlmary-care provlders. CoordlnaLed care wlll
be provlded Lo lndlvlduals wlLh serlous menLal lllness or serlous emoLlonal dlsLurbance.
8elmbursemenL Lo pracLlces ls $12 MM, relmbursemenL for CC1s ls $129.30 MM. As of
november 2013, uPPS dld noL have a monLhly Lracklng of cases and cosLs, an lnlLlal query of
Lhe 1ruven daLabase ldenLlfled sevenLy-flve Lhousand persons classlfled as healLh-home
ellglble. uPPS esLlmaLes LhaL 63 of CCM members would quallfy for healLh homes (Mlchelle
rovosL, november 2012). hyslclan pracLlces noL quallfylng as a healLh home wlll recelve
paymenL as a CCM. lL ls noL clear how uPPS plans on flnanclng Lhe currenL cosLs or Lhe hlgher
sLaLe share once Lhe demonsLraLlon perlod ends.

1he nexL sLep ln Lhe value-based purchaslng lnlLlaLlve ls developmenL of ACCs sharlng
Lhe rlsk and savlngs deflned by quallLy benchmarks. ACCs wlll dellver prlmary-care servlces and
commlL Lo lnLegraLlng behavloral-healLh servlces. ACCs wlll be allowed Lo share ln savlngs only
or enhanced savlngs wlLh accepLance of rlsk corrldors.



149





14. Ma|neCare Cost Dr|vers


value-based purchaslng lnlLlaLlves have Lhe goal of dellverlng care Lhrough a more
coordlnaLed and cosL-effecLlve approach. ln order Lo deLermlne lf Lhese lnlLlaLlves wlll address
Lhose opporLunlLles, lL ls necessary Lo look aL boLh Lhe drlvers of expendlLures, as well as Lhe
caLegorles where growLh ls an ouLller Lo Lhe annual 3.3 growLh ln MalneCare over Lhe pasL Len
years and 3.2 growLh over Lhe pasL flve years.
49
LxpendlLures for hosplLals, resldenLlal, and
walver caLegorles comprlse 60 of Lhe MalneCare clalms pald ln Sl? 2013. Cf Lhose caLegorles,
only hosplLal clalms had an average flve-year growLh raLe exceedlng MalneCare's 3.2 growLh.
Powever, Lhe large share of MalneCare clalms and hlgher cosL per case for resldenLlal and
walver servlces warranL revlew for posslble paymenL reform.


nosp|ta|s

1he expanslon of ellglblllLy for adulLs and parenLs ln Lhe early 2000s lncreased hosplLal
spendlng beyond Lhe avallable monLhly prospecLlve paymenLs descrlbed below. 1he pracLlce of
Lhe CovernmenL AccounLlng SLandard 8oard generally would requlre Lhls lncurred, buL noL-pald
amounL, Lo be recorded as a year-end llablllLy. Powever, Lhe sLaLe lgnored Lhls llablllLy and
closed Lhe ensulng flscal years wlLh a growlng debL Lo Malne's LhlrLy-nlne communlLy hosplLals.
llnally seLLllng Lhe years afLer 2008, MalneCare made $490.2 mllllon ln paymenLs Lo hosplLals as
auLhorlzed under ubllc Law 2013, chapLer 269. 1he $183.3 mllllon sLaLe share of Lhese
paymenLs was funded uslng Lhe bond proceeds from Lhe sale of llquor-operaLlon revenue
bonds. 1hese funds were maLched by $306.7 mllllon ln federal funds.

1oLal MalneCare lnpaLlenL and ouLpaLlenL paymenLs Lo hosplLals ln Sl? 2013 amounLed
Lo $618 mllllon, or a 24.1 share of MalneCare cosLs, Lhe largesL provlder group. lor lnpaLlenL
servlces, hosplLals recelved an eplsode-based paymenL based on a u8C (ulagnosLlc 8elaLed
Croups) sysLem ln place slnce !uly 2011. revlously lnpaLlenL and ouLpaLlenL clalms were pald
prlmarlly wlLh prospecLlve lnLerlm paymenLs (l) wlLh a cosL-based, year-end seLLlemenL. lrom
Sl? 2008-13, Lhe LoLal of lnpaLlenL, ouLpaLlenL, and l paymenLs, lncludlng seLLlemenLs and
uSP paymenLs, lncreased from $317.4 mllllon Lo $618 mllllon, an annual growLh raLe of 3.3
(noL ad[usLed for Lhe $490.2 seLLlemenL debL). Cn !uly 1, 2012, Malne began paylng ouLpaLlenL
clalms based on AC (ambulaLory paymenL classlflcaLlon) fee schedules.

49. CalculaLed as compounded annual growLh raLe over Sl? 2008-13.


130
Long-1erm Care for L|der|y and Adu|ts w|th hys|ca| D|sab|||t|es

1he second mosL expenslve parL of Lhe MalneCare budgeL ls long-Lerm care sysLem
supporLs. When coupled wlLh acuLe hosplLal servlces, Lhe Lwo caLegorles comblned represenLed
38 of MalneCare spendlng ln Sl? 2013 (see CharL 11-2: hosplLal, resldenLlal, and PC8S-walver
expendlLure caLegorles).

nurslng homes, resldenLlal care ln nMls and adulL famlly homes, walvers for elders and
adulLs, personal care, home healLh, and prlvaLe-duLy nurslng LoLaled $344.2 mllllon ln Sl? 2013
(uPPS AnalyLlcs). AlLhough Lhe ma[orlLy of Lhese members have Lhlrd-parLy lnsurance,
Medlcare (dual ellglble) and prlvaLe healLh lnsurance cover llLLle of Lhelr long-Lerm care needs.
nurslng homes recelved $242 mllllon, Lhe second largesL provlder of servlce ln MalneCare afLer
Lhe developmenLal-dlsablllLy walvers. nurslng-home Medlcald days have been decllnlng slnce
Sl? 2008, conLrlbuLlng Lo an average annual decrease ln expendlLures of 1.93.

Slnce Sl? 2000, resldenLlal-servlce cosLs have been falllng whlle home-based servlce
expenses conLlnue Lo represenL a greaLer share of L1SS. Powever, Lhls Lrend has sLalled slnce
Sl? 2008 as resldenLlal servlces for elders and lndlvlduals wlLh dlsablllLles remalns abouL 87 of
all L1SS. Moreover, L1SS servlces conLrlbuLe Lo a slgnlflcanL number of hlgh-cosL cases.
30


CharL 14-1: Lst|mates of Average Age of L1C Users by Sett|ng, SI 2010
Source: Muskle School of ubllc Servlce.

30. uPPS, Clder AdulLs and AdulLs wlLh ulsablllLles: opulaLlon and Servlce use 1rends ln Malne,"
2012.


131
nurslng-faclllLy raLes are based on a provlder's allowable cosLs compared Lo Lhe mosL
efflclenL operaLors. MalneCare dally raLes are approxlmaLely 69 of Lhe average prlvaLe raLe of
$273 per day. 1hls has resulLed ln a loss of approxlmaLely $21 per Medlcald bed day.
31
1he Lwo
PC8S walver programs for elders and adulLs wlLh physlcal dlsablllLles provlde help wlLh
housekeeplng, chores, meals, and oLher servlces Lo reclplenLs who would need nurslng-home
care buL for Lhese servlces. 1he raLlo of Lhe sLaLe's L1C expendlLures for lnsLlLuLlonal and
resldenLlal care versus home- and-communlLy-based servlces has decreased slnce Sl? 2008, buL
Lhe raLlo remalns aL 87 Lo 13 lnsLlLuLlonal-resldenLlal Lo communlLy- based servlces,
excludlng servlces for lndlvlduals wlLh lnLellecLual dlsablllLles.

1hls comparlson ls aL odds wlLh Lhose reporLed ln Lhe sLaLe's 8alance lncenLlve rogram
(8l). 1he 8l lncludes a raLlo of 31 Lo 49 buL lncludes servlces for lndlvlduals wlLh
developmenLal dlsablllLles and may classlfy resldenLlal servlces as communlLy based. More
lmporLanLly, Lhe use of elLher resldenLlal or lnsLlLuLlonal seLLlngs remalns hlgh, conLrlbuLlng Lo
Lhe hlgh cosL of members uslng L1SS. ln Sl? 2010, 71 of hlgh-cosL members (meanlng Lhe Lop
3 of Lhe hlghesL cosL MalneCare enrollees) used long-Lerm care supporLs LhaL represenLed
33 of Lhe hlgh-cosL members' clalm paymenLs (uPPS Plgh CosL Member lacL SheeL, 2010).


Ind|v|dua|s w|th Deve|opmenta| D|sab|||t|es

1he Lhlrd largesL group of servlces lncludes persons wlLh auLlsm and developmenLal
dlsablllLles, maklng up more Lhan $330 mllllon of Lhe Medlcald budgeL. ln conLrasL Lo Lhe L1SS
servlces for Lhe elderly, Lhe sLaLe's conLlnuum of care for Lhe developmenLally dlsabled ls
welghLed much more Loward Lhe communlLy-based walver servlces. 1he share of spendlng on
communlLy provlders compared Lo large lnsLlLuLlonal provlders ls [usL Lhe reverse of Lhe elderly
long-Lerm care caLegory, however, servlces are sLlll welghLed Loward group resldenLlal care,
alLhough ln smaller seLLlngs.

1he predomlnanL means for provldlng servlces Lo lndlvlduals wlLh developmenLal
dlsablllLles ls Lhe PC8S walver program, whlch pays for an array of supporLs Lo help lndlvlduals
remaln ln Lhe communlLy as opposed Lo an lnsLlLuLlon. ln 2013, MalneCare provlders served
more Lhan four Lhousand lndlvlduals ln Lhe lnLellecLual/developmenLal dlsablllLy (l/uu) walver
programs, lncludlng 2,833 ln Lhe SecLlon-21 comprehenslve resldenLlal program, as compared
Lo approxlmaLely Lwo hundred lndlvlduals ln Lhe larger prlvaLe resldenLlal seLLlngs known as
lnLermedlaLe-care faclllLles (lCl) for lndlvlduals wlLh developmenLal dlsablllLles. MalneCare
l/uu-walver servlces are consLralned by person llmlLs of 2,933 and 1,430 for SecLlon 21 and 29,
respecLlvely. AlLhough Lhe expendlLures ln Lhe l/uu walver lncreased by only 1.4 per year -
and lCl programs decreased an average 1.3 - beLween 2008 and 2013, Lhe average
expendlLure per reclplenL was $77,736 ln Sl? 2010, far greaLer Lhan Lhe cosL ln oLher new

31. A 8eporL on ShorLfalls ln Medlcald lundlng for nurslng Pome Care," LL!A?, LLC for Lhe Amerlcan
PealLh Care AssoclaLlon, uecember 2011.


132
Lngland sLaLes.
32
Cnly 8hode lsland spenL more on l/uu-walver servlces per clLlzen. 1hese cosLs
do noL lnclude Lhe oLher medlcal servlces LhaL are provlded Lhrough Lhe MalneCare fee-for-
servlce program.

CharL 14-2: I]DD Wa|ver Spend|ng per C|t|zen, 2011
State Spend|ng
1op I|ve
8hode lsland $236
Malne $222
new ?ork $222
MlnnesoLa $207
vermonL $196
8ottom I|ve
llllnols $36
Ceorgla $34
1exas $29
nevada $23
Mlsslsslppl $13
Source: hLLp://sLaLeofLhesLaLe.com.


lL ls noL clear lf Lhe sLaLe ls seeklng l/uu provlders (ln coordlnaLlon wlLh prlmary-care
physlclans) as healLh homes Lo coordlnaLe all Lhe care for lndlvlduals wlLh developmenLal
dlsablllLles. 1here are oLher alLernaLlve fundlng models LhaL may provlde more approprlaLe and
cosL-effecLlve servlces for Lhls populaLlon LhaL are dlscussed ln Lhe lasL chapLer of Lhls reporL.
Powever, AC has noL yeL revlewed Lhe daLa necessary Lo provlde a formal recommendaLlon.
1hese wavler servlces have been overwhelmed by conLlnulng walLlng llsLs currenLly LoLallng
1,401 lndlvlduals. lL ls hoped LhaL use of Lhe recommended alLernaLlve dellvery sysLems wlll
allevlaLe Lhe backlog for mosL of Lhese underserved persons.


32. uPPS, Clder AdulLs and AdulLs wlLh ulsablllLles: opulaLlon and Servlce use 1rends ln Malne,"
2012 LdlLlon.


133
CharL 14-3: Wa|t||sts for State-Iunded and Ma|neCare rograms


CharL 14-3 dlsplays Lhe walLllsL counL - and average operaLlng cosLs - of sLaLe-only
home-based servlces as well as federal walver servlces for lndlvlduals wlLh lnLellecLual
dlsablllLles, physlcal dlsablllLles, and braln ln[urles. 1he LoLal number of persons walLlng for
servlces for all programs ls sllghLly less Lhan LhlrLy-Lwo hundred. 1hls number ls larger Lhan Lhe
acLual walLllsL due Lo Lhe allowance for enrollmenL ln more Lhan one program. SLaLe fundlng
alone would noL ellmlnaLe Lhls walLllsL slnce wavler llmlLs would prevenL fllllng all requesLs.
ChapLer 16 ouLllnes a budgeLlng lnlLlaLlve LhaL ellmlnaLes boLh lndlvldual program fundlng and
enrollmenL llmlLs whlle allowlng Lhe use of leasL-resLrlcLlve care seLLlngs. All programs llsLed
offer a range of servlces LhaL lnclude personal asslsLance ln Lhe home wlLh acLlvlLles for dally
llvlng such as baLhlng, dresslng, meal preparaLlon, and housekeeplng. AddlLlonal servlces
lnclude lnpaLlenL cosLs aL nurslng faclllLles and oLher resldenLlal-care servlces.


Menta| nea|th

MenLal-healLh servlces for 6 of Lhe adulL MalneCare populaLlon accounL for 19 of
adulL MalneCare expendlLures.
33
8esldenLlal-care and behavloral-healLh cosLs represenL Lhe

33. resenLaLlon Lo Lhe AS-uPPS CuarLerly uaLa lorum, uPPS Cfflce of ConLlnuous CuallLy
lmprovemenL and Muskle School of ubllc Servlce, May 30, 2013.
!"#"$%&'()$) +,-.,#/01
2-(0'/$,%)3,$4"$) 5-/$ 6#0$) 2#,$ !" #$%&'"" #)*%&"""
5-/$ 6#0$) 2#,$ '+ #%&%,- #%)!&+-+
5-/$ 6#0$) 2#,$ 700$00/$(" 8#3"930" !+- #%&%,- #!&$*%&,*-
5-/$/#:$, ;<()$=$()$(" !'==-," !$,>34$0? $)** #$&+!% #$&'--&),-
7(('#9 !"#"$%&'()$) +,-.,#/ @$$)0 A-"#90 BCDED #,&),,&)'- #,&),,&)'-
F#3($2#,$ +,-.,#/01
!$4"3-( GBC 5-/$ #() 2-//'(3"H 6#0$) !$,>34$0
2-/=,$I$(03>$ 8#3>$,
!$4"3-( GJC 5-/$ #() 2-//'(3"H 6#0$) 8#3>$,
!'==-," 8#3>$,
+IH034#99H K30#L9$) 8#3>$, *+ #!*&*$' #*%%&-%% #!&",$&!"-
6,#3( <(M',H N$03)$("3#9 !$,>34$0 !$ #',&-', #**!&-%' #!&""'&,',
7(('#9 F#3($ 2#,$ A-"#90 ;!"#"$ &'()0 -(9H? BCOPB #+"&"),&-""
A-"#9 !"#"$ &'()3(. @$$)$) QOPCEJRCJJS
A-"#9 !"#"$ T &$)$,#9 QBRJCODJCBJD
+-* #!!&""" #)&',"&),) #$"&!*+&"""
8#3"930"
;70 -U GVBVBO?
7>$,#.$ ++ 7(('#9
2-0" ;!"#"$ &'()0
-(9H?
7(('#9 !"#"$ 2-0"
"- &'()
7(('#9 !"#"$ T &$)$,#9
2-0" "- &'()
%%' #$"$&""" #)+&,!)&%*" #%'&*%'&"""


134
hlghesL cosL caLegorles for people wlLh menLal lllness. 8ehavloral-healLh cosLs lnclude
communlLy lnLegraLlon, subsLance abuse, day LreaLmenL, home-based menLal healLh, rehab
servlces, soclal worker, and cllnlcal counselors. MenLal-healLh relaLed hosplLal lnpaLlenL-and-
ouLpaLlenL cosLs are also ma[or cosL drlvers buL are lncluded wlLh nMl menLal-healLh
resldences ln Lhe broader hosplLal and resldenLlal/long-Lerm care caLegorles. Lxcludlng hosplLal
and resldenLlal cosLs, MalneCare spenL $196 mllllon, a 7.3 share, for communlLy menLal-
healLh servlces ln Sl? 2013.

MalneCare menLal-healLh communlLy spendlng has grown by more Lhan 116 slnce Sl?
2008, or an average annual growLh raLe of 17. 1hls lncrease would be less of a concern had
LoLal sLaLe spendlng by Malne's Cfflce of MenLal PealLh and SubsLance Abuse reallzed offseLLlng
savlngs. MosL sLaLe menLal-healLh fundlng goes Lo cenLers and cllnlcs operaLed by prlvaLe flrms.
A much smaller porLlon funds sLaLe hosplLals. Covetoloq Moqozloe examlnes LoLal sLaLe menLal-
healLh per-caplLa spendlng ln all seLLlngs, lncludlng prlsons. 8y Lhls measure, Lhe ulsLrlcL of
Columbla and Malne reporLed Lhe hlghesL per-caplLa raLes ln l? 2010. Malne ls confldenL LhaL
Lhe recenLly enhanced care managemenL under Lhe ACA home-healLh opLlon wlll ald ln bendlng
Lhese sLeep cosL curves, however, Lhe healLh-home lnlLlaLlve - whlle currenLly LreaLlng
lndlvlduals wlLh subsLance abuse - has yeL Lo lnLegraLe reclplenLs wlLh dlagnoses such as
serlous and perslsLenL menLal lllness, a conLrlbuLor Lo Lhls above-average growLh.

ln Lhe subsLance-abuse fleld, confldenLlallLy ls governed by federal law (42 u.S.C.
290dd-2) and regulaLlons (42 Cl8 arL 2), whlch ouLllne under whaL llmlLed clrcumsLances
lnformaLlon abouL Lhe paLlenL's LreaLmenL may be dlsclosed wlLh and wlLhouL Lhe paLlenL's
consenL. ueLermlnlng when 42 Cl8 arL 2 ls appllcable and how Lo legally access lnformaLlon
abouL subsLance-abuse LreaLmenL requlres pracLlLloners Lo work Lhrough a mulLlLude of
quesLlons. As a resulL, lL ls ofLen necessary for sLaLes Lo phase-ln behavloral-healLh servlces Lo
devoLe Lhe necessary resources Lo properly proLecL paLlenL lnformaLlon.



133
CharL 14-4: Menta|-nea|th Spend|ng |n New Lng|and
SI 2010
State 1ota| Lxpend|tures
Lxpend|ture
er-Cap|ta
er-Cap|ta
kank
overty er-
Cap|ta
Lxpend|ture
overty
er-Cap|ta
kank
Ma|ne (1) 54S9,680,997 5346.92 2 51,972.88 1
vermonL $130,000,000 $239.84 6 $1,483.13 3
ConnecLlcuL (2) $673,300,000 $189.34 9 $1,639.71 3
new Pampshlre $192,390,991 $146.40 17 $1,336.27 7
MassachuseLLs (3) $714,300,000 $109.07 24 $663.70 20
8hode lsland (4) $94,919,34 $90.31 30 $494.37 30
Source: naLlonal AssoclaLlon of SLaLe MenLal PealLh rogram ulrecLors 8esearch lnsLlLuLe, Covetoloq
Moqozloe, 2010.

(1) 1oLals lnclude funds for menLal healLh servlces ln [alls and prlsons.
(2) Medlcald revenues for communlLy programs and chlldren's menLal healLh noL lncluded.
(3) Medlcald revenues for communlLy programs noL lncluded.
(4) Chlldren's menLal healLh expendlLures are noL lncluded.



136



137





1S. harmacy System


1he MalneCare sysLem noL only provldes reclplenLs affordable access Lo medlcaLlons buL
also manages cosL and quallLy. 1he MalneCare pharmacy programs serve a populaLlon
predomlnanLly comprlsed of younger adulLs and chlldren. Whlle Malne's 63-and-above age
group ls pro[ecLed Lo grow aL a raLe LhaL exceeds oLher new Lngland sLaLes and Lhe naLlon,
slnce 2006, lndlvlduals who are also ellglble for Medlcare recelve pharmacy beneflLs Lhrough
Medlcare arL u drug plans. 1hls lncludes a ma[orlLy of elders recelvlng long-Lerm nurslng-home
care. An esLlmaLed 23 of MalneCare reclplenLs are Medlcare-ellglble elderly or adulLs wlLh
dlsablllLles LhaL recelve Lhelr pharmacy beneflLs Lhrough Medlcare, raLher Lhan Lhrough Lhe
MalneCare pharmacy program.

A brlef revlew of Lhe MalneCare pharmacy program was conducLed ln !anuary 2014.
lnformaLlon sources revlewed lncluded program descrlpLlons provlded vla publlcly avallable
reporLs and webslLes, posLed pollcles and meeLlng mlnuLes of Lhe MalneCare urug uLlllzaLlon
8evlew 8oard, and lnLervlews of MalneCare pharmacy program admlnlsLraLors. llndlngs are
presenLed below, caLegorlzed ln four secLlons: aymenL and rlclng, urug Coverage ollcy,
urugs of Abuse, and opulaLlon PealLh and harmacy Servlces.


ayment and r|c|ng

Drug ke|mbursement. MalneCare prescrlpLlon-drug relmbursemenL raLes are wlLhln Lhe
range esLabllshed across mosL sLaLes. lor brand name producLs, relmbursemenL ls seL aL Lhe
lesser of Lhe average wholesale prlce (AW) -16, or Lhe wholesale acqulslLlon cosL (WAC)
+0.8. 1he dlspenslng fee pald Lo pharmacles ls $3.33 (per prescrlpLlon). 8elmbursemenL for
brand drugs ls generally comparable Lo nelghborlng sLaLes: Lhe new Pampshlre brand-drug
relmbursemenL raLe ls Lhe lesser of AW -16 or WAC +0.8, wlLh a dlspenslng fee of $1.73,
whlle Lhe brand-drug relmbursemenL raLe ln vermonL ls AW -14.2, wlLh an ln-sLaLe
dlspenslng fee of $4.73.

MalneCare relmbursemenL for generlc producLs ls seL aL Lhe lower of AW -13 or WAC
+4.4, wlLh Lhe same dlspenslng fee ($3.33). As many generlc producLs are avallable from
mulLlple manufacLurers, relmbursemenL ls also capped aL Lhe lesser of Lhe CMS federal upper
llmlL for relmbursemenL, or Lhe maxlmum allowable cosL seL by Malne. AddlLlonally, a
supplemenLal dlspenslng fee of up Lo 63 cenLs ls provlded Lo rural pharmacy provlders.


138
MedlcaLlons dlsLrlbuLed Lhrough speclalLy pharmacy provlders are relmbursed aL a
sllghLly lower raLe (lesser of AW -17 or WAC -0.4, plus a $3.33 dlspenslng fee).

Lfflclencles of mall-order dlsLrlbuLlon are leveraged by MalneCare, whlch relmburses
Lhese provlders Lhe lesser of AW -60 or WAC -32. 1he dlspenslng fee pald Lo mall-order
pharmacles ls $2.30.

MosL sLaLe Medlcald programs have added a WAC-based scheme ln response Lo
publlshers plannlng Lo cease reporLlng Lhls benchmark, and also as a means Lo closer allgn
relmbursemenL wlLh acLual cosL. 1he WAC reflecLs Lhe llsLlng prlce for a drug producL as sold by
Lhe manufacLurer, and more closely represenLs Lhe pharmacy's acLual purchase prlce as
compared wlLh AW, whlch was wldely recognlzed as an lnflaLed sLlcker" prlce. Powever, WAC
does noL reflecL all dlscounLs recelved (e.g., for Llmely paymenL or bulk purchaslng), and cannoL
be audlLed pracLlcally. SLaLes lncludlng Alabama, Colorado, and Cregon have lmplemenLed an
acLual-acqulslLlon cosL (AAC) relmbursemenL scheme LhaL allgns relmbursemenL more closely
wlLh acLual pharmacy purchase prlce, as verlfled Lhrough perlodlc reporLlng requlred of Lhe
pharmacy. As Lhe AAC benchmark ls llkely Lo resulL ln decreased relmbursemenL, sLaLes shlfLlng
Lo Lhls meLhod have lncreased Lhe pharmacy-dlspenslng fee (for example, from $3.40 Lo $10.60
ln Alabama). lurLher analysls and modellng may reveal cosL savlngs ylelded from Lhls approach.
Powever, declslon-makers musL ensure LhaL any change ln relmbursemenL pollcy does noL
LhreaLen access Lo pharmacy provlders, parLlcularly Lhose servlng lndlvlduals ln rural areas.

kebates. 8y federal mandaLe, drug manufacLurers provlde rebaLes Lo all sLaLe Medlcald
pharmacy programs, as based upon volume of uLlllzaLlon. Slnce 1996, Lhe rebaLe provlded for
lnnovaLor (brand) medlcaLlons was seL aL Lhe greaLer of 13.1 of Lhe average manufacLurer
prlce (AM) or Lhe margln beLween AM and Lhe lnflaLlon-ad[usLed besL-unlL prlce. lor generlc
drugs, Lhe rebaLe has been seL aL 11 of Lhe AM. 1he Affordable Care AcL lncreases Lhe rebaLe
amounL Lo 23.1 of AM for lnnovaLor drugs, and 13 of AM for generlc producLs, however
Lhe lncrease ln Lhls range wlll be dlrecLed federally and noL shared wlLh sLaLes. AddlLlonally,
Malne Medlcald ls a member of Lhe mulLl-sLaLe Soverelgn SLaLes urug ConsorLlum, whlch
provldes a purchaslng pool Lo maxlmlze supplemenLal rebaLe opporLunlLles.

As coupled wlLh MalneCare's referred urug LlsL (uL), Lhe mandaLed and supplemenLal
rebaLes can resulL ln neL drug cosLs LhaL approxlmaLe generlc drug cosLs or, ln some lnsLances,
fall below Lhe cosL of generlc alLernaLlves. 8roadly, managed care has ylelded dramaLlc cosL
savlngs by drlvlng lncreases ln Lhe use of generlc producLs. 1he u.S. Cenerlc harmaceuLlcal
AssoclaLlon reporLed LhaL savlngs assoclaLed wlLh Lhe uLlllzaLlon of generlc drugs ln 2012
LoLaled an esLlmaLed $217 bllllon. lncreases ln generlc medlcaLlon uLlllzaLlon wlLhln Medlcald
would reallze savlngs measured ln Lerms of reduced pharmacy relmbursemenLs. Powever,
decreases ln rebaLes for branded producLs would be a Langlble offseL. 1argeLed, conLlnual
evaluaLlon of brand/generlc alLernaLlves ls necessary Lo ldenLlfy whlch sLraLegy ylelds Lhe
greaLesL cosL savlngs (l.e. promoLlng generlc use versus maxlmlzlng branded producL rebaLe),
parLlcularly glven Lhe dynamlc naLure of drug prlclng, LherapeuLlc compeLlLlon, and drug paLenL
llfe. Accordlngly, MalneCare publlshes a 8rands referred Cver Cenerlc verslon LlsL."


139
Drug Coverage o||cy

referred Drug L|st. 1he MalneCare pharmacy beneflL ls managed by Coold PealLh
SysLems (CPS), whlch lmplemenLs Lhe uL and relaLed acLlvlLles, ln concerL wlLh a robusL
managemenL lnformaLlon sysLem supporLed by unlsys CorporaLlon. 1he uL ls well deslgned
and updaLed regularly Lo reflecL changes ln drug evldence, prlclng, and avallablllLy. SLepped
Lherapy proLocols ensure LhaL hlgher-cosL medlcaLlons are uLlllzed only when medlcally
[usLlfled, and lnclude essenLlal cllnlcal conslderaLlons.

1he MalneCare urug uLlllzaLlon 8evlew (uu8) 8oard, comprlsed of physlclans,
pharmaclsLs, and oLher experLs, conducLs evaluaLlons and assesses medlcaLlon use wlLhln
speclflc populaLlons, conslderlng parLlcular areas of medlcaLlon safeLy and quallLy. 1he
MalneCare uu8 8oard also serves as Lhe program's drug formulary commlLLee, acLlng Lo add
and remove drugs from Lhe uL. 1he MalneCare uu8 8oard, CPS, and Lhe sLaLe pharmacy
admlnlsLraLors work ln concerL Lo provlde a hlgh-quallLy pharmacy beneflL LhaL promoLes access
Lo necessary drug Lheraples wlLh a focus on cosL conLalnmenL.

Llke all sLaLe Medlcald programs, medlcaLlons for menLal-healLh dlagnoses are a leadlng
cosL caLegory. 8esLrlcLlng access Lo expenslve Lheraples, such as aLyplcal anLlpsychoLlc
medlcaLlons, has been applled as a sLraLegy Lo mlLlgaLe cosL. CurrenLly, open access Lo aLyplcal
anLlpsychoLlcs and anLldepressanLs are provlded for several preferred drugs, whlle Lhe
remalnlng drugs ln Lhese classes are deslgnaLed as non-preferred, requlrlng prlor auLhorlzaLlon
for coverage. Some evldence suggesLs LhaL Lhls pollcy has noL resulLed ln unLoward paLlenL
healLh ouLcomes,
34
whlle oLhers have reporLed LreaLmenL dlsrupLlons.
33
Clven LhaL
hosplLallzaLlons for menLal-healLh condlLlons represenL 10 Lo 12 of all heaLh-care uLlllzaLlon
expense, careful and conLlnual assessmenL of Lhe lmpacL of Lhe uL on access Lo anLlpsychoLlc
and anLldepressanL medlcaLlons ls warranLed.

Spec|a|ty Drugs. Llke all pharmacy-beneflL provlders, Lhe program ls challenged Lo
address Lhe rlslng expendlLure pro[ecLed for hlgh-cosL speclalLy medlcaLlons. 1hese medlcaLlons
lnclude long-acLlng formulaLlons of aLyplcal anLlpsychoLlcs, producLs for auLolmmune dlsorders,
and varlous oLher ln[ecLable producLs spannlng a range of condlLlons. ln lLs urug 1rend` reporL,
Lhe pharmacy-beneflL organlzaLlon Lxpress ScrlpLs documenLs a 16.7 yearly lncrease ln overall
Medlcald spendlng for speclalLy drugs, as compared wlLh a mlnlmal 1.3 lncrease ln
expendlLures for convenLlonal drugs. volume-drlven rebaLes and uL placemenL wlll llkely be
lnsufflclenL as sLraLegles Lo mlLlgaLe Lhe pro[ecLed lncreases ln speclalLy drug cosLs over Lhe
nexL decade. ln addlLlon Lo Lhe developmenL of evldence-based prlor auLhorlzaLlon proLocols,
cosL-mlLlgaLlng LacLlcs commonly consldered lnclude supply-channel managemenL, ouLcomes-

34. Alyce S. Adams eL al., rlor AuLhorlzaLlon for AnLldepressanLs ln Medlcald: LffecLs among ulsabled
uual Lnrollees," Atcblves of lotetool MeJlcloe 169.8 (Aprll 27, 2009): 730-36.
33. S. 8. Soumeral eL al., use of ALyplcal AnLlpsychoLlc urugs for Schlzophrenla ln Malne Medlcald
lollowlng a ollcy Change," neoltb Affolts 27.3 (May-!une 2008): w183-w193.


160
based relmbursemenL, augmenLed case managemenL, and dlrecLlng paymenL Lhrough Lhe
medlcal beneflL.

MalneCare has developed a pharmacy-care managemenL program deslgned Lo helghLen
Lhe managemenL of hlgh-cosL pharmaceuLlcals. Case managemenL ls a common approach,
provldlng overslghL and supporL for hlghesL-cosL cases. lor paLlenLs uLlllzlng speclalLy
pharmaceuLlcals, key aspecLs of case managemenL mlghL lnclude ln-depLh paLlenL educaLlon
regardlng approprlaLe admlnlsLraLlon and self-managemenL, close LherapeuLlc monlLorlng by
cllnlcal provlders, and Lhe lnvolvemenL of pharmaclsLs Lo assure LhaL medlcaLlon ls noL
sLockplled or wasLed. lmporLanLly, Lhese Lechnlques may reduce cosLs assoclaLed wlLh
unnecessary use or adverse evenLs, yeL wlLh llmlLed effecL on LoLal drug expendlLures.


Abuse of Drugs

Cveruse and abuse of narcoLlc paln medlcaLlons ls a naLlonal epldemlc. ln 2013,
MalneCare lmplemenLed Lwo pollcles addresslng Lhe uLlllzaLlon of medlcaLlons for paln and
oplaLe addlcLlon. Cne pollcy perLalns Lo Lhe prescrlblng of oral oplold medlcaLlons, whlch have
been llmlLed Lo up Lo a forLy-flve-days supply of medlcaLlon over a Lwelve-monLh perlod.
AddlLlonally, chronlc users of narcoLlc paln medlcaLlons are requlred Lo Lry oLher non-drug
opLlons for paln rellef. 1he second pollcy seL a llfeLlme llmlL of LwenLy-four monLhs for Lhe use
of buprenorphlne/naloxone (Suboxone) for Lhe LreaLmenL of oplold addlLlon. 1hese pollcles
are progresslve, almlng Lo address Lhls publlc-healLh concern. 1he Summer-lall 2013 lssue of
Lhe MalneCare's uL newsleLLer noLes LhaL Lhe pollcles are beglnnlng Lo reduce Lhe level of use
of Lhese medlcaLlons. ?eL formal evaluaLlon of Lhe success of Lhese pollcles should lnclude
measurlng unlnLended ouLcomes, such as lncreases ln use of alLernaLlves (buprenorphlne and
oxycodone) and Lhe use of emergency servlces for oplaLe lnLoxlcaLlon, as well as conslderlng
Lhe poLenLlal soclal consequences such as crlme and faLal overdoses.


opu|at|on nea|th and harmacy Serv|ces

1he dlssemlnaLlon of Lhe medlcal-home model presenLs slgnlflcanL opporLunlLy for
lnLegraLlng pharmacy lnLo care-dellvery models. 1hls can be consldered from Lhree
perspecLlves: 1he role of medlcaLlons ln achlevlng alms for populaLlon healLh and prevenLlve
care, Lhe role of cllnlcal pharmacy servlces as dellvered wlLhln an lnLerdlsclpllnary ambulaLory-
care model, and leveraglng Lhe sLaLe's healLh-lnformaLlon exchange and oLher lnformaLlon
Lechnology Lo vlrLually connecL pharmaclsLs wlLh prescrlbers and paLlenLs Lo prevenL adverse
drug evenLs, promoLe medlcaLlon adherence, and maxlmlze drug efflcacy.

MedlcaLlons are fundamenLal Lowards achlevlng alms for populaLlon healLh and
prevenLlve care. lor example, paLlenLs wlLh menLal-healLh condlLlons are aL lncreased rlsk of
developlng cardlovascular dlsease and dlabeLes, parLly as a resulL of Lhe medlcaLlons prescrlbed


161
for Lhelr lllness. MedlcaLlons for blood pressure and glycemlc conLrol are cruclal aspecLs of
prevenLlng dlsease progresslon and compllcaLlons. AddlLlonally, Lhe pharmacy program can
dellver a range of healLh-promoLlon acLlvlLles, lncludlng provldlng lmmunlzaLlons and offerlng
smoklng-cessaLlon programs. Cpenness Lo new paymenL meLhods provldes an opporLunlLy for
conflgurlng Lhese servlces wlLhln rlsk-based global paymenL models.

Slmllarly, prospecLlve relmbursemenL allgned wlLh Lhe medlcal-home model of care
affords flexlblllLy ln sLafflng Lhe cllnlc wlLh healLh-care provlders LhaL besL meeL Lhe needs of
paLlenLs. harmaclsLs worklng ln ambulaLory-care seLLlngs manage medlcaLlon reglmens,
provlde guldance for drug selecLlon and monlLorlng, educaLe paLlenLs, and reconclle medlcaLlon
llsLs among provlders and across seLLlngs. Moreover, Lhe pharmaclsL ln Lhe medlcal-home
model ls ldeally slLuaLed Lo help paLlenLs and provlders uLlllze speclalLy pharmaceuLlcs
effecLlvely.

LasLly, lnformaLlon Lechnologles can vlrLually connecL pharmaclsLs Lo prescrlbers and
paLlenLs ln a varleLy of ways LhaL serve Lo promoLe safe medlcaLlon use whlle reduclng wasLe.
l1-connecLed pharmaclsLs can revlew drug-dlspenslng daLabases Lo assess paLlenL adherence or
check for abuse, whlle also checklng recenL laboraLory resulLs prlor Lo dlspenslng a medlcaLlon.



162




163





16. Med|ca|d I|ex|b|||ty and I|sca| Certa|nty:
1he rom|se of G|oba| keform


Medlcald's purpose ls flrmly rooLed ln law: 1o furnlsh rehablllLaLlon and oLher servlces
Lo help such famllles and lndlvlduals aLLaln or reLaln capablllLy for lndependence or self care."
36

uesplLe Lhls orlglnal charLer, subsequenL amendmenLs of Lhe law and many Lhousands of
regulaLlons promulgaLed by Lhe federal CMS have burdened Lhe Medlcald program wlLh a
defaulL focus on lnsLlLuLlonal care, a blas Loward relmbursemenL of hlgh-cosL seLLlngs and
servlces, and an lnefflclenL sysLem of provlders and care glvers.

1he lnsLlLuLlonal blas and lnefflclencles remaln even Lhough mosL Medlcald long-Lerm
care reclplenLs would prefer Lo sLay aL home and mosL quallLy-drlven Medlcald provlders would
raLher be dellverlng more lucraLlve posL-acuLe care and rehablllLaLlon servlces. Moreover, Lhe
blas remalns enLrenched even as pollcymakers have been Lrylng for decades Lo rebalance"
Medlcald's long-Lerm care sysLem so LhaL Lhe frall elderly and people wlLh dlsablllLles have
access Lo beneflLs no maLLer where Lhey recelve care. And lL conLlnues Lo shape Lhe program
even Lhough Lhe Supreme CourL ruled fourLeen years ago LhaL persons wlLh dlsablllLles had Lhe
legal rlghL Lo care ln communlLy seLLlngs whenever posslble.
37
!"#$$#% '()$ *+," +,-. (.
!"#$%&$# ()*+-!"#$ &'#" ()**'#+ ,'!-),.-(" &),!-,/" !) 0" !"#$% '$ $()!*$+-!"#$ &$'()*$&+

!"#$% '()* +%,#-!"# !#%"&"'()!(*)' +*,-# -"./ (* '// (0"' "&'("(,("*&!- 1"!' 2*%/ (* !&
!"#$ &!#!'() *+),-./(0!'1 2(3! .!4 4+ /(0! 5!#,-(,# (11,14("-! !67()). (3(,)(8)! '!9('#)!11 +&
!"#$# &'(()$*& +,- &#$./0#& +$# ,##-#- - !" $%! &'()*'"+ ,%'-. /%' )++0' $1+ &'21,'& $%'3
!"#$%&'' )*' +"#',-&%,#$ ./& !"!! #$% &'()'*+,- #&./*+0! -$11+-%./1 2/&3 )20+-% 45'/1+- %2
!"# %&''#(! )(*!)!&!)+(,--. /,*#0 "+1#-!"#$%&! ()($"*+ ,-%" %"!"#$.)/ $0" !-#1%"((&-#2. 3-#1-
!"#$ &'#" &($$)**)(+, -.)/. )**0"1 )2* 3)+'4 #"/($$"+1'2)(+* )+ 5"62"$7!" $%&'( )*+,- .*/
!"#$$ &' (!)$ *$+,-!,+ $./!001 !--$22,30$ 4'# 5$'50$ #$-$,6,7" 8$05 !& 8'($9
38


!"#$% '(%%$") *$#$%+, ,+-. *%+/, $,#$%0 +"# 1$%02"0 -/)3 #/0+4/,/)/$0 +%$ $")/),$# 2",5 )2
!"#$!$%$!&"'( *'+,- ./,0 *'" +,*,!1, +,('$,2 /&3, *'+, '"2 '"*!(('+! #$%&'($#) *+, +#+-..! /0.! '1

36. 42 u.S.C. 1396 (2).
37. OlmsteoJ v. l. c. (98-336) 327 u.S. 381 (1999) 138 l.3d 893.
38. AlLhough broad agreemenL was noL reached, Lhe commlsslon provlded flrm recommendaLlons on
sLaLe flexlblllLy and ways ln whlch efflclency could be achleved! #$$ !"##$%%$"& "& ("&) *+,#
!"#$! !"#$%& &$ ($)*%"++! #$%&$'($) *+,-! .%%$/012 .3


164
!"#$% '!(!# %#)#$*#' '+#)$(, +#%-$''$./ 0%.- !"# 0#1#%(, 2.*#%/-#/!3 4"$' +#%-$''$./ ).-#' $/
!"# %&'( &% )*+,#'- %&' #*." &% !"# /#0+.*+0 -#',+.# 1&123*!+&4-5 633 -!*!#- "*,# 7##4 8'*4!#0
!"#$%&' )* $"&+#,- .%-&%%'/ 01) )2%!" $%&'- !"# %&''(")*+-!"#$% '()*("+# ($+",-. ,- +)#/
!"#$#% '()$*+'()$), -'*./$*% #.".$# /"0$ .1 "2234 +1* "() 5"("6$ 5'3.723$ 8"70$*# "!*1##
!"##$%$&' )*)+,-'"*&./ 01$.$ 2-"3$%. "4)*.$ 3-%"*+. $,"5"6","'7 ,"4"'.8 .$%3"9$ !$#"&"'"*&.8 :+-,"'7
!"#$%#&%! ()! #$%& '()!)*+,- ./00/1/#$! !2#)0- $3. !)4*!'/35 !)62/!)1)3'07 8'$')0 $#0* 2'/#/9)
!"#$%"#$&' Lo change admlnlsLraLlve aspecLs of Lhelr Medlcald sLaLe plans. Lxamples of Lhese
efforLs lnclude changlng provlder-paymenL raLes, addlng or cuLLlng opLlonal servlces, addlng
managed care,
39
and changlng beneflL sLrucLures llke prescrlpLlon-drug llmlLs or cosL-sharlng.

8y 8alkanlzlng" Lhe program, Lhe federal-walver sysLem makes Medlcald dlfflculL Lo
manage aL Lhe sLaLe level. 1haL's because ln essence, each walver funcLlons as a separaLe
program, ofLen ln confllcL wlLh oLhers. Lach walver program requlres mulLlple flllngs, reporLs,
meeLlngs, and publlc hearlngs - noL Lo menLlon reams of paperwork and sLaff Llme - before a
sLaLe can achleve even a modesL amounL of flexlblllLy from federal rules and regulaLlons.

!"# %&'(#) *+*,#- &.*/ 0#1&,'(#.+ &22#3,* ,"# -/*, (4.0#)&5.# 6/64.&,'/0* ,"&, ,"#
!"#$"%& () *+)($,+* -# )+".+/ 0#- #,12 %"+ 3#&&4,(-2 )+".(3+) 1(&(-+* 54- %1)# !#-+,-(%1
!"#$%$"&'( *$&+ ',"-("./"( ('0#1 2! #$!% #&'(' )*&(&!% ($ +, ,!-$##,. &! * /$0,-!"#$ &#'(#")*
!"#$# &' '()#*"&+, #'-#.&/001 .$2#0 /3(2* -2**&+, / 4$/&0 56-!"#$-!"# !% & '(!-!"#$ &#'(')* +',(-
!"#!$%&''( *+!, & "-&-! %,.%-!" &/'!0-!"#$%# '%($)$%*+, +" ,$-* .) /*# '%(%$0% 1'%% 2%#$(/$#
!"#$%!"# %&&"'%()"*+, (- %-"./%)+ "0(!"12()"' 2+ )3" !"!! #$ %&' (#$% )#*+,-%. +/ '0-1-20'
!""#$%!&'( *(+ ('!'+ ,+!#', +-%,!&.+( '/ +&0/## $& 1+2$%!$23

!" $%%&'&(" '( ')* &"+'&','&("$- .&$+/ 0*%&1$&% +,22*3+ 23(4 (')*3 $31$"* 3,-*+ ')$' +'&2-*
!""#$%&!#" - !"#!"#$%& ()*+, ()-( -!!*. /-%0 .$!!$%& 12*3$#,245 /62,,#*7 *6 8)*$8,45 +(-(,-
!"#$%$&&' )%# *"+",& -% .-&,-!"#$%&' - !"#$%&' $)"$ !"#$%&'($) $" + ,)---!"#$-!"#$%&%
!"#$%"&'$"() (+ #,%-".,#/ !" !"#$!%!&' &) &#*+,& -,*.!/,-0 #"1 /)-& ).,**2"-3 SLaLes can and do
recelve rellef from Lhese burdensome rules, however, such rellef ls usually granLed only ln
plecemeal fashlon over mulLlple walvers and servlce populaLlons. And achlevlng such flexlblllLy
ofLen Lakes many years and over many admlnlsLraLlons.


1he Ma|neCare Cha||enge

Llke all sLaLes, Malne musL funcLlon under Lhe exlsLlng federal framework LhaL rewards
lnsLlLuLlonal placemenL and hlgh-cosL care seLLlngs over LargeLed low-cosL alLernaLlves LhaL
would acLually lmprove care quallLy. Llke oLher sLaLes where Lhe Medlcald peneLraLlon raLe ls
hlgh, Lhls lnsLlLuLlonal blas has shaped Malne's healLh-care servlces markeL (l.e., access and
avallablllLy) and uLlllzaLlon Lrends far more Lhan Lhe preferences of reclplenLs or Lhe Supreme
CourL (l.e., Lhe OlmsteoJ declslon, see fooLnoLe 37).

39. Managed care can also be added vla Lhe walver process.


163
ln recenL years, MalneCare has lmplemenLed changes LhaL have lmproved servlce
opLlons avallable Lo reclplenLs wlLh chronlc and/or dlsabllng condlLlons. lor Lhe mosL parL,
Lhese lmprovemenLs have been llmlLed Lo speclflc populaLlons or programs. Moreover, Lhese
changes affecL only reclplenLs covered under Lhe sLaLe plan as well as Lhe varlous SecLlon 1913l
home- and communlLy-based walvers. lndeed, Lhe small populaLlon of Malne and lLs affecLed
servlce populaLlons make lL dlfflculL Lo lnLegraLe and/or LargeL servlces Lo meeL Lhe changlng
needs of reclplenLs across Lhe llfe-cycle, leL alone comply wlLh 1lLle l requlremenLs - walver
and non-walver - relaLed Lo scope, freedom of cholce, comparablllLy, and sLaLe-wldeness.

ln chapLer 12, CharL 12-2 ldenLlfled SecLlon-1913l walvers LhaL Malne has secured Lo
allow Medlcald reclplenLs Lo obLaln coverage whlle llvlng ln less-resLrlcLlve resldenLlal seLLlngs
and Lo en[oy greaLer conLrol over Lhelr care. 1hese slx walvers, however - each wlLh dlfferenL
servlce deflnlLlons, rules, and requlremenLs LhaL may or may noL comporL - preclude Lhe sLaLe
from pursulng reforms LhaL LargeL servlces ln Lhe mosL approprlaLe seLLlngs or allevlaLe walLlng
llsLs. nor do Lhey allow Lhe sLaLe Lo Lry servlce meLhods LhaL lmprove care quallLy. lf Malne
wlshes Lo add a servlce LhaL ls noL auLhorlzed under a currenL walver, Lhe sLaLe has Lo submlL a
walver amendmenL. 1hls mlghL be approved qulckly - dependlng on who answers Lhe peLlLlon
aL CMS - or lL could Lake years. lurLher, per CMS rules, each of Lhese walvers lmposes lLs own
admlnlsLraLlve reporLlng requlremenLs. WlLh llmlLed sLaff, Lhe mulLlple walvers creaLe
admlnlsLraLlve burdens LhaL shlfL Lhe sLaLe's focus Lo bureaucraLlc process raLher Lhan leverage
Lhe sLaLe's purchaslng power Lo drlver lnnovaLlons ln servlce deslgn, dellvery, and seLLlngs.

ln addlLlon Lo Lhese slx walvers, Lhe sLaLe has pursued lnlLlaLlves across servlce
populaLlons deslgned Lo: 1) reduce Lhe rellance on lnsLlLuLlonally-based long-Lerm care (e.g.,
8eal Cholces SysLems 1ransformaLlon granLs and Money lollows Lhe erson granLs among
oLhers), 2) dlverL or LranslLlon reclplenLs from hlgh-cosL lnsLlLuLlonal and resldenLlal seLLlngs
lnLo less-resLrlcLlve seLLlngs (e.g., deparLmenL programs developlng Lhe shared-llvlng opLlon for
lndlvlduals wlLh developmenLal dlsablllLles, alLernaLlves Lo hosplLallzaLlon for adulLs wlLh
psychlaLrlc condlLlons, and wraparound servlces for chlldren wlLh behavloral-healLh needs llvlng
ln Lhe communlLy), and 3) expand Lhe capaclLy of provlders dellverlng home- and communlLy-
based servlces and supporLs (e.g., lncrease raLes for adulL day-servlce provlders and expand
asslsLed-llvlng walver sloLs).

Malne's efforLs aL reform are furLher hampered by federal law LhaL allows Medlcald
reclplenLs Lo obLaln servlces from any lnsLlLuLlon, agency, communlLy pharmacy, or person,
quallfled Lo perform Lhe servlce or servlces requlred . . . who underLakes Lo provlde hlm such
servlces."
60
1hls provlslon ls ofLen referred Lo as Lhe any wllllng provlder" or freedom cholce
of provlder" provlslon. SLaLes are noL permlLLed Lo exclude provlders from Lhe program solely
on Lhe basls of Lhe range of medlcal servlces Lhey provlde. ConsequenLly, MalneCare deals wlLh
more Lhan seven Lhousand provlders, noL counLlng subconLracLors. 1hus, as MalneCare offlclals
have acknowledged, Lhere may be more Lhan LwenLy Lhousand provlders. ln a small sLaLe llke

60. SecLlon 1902(a)(23) of 1lLle l of Lhe Soclal SecurlLy AcL.


166
Malne, LhaL ls an enormous number of provlders Lo monlLor. 1hose numbers ralse quesLlons of
how quallLy ls measured and Lhe approprlaLeness of servlces LhaL are selecLed.

SLaLes can recelve permlsslon Lo brlng more compeLlLlon lnLo Medlcald Lhrough Lhe
walver process. lor example, a sLaLe could uLlllze a SecLlon-1113 walver Lo provlde managed
care Lo reclplenLs. WlLhln LhaL walver, managed-care companles have flexlblllLy Lo selecLlvely
conLracL wlLh provlders. Malne however, does noL uLlllze managed care, even lf Lhe sLaLe dld,
LhaL opLlon may be llmlLed Lo [usL one servlce populaLlon and noL across Lhe enLlre sysLem. 1he
sLaLe, Lherefore, needs Lhe ablllLy and flexlblllLy - where approprlaLe - Lo be able Lo
compeLlLlvely bld servlces or producLs Lo lmprove quallLy sLandards and performance. Lxamples
where Lhls mlghL be useful are for durable medlcal equlpmenL or wlLh ACCs.
61


All of Lhese facLors work agalnsL Malne's efforLs Lo reverse Lhe conLlnued over-rellance
on hlgh-cosL servlce venues and lnsLlLuLlonal care. lor example:

Malne spends 87 of lLs long-Lerm care dollars on lnsLlLuLlonal/resldenLlal care.
nurslng-home resldenLs possess a relaLlve hlgh level of aculLy as frall elders, who could
noL oLherwlse flnd approprlaLe communlLy seLLlngs, have been shlfLed Lo prlvaLe non-
medlcal lnsLlLuLlons (nMl). nMl-user cosLs, on average, are lower Lhan comparable
nurslng-home care. Powever, Lhe avallablllLy of nMl seLLlngs has drlven Lhose
aggregaLe cosLs Lo now exceed LoLal nurslng-home expendlLures.
1he sLaLe malnLalns long walLlng llsLs for long-Lerm servlces and supporLs ln Lhe
communlLy for Lhe mosL vulnerable reclplenLs.
MalneCare's resldenLlal chlld care cosLs per user exceed $120,000. new approaches are
requlred Lo lower cosLs and provlde Lhe leasL resLrlcLlve seLLlng.
AlmosL Lwo-Lhlrds of Medlcald reclplenLs ln resldenLlal care and Lhree quarLers of Lhose
ln nurslng faclllLles have elLher a dlagnosls of demenLla or lmpalred declslon-maklng
sklll.
62
Malne's long-Lerm servlce and supporLs requlre expanded capaclLy for famllles
wlshlng Lo uLlllze home-based care.
CurrenL Medlcald paymenL/program pollcles do noL sufflclenLly faclllLaLe Lhe ablllLy of
malnLalnlng adulLs wlLh developmenLal dlsablllLles Lo remaln ln Lhelr own homes. Cnly
Loken flnanclal asslsLance ls avallable, and arranglng for and accesslng servlces ls more
compllcaLed Lhan lf provlded ln Lhe much more cosLly lCl/M8 or group-home seLLlng.
MalneCare does noL currenLly offer shared-llvlng servlces for elders.

61. An ACC allows docLors and hosplLals Lo [oln volunLarlly wlLh oLhers ln new legal enLlLles LhaL are
accounLable for provldlng care across lnsLlLuLlonal and ouLpaLlenL seLLlngs. 1he ldea ls Lo puL
physlclans and hosplLals ln new organlzaLlonal arrangemenLs LhaL share revenue and keep Lhe
savlngs lf Lhey provlde quallLy care aL less cosL Lhan llS would normally pay. MalneCare has begun
Lo lmplemenL Lhls model buL needs greaLer flexlblllLy Lo lower Lhe cosL curve.
62. !ulle lrallch eL al., uemenLla ln Malne: CharacLerlsLlcs, Care, and CosL Across SeLLlngs," Muskle
School of ubllc Servlce, 2013.


167
I|sca| 1rends and Cross-ressures

1he federal Medlcald sLrucLure ls noL Lhe only facLor presslng on Malne. Cn Lhe
flnanclng slde, Lhe sLaLe has suffered a wldenlng gap beLween general revenues and MalneCare
expendlLures due Lo flucLuaLlons ln Lhe economy, a decllne ln federal flnanclal supporL, poverLy
growLh, and Lhe escalaLlon ln healLh cosLs.

Slnce Sl? 2011, Lhe sLaLe has lnlLlaLed measures Lo curb Medlcald enrollmenL growLh,
conLaln program cosL, and lmprove Lhe efflclency of servlces. AlLhough Lhese efforLs have
slowed Lhe raLe of growLh ln Medlcald enrollmenL and expendlLures, caseloads conLlnue Lo
grow and Lhe budgeL gap perslsLs. Lven wlLh modesL economlc lmprovemenLs, Lhe MalneCare's
flscal prognosls pro[ecLs a deflclL for Lhe blennlum 2014-13 budgeL of $78 mllllon. 1hese budgeL
pro[ecLlons are Lroublesome because MalneCare consLlLuLes a llon's share of Lhe sLaLe's annual
budgeL (32.2 ln Sl? 2013).

Lven Lhe recenL success ln moderaLlng MalneCare growLh wlll noL be sufflclenL Lo
overcome Lhe long-run Lrend. When exLrapolaLed by flnanclal modellng, Lhe Lrend shows LhaL
by Sl? 2023-24, MalneCare wlll represenL 36.2 of Lhe general-fund budgeL, and 40.2 of Lhe
LoLal budgeL, conslsLlng of all funds.
63


1he program's hlgh cosLs lmplnge upon Lhe flnanclal resources avallable for Lhe sLaLe Lo
address oLher presslng needs, spur economlc growLh, and/or prepare for an uncerLaln fuLure. lf
demographlc forecasLs are correcL, Lhe range of cholces open Lo Lhe sLaLe wlll narrow as Lhe
ma[orlLy of Lhe 8aby 8oomers reLlre, program cosLs surge hlgher, and Lhe gap beLween Lhe rlse
ln Medlcald expendlLures and general revenues grows wlder.

Cne of Lhe rooL causes of MalneCare's flscal problem ls lLs fundlng sLrucLure. 1he
lnLermlngllng of sLaLe and federal flnances Lhrough Lhe federal maLchlng program spllLs pollLlcal
accounLablllLy for expendlLures, creaLes lnsLablllLy ln Lhe sLaLe budgeL, and lncenLlvlzes Lhe
sLaLe Lo spend more, noL less, ln order Lo draw down more federal dollars. 1he federal
governmenL pays sLaLes Medlcald maLchlng funds accordlng Lo Lhe lMA, calculaLed based on a
sLaLe's per-caplLa lncome. Sharlng responslblllLy wlLh Lhe federal governmenL for flnanclng
Medlcald ln Lhls fashlon has affecLed, and wlll conLlnue Lo affecL, Lhe sLaLe's ablllLy Lo balance
program cosLs, revenues, and oLher pollcy prlorlLles. As federal Medlcald dollars are Lhe slngle
largesL source of granL supporL Lo Malne, Lhe consequences of changes ln federal fundlng for
Lhe sLaLe cannoL be oversLaLed.



63. 1he Alexander Croup, leaslblllLy of Medlcald Lxpanslon under Lhe Affordable Care AcL,", p. 61.


168
!"#!$
%&#'$
(&#!$
)!#!$
'$
%'$
!'$
)'$
"'$
('$
*'$
+,-,./0 23-4 500 67/7, 23-48 2,4,./0 23-48 9:7/0 23-48
;/<-,=/., 6,.><?,8 /8 @,.?,-7 :A 23-4<-B 6:3.?,
CharL 16-1: Ma|neCare Serv|ces As ercent of Iund|ng Source


lor example, reducLlons ln lMA beLween Sl? 2011 and 2013 decreased federal
conLrlbuLlons Lo Lhe MalneCare program by approxlmaLely $230 mllllon per year. 1haL ls
because every one-polnL decllne ln Malne's lMA equals approxlmaLely a loss of $23 mllllon.
1he MalneCare cosL-conLalnmenL lnlLlaLlves lmplemenLed over Lhe same perlod parLlally offseL
a Lwo-year general-fund deflclL of $220 mllllon (uPPS, lebruary 2012 esLlmaLe) wlLh general
revenues coverlng Lhe balance. 1he ma[or lnlLlaLlves lncluded fundlng for chlldless adulLs by
freezlng enrollmenL and reduclng Lhe ellglblllLy Lhreshold for parenLs of chlldren on MalneCare
from 200 of Lhe federal poverLy level Lo 133.

Compoundlng Lhese pressures has been Lhe roll ouL of Lhe Affordable Care AcL and
oLher changes ln federal guldellnes LhaL make lL easler for abled-bodled lndlvlduals Lo access
MalneCare. 1hls means LhaL MalneCare wlll see a larger Lhan normal growLh ln lLs caseload.

uncerLalnLy abouL Lhe sLaLe's capaclLy Lo handle Lhe flucLuaLlons ln Lhe economy as well
as conLlnued changes ln federal flnanclal asslsLance and guldellnes underscore Lhe need for
comprehenslve reform. ?eL, Lhe sLaLe's ablllLy Lo Lake acLlon has been lmpeded by Lhe
program's scope and cosL, whlch make lL a LargeL for budgeL cuLs. lndeed, slnce 2008, changes
ln Lhe Medlcald program have largely Laken Lhe form of cosL-cuLLlng measures LhaL, Lhough ln
llne wlLh some prlnclples of reform, are deslgned prlmarlly Lo reduce Lhe sLaLe-budgeL deflclL.



169
ln conLrasL, a global reform would represenL an enLerprlse-wlde and broad-based
sLraLeglc redeslgn framework LhaL would anLlclpaLe, raLher Lhan reacL Lo, such cross-pressures.
Such global measures would also provlde reclplenL-cenLered servlces, glve reclplenL famllles
more cholces, offer LargeLed servlces aL Lhe rlghL Llme and place, and lmplemenL pragmaLlc cosL
reducLlons LhaL lmprove care quallLy. lurLher, a global-reform lnlLlaLlve wlLh budgeL caps would
provlde accounLablllLy by challenglng Lhe spendlng" culLure aL Lhe sLaLe admlnlsLraLlve level,
whlch ls lncenLlvlzed Lo spend more money ln order Lo recelve more money, Lhus exacerbaLlng
budgeL challenges.


1he So|ut|on: A G|oba| Wa|ver

As currenLly consLlLuLed, Lhe Medlcald program ls a one-slze-flLs-all program. lf a sLaLe
offers a servlce Lo one populaLlon, lL musL offer Lhe servlce Lo all. 1he only way Lo walve" LhaL
provlslon ls Lhrough a walver, a process LhaL can Lake many years.
64
Pow Lhen could Malne
make lLs Medlcald sysLem more manageable, accounLable, and LransparenL whlle offerlng
greaLer flexlblllLy Lo serve boLh reclplenLs and Laxpayers allke?

ldeally, converLlng MalneCare Lo a federal block-granL program would offer Lhe besL
vehlcle Lo achleve maxlmum flexlblllLy whlle offerlng clear advanLages for Malne and Lhe
federal governmenL allke. 1he federal governmenL would galn budgeLary sLablllLy, fundlng
would no longer be sub[ecL Lo sLaLe spendlng paLLerns and schemes Lo pull down ever-more
federal funds. Llkewlse, Malne would rely on a flxed amounL for Medlcald ln lLs budgeLs and
avold chronlc lssues of underfundlng, decllnes ln federal maLch, and backfllllng program-budgeL
shorLfalls. Such an approach would lncenLlvlze Malne Lo conLrol cosLs, as Lhe sLaLe would have
clear budgeL llmlLs and no unllmlLed enLlLlemenL Lo maLchlng federal funds. A block granL would
also glve Malne near-LoLal conLrol over program deslgn, ellmlnaLlng Lhe need for mulLlple
federal walvers and approval of sLaLe-plan amendmenLs. AuLhorlLy Lo deslgn and run Lhe
program would resL enLlrely wlLh Malne, as would pollLlcal accounLablllLy for ouLcomes and
performance.
63
WlLh greaLer conLrol, Malne would have flexlblllLy Lo lnnovaLe ln program
lmplemenLaLlon and lmprove boLh quallLy of, and access Lo, care servlces.

unforLunaLely, block granLs are noL allowed wlLhln Lhe currenL legal framework, only an
acL of Congress could change LhaL. 1he nexL besL opLlon ls Lherefore a global redeslgn" under
Lhe auLhorlLy of SecLlon 1113(a) of 1lLle l of Lhe Soclal SecurlLy AcL. lf granLed, a global walver
would granL Malne Lhe ablllLy Lo approprlaLely Lallor beneflL packages, lncrease provlder
compeLlLlon, and lnLroduce lnnovaLlve servlces. And lL would allow Malne Lo resLrucLure lLs

64. lL ls wldely agreed upon by mosL pollcymakers, LhaL lf Loday, Lhe governmenL were Lo sLarL a
compleLely new publlc welfare sysLem, lL ls almosL cerLaln LhaL lL would noL be deslgned wlLh Lhls
lnefflclenL framework.
63. 1he federal governmenL could seL broad performance measures around healLh, safeLy, access,
Lransparency and cosL effecLlveness.


170
enLlre program Lo esLabllsh a susLalnable cosL-effecLlve, person-cenLered and opporLunlLy-
drlven program uLlllzlng compeLlLlve and value-based purchaslng Lo maxlmlze avallable servlce
opLlons" and a resulLs-orlenLed sysLem of coordlnaLed care."

1o daLe, Lwo sLaLes have been granLed Lhls Lype of comprehenslve flexlblllLy, a reform
LhaL encompasses all Medlcald programs, walvers, and servlces buL also dellvers admlnlsLraLlve
rellef: 8hode lsland and new !ersey.
66
8oLh sLaLes have successfully used Lhe flexlblllLy achleved
Lhrough a global walver Lo redeslgn servlces, lncrease compeLlLlon, slmpllfy Lhe admlnlsLraLlve
sLrucLure, and lower cosLs. under 8hode lsland's demonsLraLlon, CMS allowed Lhe sLaLe Lo
esLabllsh an overall spendlng cap on federal maLchlng funds. 1he cap puL Lhe sLaLe aL rlsk for
expendlLures ln excess of Lhe cap, as Lhe sLaLe was requlred Lo conLlnue provldlng coverage for
lLs Medlcald populaLlon uslng sLaLe funds. ln addlLlon, Lhe sLaLe was glven Lhe flexlblllLy Lo make
cerLaln programmaLlc changes wlLhouL havlng Lo follow convenLlonal procedures. lor changes
LhaL would oLherwlse need Lo be processed as an amendmenL Lo Lhe sLaLe Medlcald plan, or for
changes of Lhe demonsLraLlon Lerms and condlLlons or LhaL dld noL affecL ellglblllLy, Lhe sLaLe
only had Lo noLlfy CMS. CMS offlclals noLed LhaL Lhls was Lhe flrsL Llme Lhey approved a
demonsLraLlon of Lhls Lype of admlnlsLraLlve flexlblllLy.

8y seeklng Lhls klnd of global reform, Malne, Loo, could achleve slmllar successes,
assurlng Lhe susLalnablllLy of MalneCare for years Lo come. ln facL, Malne ls unlquely poslLloned
Lo provlde lLs slsLer sLaLes wlLh a model for re-lnvenLlng Lhe Medlcald program. 1he sLaLe's
small populaLlon and eagerness Lo lnnovaLe offers numerous advanLages Lo demonsLraLe
lnnovaLlve and comprehenslve reform. Moreover, Lhe sLaLe ls currenLly a beLa-LesL slLe for
several healLh-relaLed lnlLlaLlves (e.g., healLh homes and ACCs) LhaL would complemenL Lhe
goals of reform.

under a comprehenslve or slngle-walver demonsLraLlon, uPPS would seek maxlmum
flexlblllLy Lo change dellvery sysLems, lncrease Lransparency and cholce, and share rlsk wlLh Lhe
federal governmenL. 1hls would lmprove servlce dellvery and promoLe reclplenL cholce and
lndependence whlle drlvlng down boLh federal and sLaLe cosLs. uPPS would seek Lhe ablllLy Lo
vary Lhe amounL, duraLlon and scope of servlces offered Lo reclplenLs - regardless of ellglblllLy
caLegory - and Lhe ablllLy Lo LargeL beneflLs Lo speclflc Medlcald populaLlons. uPPS could also
requesL a global cap on Medlcald expendlLures, a proven moLlvaLlon for reduclng spendlng,
over Lhe llfe of Lhe demonsLraLlon.
67


A comprehenslve SecLlon-1113 research-and-demonsLraLlon walver, encompasslng all
servlces and ellglble populaLlons served under a slngle auLhorlLy, would dellver flexlblllLy Lo
manage all programs efflclenLly by:


66. llllnols ls currenLly conslderlng a global walver Lype reform.
67. lL ls unllkely LhaL Lhe currenL CMS admlnlsLraLlon would agree Lo any global cap on spendlng. 1hls
does noL however, preclude Lhe sLaLe from seeklng such accounLablllLy.


171
ConsolldaLlng all Medlcald programs, servlces, walvers, and CPl under a slngle-walver
auLhorlLy,
SLreamllnlng servlce deflnlLlons across populaLlons,
Maklng key lmprovemenLs Lo Lhe ellglblllLy sysLem (boLh processes and Lechnology),
romoLlng lncreased uLlllzaLlon and cholces of home- and-communlLy-based servlces for
lndlvlduals ln need of long-Lerm care,
lnLegraLlng prlmary, acuLe, long-Lerm care, and behavloral-healLh care,
Allowlng new and lnnovaLlve care models llke Lele-healLh across all populaLlons,
uLlllzlng rlsk-based caplLaLlon across all populaLlons,
romoLlng efflclenL and value-added healLh care Lhrough enhanclng currenL Medlcald
accounLable-care organlzaLlon plloLs,
rovldlng flexlblllLy Lo promoLe prlmary- and prevenLlve-care access by balanclng
ellglblllLy and enrollmenL for servlces, beneflLs, and Lhe raLe of paymenL for servlces,
rovldlng flexlblllLy ln admlnlsLraLlon of Lhe program Lo lmplemenL compeLlLlve
conLracLlng, managemenL efflclencles, and purchaslng sLraLegles,
romoLlng healLhler behavlors and personal responslblllLy for reclplenL healLh care
across Lhe enLerprlse, and
lnsLlLuLlng greaLer accounLablllLy for reclplenLs and admlnlsLraLors of Lhe programs.

More speclflcally, Malne would en[oy numerous admlnlsLraLlve and program
enhancemenLs, lncludlng:

Wa|ver Stream||n|ng. 1he sLaLe currenLly admlnlsLers slx PC8S walver programs for
varlous populaLlons ln need of long-Lerm care. Lach walver has a varled seL of servlce
deflnlLlons, relmbursemenL pollcles, and raLe sLrucLures for provlders. ersonal emergency-
response sysLems servlces, for example, are offered ln Lhe consumer-dlrecLed aLLendanL
servlces walver, Lhe MalneCare sLaLe plan, and Lhe sLaLe-funded program aL dlfferenL
allowances. 1hls ls [usL one of many servlces offered by Lhls parLlcular walver, lLs range of
paymenL raLes has creaLed lnadequaLe cosL conLrols wlLhln uPPS. uPPS cannoL afford Lo
malnLaln a dupllcaLlve flnanclal sLrucLure whereby Lhe same servlce ls provlded aL dlfferenL
raLes based on mulLlple walvers. 8uL a comprehenslve, global walver/redeslgn would allow
uPPS - under a slngle walver-reform mechanlsm - Lo sLandardlze servlces, lmprove raLe
conslsLency, and reallgn servlces across Lhe enLlre enLerprlse. lL would also allow Malne Lhe
capablllLy of bulldlng a unlfled assessmenL and coordlnaLlon operaLlon Lo dellver Lhe rlghL
servlces, aL Lhe rlghL Llme and place, for each populaLlon regardless of dlagnosls.

1arget|ng Serv|ces and keward|ng nea|thy 8ehav|or. 1he flexlblllLy offered from a
global walver wlll ensure LhaL every reclplenL has access Lo Lhe rlghL servlces ln Lhe rlghL
seLLlngs and ln Lhe rlghL place. Walvlng amounL, duraLlon, and scope" of servlces wlll allow
MalneCare Lo more approprlaLely LargeL servlces where needed, and noL necessarlly offer Lhem
for Lhe enLlre servlce populaLlon. A one-slze-flLs-all federal model would be replaced wlLh
reclplenL and admlnlsLraLlve flexlblllLy. 1he sLaLe could Lallor beneflL packages for dlsease and
medlcaLlon managemenL wlLhouL havlng Lo offer Lhese opLlons for Lhe enLlre populaLlon. 1he


172
flexlblllLy mlghL allow Lhe opLlon of rewardlng reclplenLs who parLlclpaLe ln healLhy behavlors
and prevenLlve measures.

New Innovat|on and Serv|ce-De||very Mode|s. WlLh real flexlblllLy, Malne would have
Lhe opporLunlLy Lo qulckly adopL newer models of care and paymenL sysLems, or adapL currenL
lnnovaLlons lnLo MalneCare. lnnovaLlons llke Lele-healLh, global paymenLs, eplsodlc-care
paymenLs, and even creaLlng an lnLernal-care managemenL sysLem - one LhaL caplLaLes rlsk-
based paymenLs based on populaLlons Lo selecLlvely conLracLed provlders based on quallLy -
can become a reallLy across Lhe enLlre sysLem more expedlLlously Lhan Lhe currenL operaLlon.

Compet|t|on. A global walver would allow Lhe sLaLe Lo selecLlvely conLracL wlLh
provlders and compeLlLlvely bld for goods and servlces. 1hls has Lhe poLenLlal Lo lncrease Lhe
quallLy offered and lmprove healLh whlle lowerlng expendlLures.

Sav|ngs. AlLhough esLlmaLlng savlngs can always be challenglng, Malne can look Lo
8hode lsland's achlevemenLs. ln uecember of 2011, Lhe Lewln Croup - ln collaboraLlon wlLh
Lhe new Lngland SLaLes ConsorLlum SysLems CrganlzaLlon and Lhe 8hode lsland Cfflce of
PealLh and Puman Servlces - evaluaLed Lhe effecLlveness of Lhe 8hode lsland Clobal
Consumer Cholce CompacL Walver (Clobal Walver) LhaL CMS granLed Lhe sLaLe ln !anuary 2009.
Lewln reporLed LhaL 8hode lsland saved $34 mllllon over Lhree years as a resulL of lncreased
flexlblllLy Lo move more of Lhe Medlcald populaLlon lnLo managed care, redeslgned paymenL
sLrucLures for cerLaln servlces for chlldren wlLh speclal needs, and resLrucLured provlder
relmbursemenL. 1he reporL also found LhaL Lhe provlslons of Lhe walver allowed 8hode lsland
Lo clalm $42 mllllon ln federal funds lL would noL oLherwlse have recelved. Malne could achleve
slmllar resulLs. Malne's sysLem ls cerLalnly larger Lhan 8hode lsland buL Lhese savlngs numbers
offer a conservaLlve way of esLlmaLlng Malne's poLenLlal.

Cperat|ona| I|ex|b|||ty and kec|p|ent Cho|ce. 8y dellverlng operaLlonal flexlblllLy, a
global walver and redeslgn would creaLe a sLronger and more sLreamllned sysLem LhaL wlll
ldenLlfy reclplenLs' needs, bulld servlce capaclLy, and enhance currenL-care managemenL
reforms Lo beLLer meeL Lhe needs of Lhe mosL vulnerable. Moreover, lL would offer reclplenLs
greaLer cholces. Pavlng one walver across all populaLlons would allow uPPS Lo offer a servlce
or beneflL, currenLly only offered Lo one servlce populaLlon, Lo anoLher populaLlon. lor
example, shared llvlng, whlch ls LradlLlonally offered for Lhe lnLellecLually dlsabled populaLlon,
could qulckly be expanded for elders wlLhouL an addlLlonal approval. lL would allow flexlblllLy -
wlLhouL requesLlng mulLlple walvers or lnlLlaLlng Lhe sLaLe-plan amendmenL process over and
over agaln - Lo pay provlders based on provlders meeLlng quallLy-care and value-based crlLerla
raLher Lhan Lhe currenL fee-for-servlce approach. lL would allow lnnovaLlve paymenL
meLhodologles Lo encourage care coordlnaLlon for all Medlcald 172llglble wlLhouL excepLlon.

Inst|tut|ona| Cu|ture Change. A global reform Lhrough a SecLlon-1113 walver ls noL a
panacea for all Lhe challenges faclng MalneCare, buL lL represenLs a crlLlcal flrsL sLep ln
Lransformlng an admlnlsLraLlvely dysfuncLlonal sysLem lnLo a manageable, accounLable, and
LransparenL program focused more on healLh lmprovemenL Lhan process. 8y creaLlng one


173
sysLem across Lhe enLerprlse, a global reform would help Lhe sLaLe breakdown Lhe lnherenL
sllos LhaL exlsL across and wlLhln each dlvlslon of MalneCare and oLher healLh-relaLed dlvlslons
aL uPPS. And by seLLlng Lhe pace for reform, lL would allow Malne Lo use more lnnovaLlve ldeas
Lo lmprove care quallLy aL a prlce Laxpayers can beLLer afford, whlle slmulLaneously provldlng
reclplenLs wlLh more cholces. lndeed, a global walver has Lhe poLenLlal - lf fully embraced by
Lhe governor, Lhe leglslaLure, and uPPS - Lo change Lhe lnsLlLuLlonal culLure of Lhe publlc-
welfare sysLem, ellmlnaLe more of Lhe lnsLlLuLlonal" blas of Lhe Medlcald program, and reverse
Lhe unsusLalnable flscal course LhaL holds Lhe sLaLe budgeL, and Malne's Laxpayers, hosLage.

Stream||ned keport|ng and 1ransparency. CurrenLly, Malne has Lo wrlLe separaLe
reporLs for every slngle Medlcald walver. 1hls process requlres unnecessary paperwork, Llme,
and employee-power. WlLh llmlLed resources, Malne can lll afford Lo be spendlng Llme or
redundanL governmenL processes on bureaucraLlc paperwork, preparlng mulLlple reporLs LhaL
do noL comporL and are noL read by many people. A slngle global walver, however, would allow
Lhe sLaLe Lo consLrucL a LransparenL MalneCare reporL wlLh performance meLrlcs LhaL mlghL
acLually be read by employees, federal offlclals, and, more lmporLanLly, leglslaLors, execuLlve
branch members, and Laxpayers.

8ureaucrat|c ke||ef. Malne's commendable efforLs Lo brlng lnnovaLlon Lo MalneCare
have run up agalnsL Lhe Llme, efforL, and duraLlon lL Lakes ln deallng wlLh WashlngLon, u.C., Lo
make [usL mlnor lmprovemenLs. 8uL a global reform, lf properly deslgned wlLh maxlmum
flexlblllLy, would allow Lhe sLaLe Lo expedlLlously address Lhe needs of Lhe mosL vulnerable by
addlng, modlfylng, or deleLlng servlces across populaLlons wlLh far less lnLruslon and
bureaucraLlc overslghL from Lhe federal governmenL.


Scope of Author|ty kequested under a Sect|on-111S Wa|ver

under Lhe auLhorlLy of SecLlon 1113(a)(1) of Lhe Soclal SecurlLy AcL, Lhe followlng
walvers" of sLaLe-plan requlremenLs conLalned ln SecLlon 1902 could be requesLed ln order Lo
enable Malne Lo lmplemenL a global reform/walver demonsLraLlon.
68


1. State-W|deness]Un|form|ty, 1902(a)(1)
1o resLrlcL servlces Lo cerLaln geographlcal areas of Lhe sLaLe,
1o allow aspecLs of Lhe program Lo be phased-ln Lo new areas durlng Lhe demonsLraLlon
and Lo allow program elemenLs Lo be phased-ln durlng Lhe demonsLraLlon, and
1o enable walLlng llsLs for opLlonal Medlcald servlces and populaLlons.

2. keasonab|e romptness, 1902(a)(8)
1o malnLaln a walLlng llsL for opLlonal servlces and opLlonal populaLlons, and

68. AlLhough Lhls llsL ls comprehenslve, lL ls noL exhausLlve. lf Malne chooses a global reform paLh, lL
wlll charL a redeslgn course LhaL ls sLaLe approprlaLe and lL may choose oLher secLlons Lo walve.


174
1o requlre appllcanLs for long-Lerm care servlces Lo compleLe a LargeLed assessmenL.

3. Comparab|||ty, 1902(a)(10)(8)
1o provlde nurslng faclllLy or home- and communlLy-based servlces based on relaLlve
need as parL of a person-cenLered assessmenL and opLlons-counsellng process for new
appllcanLs for such servlces,
1o provlde servlces under Lhe demonsLraLlon LhaL would noL oLherwlse be avallable
under Lhe sLaLe plan,
1o llmlL Lhe amounL, duraLlon, and scope of servlces,
1o Lallor beneflL plans for lncome groups wlLh a hlgher-deducLlble plan (e.g., flexlble
accounL),
1o enable Lhe sLaLe Lo vary Lhe amounL, duraLlon, and scope of servlces offered Lo
demonsLraLlon populaLlons, regardless of ellglblllLy caLegory, by calculaLlng Lhe value of
Medlcald beneflLs based on a rlsk assessmenL, deposlLlng an amounL equlvalenL Lo Lhls
value ln a flexlble accounL, and permlLLlng demonsLraLlon populaLlons Lo use Lhese
funds Lo selecL a healLh-coverage package offered by elLher a CCM, MCC, or prlvaLe
lnsurer, and
1o enable Lhe sLaLe Lo use Lhe flexlble-accounLs funds as lncenLlves and dlslncenLlves
wlLh rewards and penalLles Lo move reclplenLs Lowards lndependence. 1hese would also
be used Lo Lallor beneflL plans.

4. Covered Serv|ces and Wraparound 8enef|ts, 1902 (a)(10)(a)
- 1o allow Lhe sLaLe noL Lo cover wraparound servlces.

S. Income and kesource ku|es, 1902(a)(10)(C)(|)
1o allow reclplenLs who choose home- and communlLy-based care Lo reLaln more
lncome and resources,
1o conslder only Lhe lncome and resources of an appllcanL when deLermlnlng flnanclal
ellglblllLy for lndlvlduals ln speclflc coverage groups,
1o enable Lhe sLaLe Lo LreaL sLaLe conLrlbuLlons Lo flexlble accounLs, healLh-savlngs
accounLs or healLhy-cholce accounLs, whlch provlde lncenLlves/paymenLs Lo reclplenLs
who reach cerLaln prevenLlon and wellness LargeLs, as non-counLable lncome and
resources for purposes of ellglblllLy or cosL-sharlng deLermlnaLlons, and
1o allow Lhe sLaLe Lo use Lhe communlLy Medlcald lncome-and-resource rules for
lndlvlduals seeklng skllled nurslng faclllLles servlces raLher Lhan long-Lerm care rules.

6. Cost Shar|ng, 1902(a)(14), |nsofar as |t |ncorporates Sect|on 1916
1o expand cosL-sharlng requlremenLs LhaL exceed Lhe sLaLuLory llmlLs for reclplenLs ln
cerLaln populaLlons,
1o uLlllze premlums,
1o charge L8 copaymenLs LhaL exceed federal regulaLlon, and
1o permlL prepaymenLs of a premlum.



173
7. Ireedom of Cho|ce, 1902(a)(23)
1o resLrlcL freedom of cholce of provlder Lhrough mandaLory enrollmenL ln a care-
managemenL opLlon and Lhrough selecLlve conLracLlng. Also, Lo mandaLe premlum
asslsLance lf appllcable.

8. rov|der Agreements, 1902(a)(27)
1o allow for Lhe provlslon of care by lndlvlduals who have noL execuLed a provlder
agreemenL wlLh Lhe sLaLe Medlcald agency.

9. D|rect ayments to rov|ders, 1902(a)(32)
1o permlL paymenLs Lo be made dlrecLly Lo reclplenLs or Lhelr represenLaLlves.

10. ketroact|ve L||g|b|||ty, 1902(a)(34)
1o walve Lhe requlremenL LhaL Medlcald be provlded for only Lhree monLhs prlor Lo Lhe
monLh ln whlch an appllcaLlon for asslsLance ls made.

11. ayment kev|ew, 1902(a)(37)(8)
1o Lhe exLenL LhaL prepaymenL revlew may noL be avallable for dlsbursemenLs by
lndlvldual reclplenLs Lo Lhelr careglvers/provlders.

12. Case-Management I|ex|b|||ty
1o walve Lhe requlremenLs, lf necessary, of case-managemenL regulaLlons so LhaL Malne
has flexlblllLy Lo LargeL care managemenL.

13. I|ex|b|e Accounts, 1902 (a)(10)(C)(|)
1o enable Malne Lo exclude funds ln a flexlble accounL from Lhe lncome-and-resource
LesL esLabllshed under sLaLe and federal law for Lhe purposes of deLermlnlng Medlcald
ellglblllLy.

14. Actuar|a| Soundness, CIk 438.6 (c)
1o enable Lhe sLaLe Lo conLracL wlLh MCCs (lf Lhe sLaLe chooses Lo do so) whose raLes
are below Lhe amounL deLermlned Lo be acLuarlally sound. 1he sLaLe would conLracL
wlLh MCCs LhaL meeL all programmaLlc requlremenLs and wlll obLaln value and quallLy
by conLracLlng below Lhe acLuarlally sound amounLs. (1he sLaLe does noL currenLly
uLlllze MCCs, buL Lhe demonsLraLlon would allow conLracLlng wlLh MCCs for a LargeL
populaLlon.)

1S. roper and Lff|c|ent Adm|n|strat|on, 1902(a)(4) and 42 CIk 438.S2, 438.S6
1o permlL Lhe sLaLe Lo auLomaLlcally reenroll an lndlvldual who loses Medlcald ellglblllLy
for a perlod of nlneLy days or less ln Lhe same managed-care plan ln whlch he or she was
prevlously enrolled, lf appllcable,


176
1o permlL Lhe sLaLe Lo resLrlcL Lhe ablllLy of members Lo cancel, wlLhouL cause,
enrollmenL afLer an lnlLlal LhlrLy-day perlod from a managed-care plan, and Lo cancel
enrollmenL, wlLh cause, Lo 363 days,
1o permlL Lhe sLaLe noL Lo cover non-emergency LransporLaLlon for cerLaln populaLlons.

16. 1o perm|t the state to a||gn prescr|pt|on-drug coverage to pr|vate coverage p|ans and to
requ|re that requests for pr|or author|zat|on for drugs be addressed w|th|n seventy-two
hours, rather than twenty-four hours, 1902 (a)(S4)
- 1hls walver auLhorlLy wlll allow Lhe SLaLe Lo allgn prlor auLhorlzaLlon sLandards wlLh
sLandards ln Lhe commerclal markeL.

17. 1o perm|t the state to prov|de coverage through d|fferent de||very systems for d|fferent
Med|ca|d popu|at|ons w|th d|fferent prem|um amounts, 1902 (a)(17)
- Also Lo permlL reLroacLlve coverage.

18. 1o prov|de federa| f|nanc|a| part|c|pat|on on de||very-system reform-|ncent|ve payments,
wh|ch are not re|mbursement for hea|th-care serv|ces and wh|ch do not app|y for
determ|n|ng DSn spend|ng or federa| upper payment ||m|ts, 1902 (a)

19. 1he state may a|so attempt to request re||ef under 1|t|e kkI, name|y:
- SecLlons 2102, 2103, and 2103 for beneflL package requlremenLs, cosL-sharlng,
exempLlons for cerLaln populaLlons, famlly-coverage llmlLs, and employer-sponsored
coverage.

Lxpend|ture Author|ty Lxamp|e. under Lhe auLhorlLy of SecLlon 1113(a)(2), Lhe sLaLe
mlghL have Lhe ablllLy Lo add new servlce populaLlons. Some examples mlghL be:
LxpendlLures for demonsLraLlon populaLlon no. 1: arenLs pursulng behavloral-healLh
LreaLmenL wlLh chlldren Lemporarlly ln sLaLe cusLody.
LxpendlLures for demonsLraLlon populaLlon no. 2: Chlldren who would oLherwlse be
volunLarlly placed ln sLaLe cusLody.
LxpendlLures for demonsLraLlon populaLlon no. 3: Llders aL rlsk for long-Lerm care and
ln need of home- and communlLy-based servlce.
LxpendlLures for personal-care servlces provlded by careglver spouses, adulL chlldren, or
exLended famlly members who provlde care Lo dlsabled chlldren, adulLs, or Lhe elderly.
LxpendlLures for lncldenLal purchases pald ouL-of-cash alloLmenLs Lo parLlclpanLs who
are self-dlrecLlng Lhelr servlces prlor Lo servlce dellvery.
LxpendlLures relaLed Lo flexlble healLh-care accounLs.
LxpendlLures relaLed Lo perlods of presumpLlve ellglblllLy for lndlvlduals needlng long-
Lerm care servlces.

G|oba| 8udget Cap. AlLhough lL ls unllkely LhaL CMS, under Lhe currenL federal
admlnlsLraLlon, would allow a sLaLe Lo lmpose a global, aggregaLe budgeL cap on lLs enLlre
Medlcald program, a spendlng cap ls Lhe besL way Lo spur lnnovaLlon, lmpose accounLablllLy on


177
admlnlsLraLors and provlders, and dellver value Lo reclplenLs and Laxpayers.
69
CurrenLly, Lhe
norm ls, LhaL lf a sLaLe spends a dollar lL cannoL afford, Lhe federal governmenL ls pleased Lo
maLch lL wlLh dollars lL does noL have. 8hode lsland's spendlng cap, for example, allowed Lhe
sLaLe Lo save Lax dollars, lnnovaLe, and lmprove servlce quallLy. AlLhough crlLlcs debaLe wheLher
Lhe cap was Lhe reason why Lhe Ccean SLaLe saved money and changed Lhe sysLem, Lhere ls no
debaLlng Lhe resulLs. Cver Lhe flve-year course of Lhe walver, from 2009 Lo 2014, 8hode lsland
lowered Lhe cosL curve and lmproved care quallLy. Some hlghllghLs from LhaL experlmenL:
ConLrary Lo earller pro[ecLlons of 7 Lo 8 growLh, Medlcald expendlLures came under
conLrol. LxpendlLures grew 3.3 ln Sl? 2010 and 0.9 ln Sl? 2011, buL decreased 1.1
ln Sl? 2012.
1hls lowerlng of Lhe sLaLe's Medlcald spendlng Lra[ecLory came abouL even as Lhe
caseload lncreased 4.3 ln 2010, 3.4 ln 2011, and 2.1 ln 2012.
uecllnlng per-member per-monLh (MM) cosLs also demonsLraLe efflclency galns: $813
ln Sl? 2010, $794 ln Sl? 2011, and $770 ln Sl? 2012.
A comparlson wlLh naLlonal daLa from Lhe federal PPS Cfflce of Lhe AcLuary conflrms
Lhe promlse of Lhe global walver. 8hode lsland's Medlcald-expendlLure growLh was
pro[ecLed Lo exceed Lhe naLlonal average. lnsLead, Lhe sLaLe's paLLern now falls far
below Lhe esLlmaLed naLlonal-budgeL growLh of 4.6 over Lhe same four-year span. 1he
esLlmaLed naLlonal-MM growLh over Lhe same perlod ls 1.3.

Clobal budgeL caps are deslgned Lo:
promoLe cosL-effecLlve prevenLlon and early lnLervenLlon,
ellmlnaLe servlces of quesLlonable value,
reduce excess healLh care sysLem capaclLy,
reverse Lhe currenL lncenLlve provlders have under fee-for-servlce Lo provlde more
servlces Lo earn a hlgher lncome, and
spur lnnovaLlon because llmlLaLlons drlve urgency.

An aggregaLe cap on spendlng, however, can only work wlLh real flexlblllLy and Lhe wlll
Lo reform. 1he flscal challenges faclng MalneCare requlre prudenL sLewardshlp of federal and
sLaLe resources. A budgeL cap can be a successful Lool ln conLrolllng cosLs, spurrlng lnnovaLlon
Lo lmprove quallLy, and poLenLlally relnvesLlng Lhe savlngs Lo creaLe new servlces for Lhe mosL
vulnerable populaLlons.


69. PealLh economlsLs and oLhers are lncreaslngly promoLlng global spendlng caps or paymenLs as a
sLraLegy Lo slow growLh of healLh-care expendlLures. A New oqlooJ Iootool of MeJlcloe arLlcle
examlnlng healLh-care cosL conLrol opLlons concluded LhaL a promlslng paymenL reform ls a global
paymenL or cap Lo cover all healLh-care needs of a populaLlon of paLlenLs. An aggregaLe cap
lmposes Lhe same Lype of cosL conLrol as a global paymenL. See !ames !. Mongan, 1lmoLhy C.
lerrls, and 1homas P. Lee, CpLlons for Slowlng Lhe CrowLh of PealLh Care CosLs," New oqlooJ
Iootool of MeJlcloe 338, no. 14 (Aprll 3, 2008).


178
Gett|ng Started

1he flrsL sLep Lo achlevlng a global-walver reform ls Lo declde wheLher or noL a slngle
walver wlLh flexlblllLy ls approprlaLe for Malne. Cnce LhaL declslon ls made, uPPS should hosL a
serles of lnLernal meeLlngs among senlor sLaff Lo explore exacLly whaL Lype of flexlblllLy lL would
seek and whaL lnlLlaLlves lL would pursue. AfLer Lhese declslons are made, uPPS could pursue
Lhe followlng due-dlllgence sLeps:

1. AppolnL Lhe MalneCare dlrecLor as Lhe pro[ecL lead. Slnce Lhe MalneCare dlrecLor
oversees Lhe ma[orlLy of healLh-care relaLed servlces aL uPPS, he or she would be Lhe
approprlaLe pro[ecL leader. 1he pro[ecL leader would need addlLlonal supporL
LhroughouL Lhls process slnce he or she would sLlll malnLaln overslghL over currenL
operaLlons.

2. CreaLe a Medlcald 8eform Cfflce and sLaff Lhe efforL wlLh one Lo Lwo pro[ecL managers
noL only Lo ensure LhaL Llmellnes and dellverables are meL approprlaLely buL also Lo
allevlaLe any addlLlonal work on currenL MalneCare sLaff. Also, selecLlvely choose one
key sLaff member from each MalneCare dlvlslon Lo work approxlmaLely LwenLy hours
per week on Lhls pro[ecL - aL a mlnlmum, Lhe reform offlce should have persons wlLh
Lhe followlng experLlse: flnanclal and budgeL, program, pollcy/regulaLlon, and daLa-
mlnlng managemenL. 1hls Leam of four Lo slx persons wlll reporL Lo Lhe pro[ecL leader,
and lL can begln ouLllnlng and organlzlng Lhe followlng sLeps:

a. oLenLlal dellverables and a pro[ecL-managemenL Llmellne,
b. oLenLlal provlslons of federal regulaLlon LhaL Lhe sLaLe mlghL aLLempL Lo walve,
c. oLenLlal sLaLe law and regulaLlon changes LhaL mlghL be necessary,
d. As a condlLlon of reform, researchlng healLh-care cosLs LhaL are currenLly noL
maLched by Lhe federal governmenL for poLenLlal federal Medlcald maLch,
e. new lnlLlaLlves Lhe sLaLe mlghL llke Lo pursue,
f. Pow Lhe sLaLe mlghL reform currenL programs uslng Lhls new flexlblllLy,
g. Pow lL mlghL use Lhe flexlblllLy from walvlng cerLaln federal rules Lo pursue c and
d above.
h. 8esearch Lhe effecL of an aggregaLe budgeL cap and wheLher or noL Lhe sLaLe
would llke Lo pursue Lhls as parL of Lhe reform.
l. CrafL a prellmlnary lnLernal concepL paper of no more Lhan flfLeen pages Lo
presenL Lo Lhe commlssloner LhaL would ouLllne sLeps a Lhrough d above.
[. CuLllne a wlLh and wlLhouL walver" forecasL model, lncludlng ma[or ellglblllLy
groups and MMlS requlremenLs, Lo esLabllsh basellne and meLhodology Lo
deLermlne cosLs for aL-rlsk populaLlons LhaL could have been clalmed Lo
MalneCare buL were noL.

1hls process should Lake no more Lhan Lhree monLhs and be kepL under LlghL deadllnes.
1he prellmlnary and lnLernal concepL paper should be presenLed Lo Lhe uPPS commlssloner
and Lhe governor's offlce aL Lhe end of Lhe Lhree-monLh due-dlllgence perlod.


179

AfLer careful dellberaLlon and research, uPPS would Lhen declde lf Lhls paLh Lo reform ls
approprlaLe. lf Lhe answer ls ln Lhe afflrmaLlve, a deLalled concepL paper would Lhen be drafLed
LhaL would ulLlmaLely be shared wlLh Lhe federal governmenL and for sLakeholder lnpuL.


Conc|us|on

1he presslng challenges of Medlcald, from lLs deeply enLrenched lnsLlLuLlonal blas and
growlng caseload Lo lLs pro[ecLed cosL overruns and crowdlng ouL" of sLaLe budgeLs, demand a
proacLlve response. WlLhouL reforms across Lhe enLlre enLerprlse, MalneCare's ablllLy Lo serve
Lhe mosL vulnerable of populaLlons - namely Lhe lnLellecLually dlsabled and lndlgenL elderly -
sLands aL rlsk, even as more and more of Lhe abled-bodled populaLlon are added Lo Lhe
caseload. A global reform Lhrough a SecLlon-1113 demonsLraLlon walver, modeled afLer whaL
8hode lsland secured ln 2009, offers Lhe besL mechanlsm for Malne Lo redeslgn lLs MalneCare
program, lLs paymenL sLrucLures and enLlre sysLem, and secure lLs fuLure. Malne needs Lhe
flexlblllLy Lo creaLe and manage a Medlcald program LhaL ls conslsLenL wlLh Lhe sLaLe's needs
and culLure. under Lhe currenL naLlonal legal framework, a global walver offers Lhe besL
opporLunlLy for Malne Lo creaLe a broad ouLcome-based healLh sysLem LhaL wlll be reclplenL-
cenLered and accounLable. And by followlng a sLakeholder model of global-walver deslgn LhaL
would value lnpuL from all faceLs of sLaLe governmenL, reclplenLs, and provlders, Lhe lne 1ree
SLaLe would lead Lhe naLlon by bendlng Lhe cosL curve, slmpllfylng and sLreamllnlng lLs
Medlcald sysLem, and lmprovlng care quallLy.



180




181





Append|x A: Income Cr|ter|a for DnnS rograms

Chart A-1: 1ANI and aS Income 1ests
1ANI and aS rogram Income 1ests, Standard of Need,
and Max|mum ayment Charts for Cn-go|ng Ass|stance Un|ts

ADUL1 INCLUDLD

8ASlC SLClAL nLLu
number
ln flllng
unlL
Cross
lncome
1esL

S.C.n.
Maxlmum
CranL
Cross
lncome
1esL

S.C.n.
Maxlmum
CranL +
Speclal
need
= 1oLal Max.
Cap
1 483 294 230 378 394 230 100 330 64
2 762 463 363 833 363 363 100 463 100
3 1,023 620 483 1,116 720 483 100 383 133
4 1,286 780 611 1,379 880 611 100 711 169
3 1,348 938 733 1,641 1038 733 100 833 203
6 1,811 1,096 836 1,904 1196 836 100 936 240
7 2,072 1,233 981 2,163 1333 981 100 1081 274
8 2,333 1,414 1,103 2,427 1314 1,103 100 1203 309
AddlLlonal
Member

+262

+139

+124

+262

+139

+124

+100

+124


ADUL1 NC1 INCLUDLD

8ASlC SLClAL nLLu
number
ln flllng
unlL
Cross
lncome
1esL
S.C.n. Maxlmum
CranL
Cross
lncome
1esL
S.C.n. Maxlmum
CranL +
Speclal
need
= 1oLal Max.
Cap

1 283 174 138 332 274 138 100 238 36
2 346 332 262 639 432 262 100 362 70
3 808 491 386 901 391 386 100 486 103
4 1,071 649 308 1,164 749 308 100 608 141
3 1,334 809 634 1,427 909 634 100 734 173
6 1,397 967 736 1,690 1067 736 100 836 211
7 1,839 1,123 880 1,932 1223 880 100 980 243
8 2,120 1,284 1,004 2,213 1384 1,004 100 1104 280
AddlLlonal
Member

+262

+139

+124

+262

+139

+124

+100

+124





182
7 Cl8 273.9(a)(3), 273.10(e )(2)(ll)(C ), 273.10(e )(4)(l) 812/13 #182-18


SNA kCGkAM 8ASIS CI ISSUANCL
uecember 27, 2013
48 SLaLes and Lhe ulsLrlcL of Columbla

1hese Lables on Lhe nexL page are exLended Lo meeL Lhe needs of cerLaln caLegorlcally
ellglble households. 1herefore, Lhe amounLs shown on Lhe Lables are hlgher Lhan Lhe neL
lncome llmlLs for some household slzes. Pouseholds whlch are noL caLegorlcally ellglble musL
have lncomes below Lhe approprlaLe lncome llmlLs.

1o deLermlne a household's monLhly beneflL uslng Lhe 8asls of lssuance Lables:

1) CalculaLe Lhe household's neL monLhly lncome. Pouseholds whlch are noL caLegorlcally
ellglble wlll have neL monLhly lncomes whlch are lower Lhan or equal Lo Lhe amounLs
shown ln Column C on Lhls page CharL A-2 on nexL page..
2) llnd Lhe alloLmenL by readlng ln Lhe aLLached Lables down Lo Lhe approprlaLe lncome
and across Lo Lhe approprlaLe household slze.
3) ersons ln household slzes one and Lwo and whlch are caLegorlcally ellglble wlll be
ellglble for beneflLs of aL leasL $13, even lf Lhe Lables do noL show a beneflL amounL aL
Lhelr neL lncome levels.

1o calculaLe Lhe beneflL manually (ln lleu of SLep 2 above) or lf Lhe household ls slze 21
or larger:

1) MulLlply Lhe neL monLhly lncome by 30 percenL.
2) 8ound Lhe producL up Lo Lhe nexL whole dollar lf lL ends ln 1-99.
3) 1o obLaln Lhe household's alloLmenL, subLracL Lhe resulL from Lhe Maxlmum 8eneflL
(Column u) for Lhe approprlaLe household slze. Powever, lf Lhe compuLaLlon resulLs
ln $1, $3, or $3, round up Lo $2, $4 or $6, respecLlvely.
4) lf Lhe alloLmenL ls for a one- or two-person household and ls less Lhan $13, or ls a negaLlve
number, round Lo Lhe mlnlmum beneflL of $13 for one- or Lwo-person households.



183

CharL A-2: SNA Income 1ests

nouseho|d
S|ze
Month|y Income
L|der|y]D|sab|ed
Separate nouseho|d*
16S of overty
Max|mum
Gross Month|y
Income* 130
of overty
Max|mum Net
Month|y Income*
100 of overty
Max|mum
8enef|t

Co|umn A

Co|umn 8

Co|umn C

Co|umn D
1
$1,380 $1,243 $938
$189
2
$2,133 $1,681 $1,293 $347
3
$2,686 $2,116 $1,628 $497
4
$3,239 $2,332 $1,963 $632
3
$3,791 $2,987 $2,298 $730
6
$4,344 $3,423 $2,633 $900
7
$4,897 $3,838 $2,968 $993
8
$3,430 $4,294 $3,303 $1137
Lach addlLlonal
member

+ $333

$436

$333

$142

*Maxlmum Cross and neL MonLhly lncome flgures are noL used for compuLlng Lhe beneflL
amounL. 1hey are lncluded as a reference for deLermlnlng Lhe household's ellglblllLy.



184
CharL A-3: Ch||d Care Income 1ests

MAkIMUM INCCML GUIDLLINLS: CnILD CAkL SLkVICLS
2S0 of the I13 Iedera| overty Leve| or 8S of the SMI for SLaLe lunds (SSS), lund for a
PealLhy Malne (lPM) Chlld Care uevelopmenL lunds (CCul), 1emporary AsslsLance Lo needy
lamllles (1Anl).
Lffect|ve Apr|| 1, 2013 unt|| further not|ce
IAMIL SI2L ANNUAL INCCML
MCN1nL INCCML
(ANNUAL]12)
WLLkL INCCML
(ANNUAL]S2)
1 $28,736 $2,396 $333
2 $38,792 $3,233 $746
3 $48,828 $4,069 $939
4 $38,916 $4,910 $1,133
3 $68,932 $3,746 $1,326
6 $78,988 $6,382 $1319
7 $81,743 $6,812 $1,372
8 $83,361 $6,963 $1,607
9 $83,377 $7,113 $1,642
10 $87,194 $7,266 $1,677




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197





!"#$% '( )*"+,-


CharL 1-1: ComplexlLy of Lhe SLaLe-lederal Welfare SysLem .......................................................... 3
CharL 1-2: lncome & 8eneflLs CalculaLlon Lo $8 per Pour .............................................................. 3
CharL 1-3: lncome & 8eneflLs CalculaLlon Lo $16 per Pour ............................................................ 7
CharL 1-4: Comblned lncome and 8eneflLs Mapplng for lamlly of 1hree ...................................... 8
CharL 1-3: Malne 8eal 8udgeL CrowLh ln MagnlLude & ercenL .................................................. 11
CharL 1-6: Malne's SLaLe 8anklng ln lundlng Medlcald & k-12 LducaLlon .................................. 12
CharL 1-7: er-CaplLa CosL, Medlcald & ubllc AsslsLance ........................................................... 12
CharL 1-8: CosL per Lmployed erson, Medlcald & ubllc AsslsLance .......................................... 13
CharL 1-9: CosL of Medlcald & ubllc AsslsLance Lo SLaLe ersonal lncome ................................. 14
CharL 1-10: uPPS 1oLal 8udgeLs by lundlng Source .................................................................... 14
CharL 1-11: Average Annual Change ln uPPS 8udgeL .................................................................. 13
CharL 1-12: 1op SLaLes for Medlcald & ubllc-AsslsLance CosLs ................................................... 16
CharL 1-13: uPPS 8udgeL (All lunds) by rogram, Sl? 2013 ........................................................ 16
CharL 1-14: MalneCare Servlces and 8udgeL CrowLh Comparlson ............................................... 17
CharL 1-13: Comparlng MalneCare LnrollmenL Lo LmploymenL .................................................. 18
CharL 1-16: lorecasLed MalneCare-Lo-Lmployed Malners 8aLlos ................................................ 19
CharL 1-17: undersLandlng undupllcaLed CounLs ........................................................................ 19
CharL 1-18: ercenLage 8reak CuL 8ecelvlng Medlcald and SnA ............................................... 21
CharL 1-19: LsLlmaLed 8urden on Lconomlc WealLh roducers ................................................... 22

CharL 2-1: Annual 1Anl 8lock-CranL and SLaLe-MCL LxpendlLures ............................................. 28
CharL 2-2: Comblned 1Anl and MCL LxpendlLures by CaLegorles .............................................. 28
CharL 2-3: 1Anl Caseload uaLa, uecember 2013 ......................................................................... 29
CharL 2-4: CalculaLlng Work arLlclpaLlon 8aLes .......................................................................... 32
CharL 2-3: llscal enalLles under 1Anl Law ................................................................................. 32
CharL 2-6: Work arLlclpaLlon 8aLes for Malne ............................................................................ 34
CharL 2-7: Malne's Work arLlclpaLlon 8aLes, 2001-2010 ........................................................... 33
CharL 2-8: 1Anl and MCL Cash-AsslsLance Cases ........................................................................ 33
CharL 2-9: 1Anl and MCL Caseload, 2000-2013 ......................................................................... 36
CharL 2-10: 1Anl verses SLaLe-MCL lundlng .............................................................................. 37
CharL 2-11: LducaLlon & !ob-1ralnlng Servlces, 2013 ................................................................... 39
CharL 2-12: 1Anl Caseload uecllnes, 2012-13 ............................................................................. 40
CharL 2-13: Comparlson of 1wo-arenL & Cne-arenL 1Anl Pouseholds ................................... 41
CharL 2-14: ASl8L-1Anl Lmployed Cases, 2013 ......................................................................... 41
CharL 2-13: ASl8L SupporLlve Servlces Spendlng ....................................................................... 42

198
CharL 2-16: SupporLlve Servlces for ASl8L-1Anl and aS .......................................................... 43
CharL 2-17: 1ranslLlonal Chlld Care rogram, C? 2013 ................................................................. 44
CharL 2-18: Average number of lamllles 8ecelvlng SupporLlve Servlces ..................................... 43
CharL 2-19: ASl8L 1ransporLaLlon LxpendlLures ......................................................................... 43
CharL 2-20: 1Anl Chlld-Cnly Cases by 8eglonal Cfflces ............................................................... 47
CharL 2-21: 1wo-arenL lamlly LllglblllLy under 1Anl ................................................................. 48
CharL 2-22: SLaLe ollcles 8equlrlng upfronL !ob-Search AcLlvlLles .............................................. 48
CharL 2-23: lamlly-Cap ollcles among SLaLes, !uly 2012 ............................................................ 48
CharL 2-24: number of SLaLes wlLh 1lme-LlmlL LxLenslon ollcles ............................................... 49
CharL 2-23: SLaLe 1Anl 8equlremenLs for uependenL Chlldren, !uly 2012 .................................. 49
CharL 2-26: new Lngland 1Anl MonLhly Cash-AsslsLance Levels ................................................ 30
CharL 2-27: Malne's erformance under 1Anl Plgh-erformance SLandards ............................. 30
CharL 2-28: Comparlson of 1Anl Law vs. Asplre-1Anl rogram ollcles ..................................... 31

CharL 3-1: lederal and SLaLe LxpendlLures for SnA, 2012 .......................................................... 39
CharL 3-2: Malne SnA lacLs, 2009 Lo 2013 ................................................................................. 60
CharL 3-3: Malne SnA erformance lndlcaLors, 2012 ................................................................ 61
CharL 3-4: Malne SnA Lrror-8aLe uecllne, 2003 Lo 2012 ........................................................... 62
CharL 3-3: new Lngland SnA lraud lnvesLlgaLlons, l? 2012 ...................................................... 63

CharL 4-1: CCul lundlng AllocaLlons for Malne ........................................................................... 68
CharL 4-2: CCul lundlng lan, ll? 2014 ...................................................................................... 69
CharL 4-3: Malne's 1wo-1rack Chlld Care rogram SLrucLure ....................................................... 71
CharL 4-4: CCul Chlld Care Subsldy rogram ............................................................................... 73
CharL 4-3: Chlld Care LnrollmenLs by SeLLlngs, as of november 4, 2013 ..................................... 73
CharL 4-6: Malne Chlld Care rogram lacLs ................................................................................. 76
CharL 4-7: new Lngland Chlld Care ollcles, lncome-LllglblllLy Levels ......................................... 77
CharL 4-8: Chlld Care Co-aymenL lees ........................................................................................ 77
CharL 4-9: Malne Leads new Lngland ln 8elmbursemenL 8aLes .................................................. 78
CharL 4-10: PlghesL 8elmbursemenL 8aLes for CenLer-8ased Care .............................................. 78
CharL 4-11: Weekly 8elmbursemenL 8aLes for lull-1lme lnfanL Care .......................................... 79
CharL 4-12: ASl8L and 1ranslLlonal Chlld Care CosLs .................................................................. 80
CharL 4-13: Chlld Care SeLLlngs, 2013 ........................................................................................... 81
CharL 4-14: ASl8L/1CC Chlld Care SeLLlngs, 2009-13 ................................................................. 82
CharL 4-13: ASl8L Chlld Care SeLLlngs, 2009-13 ......................................................................... 83
CharL 4-16: ASl8L & 1CC Cases by uuraLlon ............................................................................... 84
CharL 4-17: number of lamllles by number of Chlldren ln Care, 2013 ........................................ 83

CharL 3-1: CoordlnaLlng Chlld SupporL across MulLlple rograms ................................................ 90
CharL 3-2: Malne's uSL8 SysLem 8anklngs ................................................................................... 92
CharL 3-3: Malne's uSL8 erformance Measures ........................................................................ 93

CharL 6-1: Ceneral AsslsLance LxpendlLures ................................................................................ 93
CharL 6-2: Ceneral AsslsLance 8llllng & aymenL rocess, orLland ............................................ 97

199
CharL 6-3: Ceneral AsslsLance Spendlng, 1op llve CounLles ........................................................ 97
CharL 6-4: Ceneral AsslsLance er-CaplLa CosLs by CounLy .......................................................... 98
CharL 6-3: 8efugee Cash-AsslsLance Caseload, 2013 .................................................................. 102
CharL 6-6: 8efugee Cash-AsslsLance Caseload, 2006-13 ............................................................ 103

CharL 8-1: CurrenL AppllcanL rocess for ASl8L-1Anl rogram ............................................... 107
CharL 8-2: new AppllcaLlon rocess for ASl8L-1Anl rogram ................................................. 108
CharL 8-3: Subsldlzed !obs rogram ........................................................................................... 112
CharL 8-4: 1Anl Work arLlclpaLlon SLakeholders ..................................................................... 121
CharL 8-3: 1Anl Coals and Measures Lach rogram ?ear .......................................................... 122

CharL 9-1: Cfflce of lamlly AsslsLance SLafflng Levels, 2013 ...................................................... 126
CharL 9-2: Source of AppllcaLlons for All rograms .................................................................... 127
CharL 9-3: 1Anl AppllcaLlon 1rends ........................................................................................... 128
CharL 9-4: ASl8L-1Anl AppllcaLlon 1rends ............................................................................... 128

CharL 11-1: Medlcald LxpendlLures ............................................................................................ 133
CharL 11-2: MalneCare Spendlng by Servlce CaLegorles, 2008-13 ............................................ 134
CharL 11-3: MalneCare Caseload CrowLh ................................................................................... 133
CharL 11-4: Medlcald and SCPl LllglblllLy Levels ln new Lngland ............................................. 136
CharL 11-3: MalneCare LllglblllLy Croups ................................................................................... 137
CharL 11-6: MalneCare Caseload and MM 8reakdown .......................................................... 138
CharL 11-7: MalneCare LnrollmenL & LxpendlLures by LllglblllLy Croup .................................... 139
CharL 11-8: u.S. Medlcald LnrollmenL & LxpendlLures by LllglblllLy Croup ............................... 139

CharL 12-1: Malne's unlnsured opulaLlon ................................................................................ 141
CharL 12-2: SelecLed SecLlon 1913-Walver opulaLlons ............................................................. 144

CharL 14-1: LsLlmaLes of Average Age of L1C users by SeLLlng, Sl? 2010 .................................. 130
CharL 14-2: l/uu Walver Spendlng per ClLlzen, 2011 ................................................................. 132
CharL 14-3: WalLllsLs for SLaLe-lunded and MalneCare rograms ............................................. 133
CharL 14-4: MenLal-PealLh Spendlng ln new Lngland ................................................................ 133

CharL 16-1: MalneCare Servlces As ercenL of lundlng Source ................................................. 168

CharL A-1: 1Anl and aS lncome 1esLs ...................................................................................... 181
CharL A-2: SnA lncome 1esLs .................................................................................................... 183
CharL A-3: Chlld Care lncome 1esLs ............................................................................................ 184

CharL 8-1: LllglblllLy CrlLerla for all Cll rograms ....................................................................... 183

CharL C-1: uPPS 2013 Chlld Care 8elmbursemenL 8aLes ........................................................... 193


200


201





./-, '( 0+%12%3,$4 5-%6 78+'349-


7): AccounLable-Care CrganlzaLlon
7)7 Affordable Care AcL of 2010
7);< AuLomaLed CllenL LllglblllLy SysLem
70=) Ald Lo lamllles wlLh uependenL Chlldren
7> 1he Alexander Croup
7??7 Amerlcan 8ecovery and 8elnvesLmenL AcL of 2009
7<@A?; AddlLlonal SupporL for eople ln 8eLralnlng and LmploymenL
BA@ 8alanclng lncenLlves rogram
)) Chlld Care
))=0 u.S. Chlld Care uevelopmenL lund
)C< u.S. CenLer on Medlcare and Medlcald Servlces
)D Calendar ?ear
=EE< Malne ueparLmenL of PealLh and Puman Servlces
=?7 ueflclL 8educLlon AcL of 2003
=<;? Malne uPPS ulvlslon of Chlld SupporL LnforcemenL and 8ecovery
00< lee-for-Servlce
00D lederal llscal ?ear
0D llscal ?ear
0C7@ lederal Medlcal AsslsLance ercenLage
0F< u.S. lood and nuLrlLlon Servlce
0@. lederal overLy Level
>7 Ceneral AsslsLance
E)B< Pome- and CommunlLy-8ased Servlces
EA@@ PealLh lnsurance remlum aymenL

202
EE< u.S. ueparLmenL of PealLh and Puman Servlces
.!) Long-1erm Care
.!<< Long-1erm Servlces and SupporL
C7 Medlcal AsslsLance
C=:. Malne ueparLmenL of Labor
CCA< Medlcald ManagemenL lnformaLlon SysLems
C:; MalnLenance-of-LfforL (1Anl program)
F7<B: naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers
:)0< Malne's Cfflce of Chlld and lamlly Servlces
:0A Malne's Cfflce for lamlly lndependence
:C< Cfflce of MalneCare Servlces
@"< arenLs-as-Scholars program
@EA@ rlvaLe PealLh lnsurance remlum rogram
@FCA rlvaLe non-Medlcal lnsLlLuLlons
@C@C Average cosL, er-MonLh er-Member
@?G:?7 ersonal 8esponslblllLy and Work CpporLunlLy 8econclllaLlon AcL of
1996
<0D SLaLe llscal ?ear
<)EA@ SLaLe's Chlldren PealLh lnsurance rogram. Also known as CPl.
<F7@ SupplemenLal nuLrlLlon AsslsLance rogram
<<A SupplemenLal SecurlLy lncome
<<=A Soclal SecurlLy ulsablllLy lnsurance
!7F0 1emporary AsslsLance for needy lamllles
!)) 1ranslLlonal Chlld Care
G;A Work Lllglble lndlvldual
G@? Work arLlclpaLlon 8aLe



203





)'3,+/#2,'+- ,' ,*/- ?%H'+,


>"+4 =I 7$%J"36%+K LI=I

Cary u. Alexander ls Lhe founder, presldenL, and CLC of Lhe Alexander Croup. Pe ls a
naLlonally recognlzed healLh-care and Medlcald experL, welfare reformer, and budgeL speclallsL.
lor more Lhan slxLeen years, he has Lransformed underperformlng sLaLe healLh and welfare
agencles lnLo accounLable, value-orlenLed, and daLa- and performance-drlven sysLems by
ploneerlng sLrucLural reforms and sLaLe-of-Lhe-arL Lechnology soluLlons LhaL have lmproved
ouLcomes and quallLy, lowered healLh-care cosLs, reduced fraud and wasLe, re-englneered
employmenL programs, modernlzed access, and ellmlnaLed budgeL deflclLs. A pragmaLlc and
declslve leader, Alexander has a Lrack record noL only of ldenLlfylng problems buL also
assembllng Lhe rlghL mlx of LalenL, pollcy makers, and sLakeholders Lo generaLe daLa-drlven
soluLlons wlLh quanLlflable resulLs Lo some of Lhe mosL vexlng challenges faclng federal, sLaLe,
and local governmenLs.

rlor Lo foundlng Lhe Alexander Croup, Alexander served as ennsylvanla's secreLary of
publlc welfare as well as Covernor 1om CorbeLL's senlor healLh and welfare advlsor from 2011
Lo 2013. ln LhaL dual role, he oversaw overall operaLlons, managemenL, and pollcy developmenL
for one of Lhe largesL publlc-welfare agencles ln Lhe naLlon, a deparLmenL wlLh a budgeL of
$27.3 bllllon, slx hosplLals, flve sLaLe lnLermedlaLe faclllLles, nlneLy-four offlces, more Lhan
slxLeen Lhousand employees, and 2.2 mllllon publlc-asslsLance reclplenLs.

When he arrlved ln ennsylvanla, Lhe sLaLe's ueparLmenL of ubllc Welfare faced
double-dlglL growLh, an uncoordlnaLed servlce sLrucLure, and a fragmenLed organlzaLlon. 1o flx
Lhese problems, he crafLed and lmplemenLed a cuLLlng-edge plan Lo eradlcaLe fraud and wasLe
called Lhe !"#$%&%'($)*'+$ -%./%01 2"#$/%'#3 0"+ 21&%.4$1$"# 2"'#'0#'4$5 1hls lnlLlaLlve has been
lauded by Medlcald and welfare-reform experLs and earned Lhe deparLmenL a naLlonal
lnnovaLlon award for Lxcellence and 8esL racLlce from Lhe Councll of SLaLe CovernmenLs.

rlor Lo hls Lenure ln Lhe keysLone SLaLe, Alexander ploneered slmllar reforms as 8hode
lsland's secreLary of healLh and human servlces, and human-servlces dlrecLor, from 2006 Lo
2011. Pe ls Lhe auLhor and archlLecL of Lhe 2009 landmark 8hode lsland Clobal Medlcald Walver
LhaL, for Lhe flrsL Llme, dellvered unprecedenLed flexlblllLy Lo a sLaLe Lo redeslgn lLs Medlcald
program. 8ellevlng Lhe sLaLe of burdensome federal mandaLes and requlremenLs, Lhls
groundbreaklng reform lmproved care quallLy, ouLcomes and access, lowered publlc cosLs,
creaLed more cholces for reclplenLs - lncludlng more approprlaLe care seLLlngs - and properly
allgned servlces and beneflLs. 1he walver's long-Lerm care redeslgn ls also belng used as a

204
model of reform around Lhe naLlon. ln lLs flrsL Lwo years, Lhe walver noL only saved Lhe sLaLe
approxlmaLely $100 mllllon buL also kepL LoLal Medlcald spendlng aL bllllons of dollars below
Lhe agreed-upon spendlng llmlL. 8y lmprovlng quallLy, cholce and access for reclplenLs and
lnLroduclng accounLablllLy lnLo Medlcald, Alexander's lnlLlaLlve has been clLed as a model of
enLlLlemenL reform, parLlcularly Medlcald and healLh care reform by varlous experLs and
publlcaLlons, lncludlng Lhe 6077 8#%$$# 9.:%"07 and Lhe -%.4'+$";$ 9.:%"07.

Alexander has worked on boLh sldes of Lhe alsle and has a repuLaLlon for reachlng
consensus Lo solve complex problems. Members of Lhe u.S. Congress, sLaLe elecLed offlclals,
and pollcy makers seek hls advlce on welfare and Medlcald reform. Pe holds a 8achelor of ArLs
from norLheasLern unlverslLy and a !urls uocLor from Suffolk unlverslLy School of Law.


C2++"4 CI B$/,M%+

Murray M. 8llLzer brlngs Lo Lhe Medlcald and human-servlces work of Lhe Alexander
Croup more Lhan LhlrLy years of experlence ln publlc admlnlsLraLlon and flnance wlLh a speclalLy
ln Medlcald and human servlces. Pe was Lhe chlef flnanclal offlcer of Lhe 8hode lsland
ueparLmenL of Puman Servlces, overseelng a $1.3 bllllon budgeL and more Lhan a Lhousand
employees. Pe also served as a depuLy Lo Lhe SenaLe flscal offlcer and as an advlsor Lo Lhe
SenaLe ma[orlLy leader ln Lhe 8hode lsland leglslaLure. ln LhaL laLer role, he lmplemenLed a
budgeL hearlng and revlew process LhaL allowed sLaLe senaLors equal parLlclpaLlon ln
formulaLlng pollcy. 8llLzer began hls career ln Lhe 8hode lsland SLaLe 8udgeL Cfflce, where he
deslgned and lmplemenLed Lhe sLrucLure for Lhe sLaLe's Consensus Medlcal AsslsLance and
Caseload LsLlmaLlng Conference, applylng professlonal forecasLlng Lools Lo more Lhan $2 bllllon
ln healLh-care and welfare spendlng. 1hroughouL hls publlc career, Murray has successfully
worked Lo reduce Lhe cosL of governmenL and dellver Medlcald servlces LhaL have had a
poslLlve lmpacL on Lhe llves of many reclplenLs. 8llLzer holds a 8achelor of Sclence ln resource
Lechnology and economlcs from Lhe unlverslLy of 8hode lsland.


='3"$6" CI )"+$-'3

A speclallsL ln Lhe fleld of famlly developmenL and economlc-supporL programs, uonald
M. Carlson ls Lhe Alexander Croup's experL on economlc supporL, welfare ellglblllLy, and
welfare-Lo-work employmenL lssues. Cver a career spannlng more Lhan LhlrLy years, she has
held admlnlsLraLlve and leadershlp poslLlons focused on helplng women, chlldren, and low-
lncome needy famllles Lhrough a broad range of servlces coverlng healLh educaLlon, baslc and
adulL educaLlon, Lralnlng and employmenL programs for publlc-asslsLance reclplenLs, lndlvlduals
wlLh learnlng dlsablllLles, prlsoner re-enLranLs exlLlng Lhe adulL correcLlonal lnsLlLuLlons, and
unemployed adulLs ln need of [ob-relaLed servlces and supporLs. unLll 2010, Carlson was Lhe
assoclaLe dlrecLor for Lhe 8.l. ueparLmenL of Puman Servlces Lconomlc SupporL rograms,
where she managed program developmenL and lmplemenLaLlon of servlce dellvery of 1Anl,

203
Chlld Care AsslsLance, SnA, lSL1, and Medlcal AsslsLance programs. She also led Lhe sLaLe's
modernlzaLlon and employmenL-reform lnlLlaLlves. noLeworLhy ls her work ln plannlng and
resLrucLurlng ellglblllLy sLaff and compuLer-processlng sysLems leadlng Lo sLreamllned
assessmenLs, deLermlnaLlons, and case-managemenL pracLlces. She was also responslble for Lhe
redeslgn of 8hode lsland's welfare-Lo-work program.

1hroughouL her career, Carlson worked exLenslvely wlLh sLaLe and federal governmenLs
as well as buslness and labor leaders, boLh locally and naLlonally. She served as speclal advlsor
Lo Lhe SLaLe of 8hode lsland ln lmprovlng access and ouLcomes ln early care and educaLlon for
chlldren, baslc educaLlon, and posL-secondary educaLlon for adulLs. And she has worked dlrecLly
wlLh communlLy-based organlzaLlons ln Lhe dellvery of a wlde range of welfare-Lo-work
programs. AddlLlonally, she was a conLrlbuLlng resource ln plannlng and developlng a more
effecLlve SysLem of Care" for chlldren affecLed by abuse and neglecL wlLhln Lhelr homes and
communlLles.

Carlson has noL only served on numerous boards and commlsslons LhaL have been
charged wlLh employmenL and placemenL servlces buL also worked wlLh publlc and prlvaLe
conLracL provlders Lo asslsL unemployed and under-employed. She has worked wlLh leglslaLors
and sLaLe governmenL leaders ln all areas of admlnlsLraLlon, reporLlng, and program lnLegrlLy ln
all asslsLance programs wlLhln 8hode lsland.


<,%N% O'P2,K @*I=I

A senlor assoclaLe wlLh Lhe Alexander Croup, ur. koguL speclallzes ln
pharmacoeconomlcs and managed-care pharmacy. Pls scholarly conLrlbuLlons span across a
range of Loplcs, lncludlng healLh economlcs and pollcy, publlc healLh, and healLh-care sysLems.
Pe has worked wlLh varlous naLlonal sLakeholders Lo lmprove medlcaLlon use ln populaLlons,
lncludlng Lhe CenLer for Medlcare and Medlcald Servlces (CMS) and Lhe harmacy CuallLy
Alllance. Pls sLaLe-level acLlvlLles lnclude pro[ecLs wlLh Lhe 8hode lsland Medlcald pharmacy
program and wlLh PealLhcenLrlc Advlsors, Lhe sLaLe's Medlcare-conLracLed CuallLy
lmprovemenL CrganlzaLlon.

ur. koguL ls an assoclaLe professor of pharmacy pracLlce aL Lhe unlverslLy of 8hode
lsland and a reglsLered and pracLlclng pharmaclsL. A former member of Lhe 8hode lsland 8oard
of harmacy, ur. koguL ls currenLly a member of Lhe SLaLe of 8hode lsland Medlcald urug
uLlllzaLlon 8evlew 8oard. Pe holds a h.u. from Lhe unlverslLy of 8hode lsland, an M.8.A.,
8ryanL unlverslLy, and a 8.S. ln harmacy from Lhe unlverslLy of 8hode lsland. ubllshed wldely
ln scholarly [ournals, hls research focus ls Lhe appllcaLlon of pharmacoeconomlc research ln
managed-care envlronmenLs, Lhe evaluaLlon of healLh-lnformaLlon Lechnologles, quallLy ln
medlcaLlon use, Lechnologles for lmprovlng medlcaLlon use, and off-label prescrlblng.


206
?'#%+, GI @",,%+-'3

A soclal, welfare, and healLh-care pollcy analysL, 8oberL W. aLLerson has elghLeen years
of senlor-level pollcy experlence - lncludlng servlng ln Lhe Ceorge W. 8ush admlnlsLraLlon and
Lhe 1homas W. CorbeLL admlnlsLraLlon of ennsylvanla - as pollcy advlsor, speechwrlLer,
professor, edlLor, and op-ed columnlsL. As a pollLlcal appolnLee aL boLh federal and sLaLe levels,
he has worked closely wlLh Lop-level governmenL offlclals Lo generaLe soluLlons Lo problems
and helped Lhose admlnlsLraLlons advance pollcles LhaL focus on rebulldlng Lhe soclal and
economlc foundaLlons of Lhe Amerlcan mlddle class.

rlor Lo [olnlng Lhe Alexander Croup ln 2013, 8ob served as a senlor pollcy advlsor Lo
Cary Alexander, Lhen secreLary of publlc welfare of Lhe CommonwealLh of ennsylvanla. lrom
2004 Lhrough 2009, aLLerson served ln Lhe 8ush admlnlsLraLlon as a pollcy advlsor and
speechwrlLer aL Lhe u.S. ueparLmenL of PealLh & Puman Servlces and as Lhe senlor
speechwrlLer aL Lhe u.S. Small 8uslness AdmlnlsLraLlon. Pe also served as a sLaff consulLanL Lo
Lhe WhlLe Pouse 1ask lorce for ulsadvanLaged ?ouLh.

8eLween 2009 and 2012, 8ob served as an ad[uncL professor of governmenL aL aLrlck
Penry College ln urcellvllle, va., Leachlng an upper-level course on pollLlcal rheLorlc and
speechwrlLlng. Also durlng LhaL Llme, 8ob was Lhe edlLor-ln-chlef of <=$ >01'73 '" ?1$%';0@ ?
9.:%"07 .A -:B7'; -.7';3C Lhe flagshlp quarLerly of Lhe Poward CenLer for lamlly, 8ellglon &
SocleLy based ln 8ockford, llllnols. ln LhaL role, 8ob Lransformed whaL had been a monLhly
monograph serles lnLo a respecLed [ournal and launched a new webslLe and Lhe [ournal's
symposlum serles on CaplLol Plll. ln addlLlon Lo hls scholarly work for <=$ >01'73 '" ?1$%';0,
8ob has been a regular op-ed conLrlbuLor Lo Lhe -='70+$7&='0 2"D:'%$% as well Lhe 60(='"/#."
!E01'"$% and F0#'."07 G$4'$* H"7'"$5 Pls wrlLlngs have also appeared ln Lhe I0'73 J$0(#C Lhe
K70%$1."# G$4'$* .A J..L(, and Lhe 6$$L73 8#0"+0%+5

8ob holds a bachelor's degree from Calrn unlverslLy ln hlladelphla as well as graduaLe
degrees from WheaLon College ln llllnols and WesLmlnsLer 1heologlcal Semlnary ln
hlladelphla.


;+/Q =I ?"36'$H*

Lrlk u. 8andolph spenL LwenLy-elghL years of hls professlonal career ln governmenL,
lncludlng LwenLy-one years wlLh experlence ln flscal analysls of leglslaLlon and governmenL
programs LhaL lnvolved deLermlnlng flscal lmpacLs, forecasLlng cosLs and revenues, budgeLlng,
and worklng wlLh flnanclal and economlc models. Pe began hls career as a program evaluaLor
wlLh Lhe u.S. Ceneral AccounLlng Cfflce, whlch was renamed Lhe CovernmenL AccounLablllLy
Cfflce ln 2004. Pe Lhen worked flve years for Lwo dlfferenL sLaLes ln Lhe flelds of economlc
developmenL and sclence and Lechnology pollcy. AfLerwards, he achleved Lhe poslLlon of senlor
analysL for Chalrman uwlghL Lvans (u) of Lhe CommlLLee on ApproprlaLlons, ennsylvanla

207
Pouse of 8epresenLaLlves. Pe also spenL Lwo years as a speclal pollcy and flscal asslsLanL
advlslng Mr. Alexander when he served as secreLary of publlc welfare under Covernor 1om
CorbeLL (8) of ennsylvanla. Pe has LaughL prlnclples of economlcs for sevenLeen years. Pe
holds a MasLer of Sclence degree from 8ensselaer olyLechnlc lnsLlLuLe and Lwo bachelor
degrees from Lhe ennsylvanla SLaLe unlverslLy.


L%33/(%+ CI G/%+

!ennlfer M. Wler ls a C..A. wlLh more Lhan sevenLeen years of experlence. She has
experLlse ln Medlcald and ls also knowledgeable abouL lnformaLlon sysLems, sysLems modellng,
and daLa mlnlng. Slnce 2009, she has been a member of Lhe ulvlslon of Arkansas LeglslaLlve
AudlL, where he has reporLed on all Medlcald and human-servlce programs Lo Lhe Ceneral
Assembly and has acLed as an lndependenL llalson beLween leglslaLors and program
admlnlsLraLors. ln LhaL role, she has noL only analyzed Lhe program from boLh quanLlLaLlve and
quallLaLlve perspecLlves, buL she has also audlLed lLs flnanclal and pollcy componenLs. Well
versed ln federal Medlcald regulaLlons, she has also asslsLed ln Lhe drafLlng of leglslaLlon
affecLlng several componenLs of Lhe program ln Arkansas, lncludlng provlslons affecLlng
provlder enrollmenL and Lhe creaLlon of Lhe Cfflce of Medlcald lnspecLor Ceneral. She has a
8achelor of Sclence ln accounLlng from Lhe unlverslLy of Arkansas, LlLLle 8ock, and ls a member
of Lhe Arkansas SocleLy of rofesslonal AccounLanLs and Lhe Arkansas lnformaLlon SysLem AudlL
and ConLrol AssoclaLlon.












!*% 7$%J"36%+ >+'2HK ..) R7>S ls a governmenL and buslness consulLlng flrm LhaL dellvers
cuLLlng-edge daLa-drlven soluLlons, sLraLeglc-buslness developmenL, and lnnovaLlve healLh-care
and Lechnology plaLforms - Lo lmprove efflclency, effecLlveness, and quallLy for our cllenLs. AC
possesses unlque experLlse ln Lhe governmenL healLh-care markeLplace, bullL upon Lwo decades
of noL only operaLlng large-scale healLh and human-servlces agencles buL also ploneerlng
reforms LhaL saved sLaLes bllllons of dollars and lmproved servlce quallLy. lounded ln 2013 by
reformer Cary u. Alexander, Lhe flrm ls Lhe only group of publlc offlclals who have deslgned,
lmplemenLed, and managed naLlonally acclalmed reforms llke Lhe G=.+$ 2(70"+ M7.B07 N$+';0'+
60'4$% and, ln ennsylvanla, <=$ !"#$%&%'($)6'+$ -%./%01 2"#$/%'#3 -70" and <=$ O$07#= 0"+
O:10" 8$%4';$( K.:"#3 J7.;L M%0"#.

1he flrm's speclalLles range from healLh-care and soclal-welfare Lo managemenL consulLlng -
lncludlng buL noL llmlLed Lo healLh-care plan deslgn, Medlcald, Medlcare, long-Lerm care and
accredlLaLlon servlces - Lo organlzaLlonal deslgn and resLrucLurlng, LransporLaLlon, LransacLlon
asslsLance, and leglslaLlve and flscal analysls. AC helps sLaLes and locallLles navlgaLe Lhe
lnLersecLlon of buslness and publlc pollcy whlle ldenLlfylng opporLunlLles LhaL enhance Lhe
boLLom-llne and advance Lhe healLh and well-belng of clLlzens5 8aLher Lhan remedlaLe complex
and ouLdaLed healLh-care plans or asslsLance programs plecemeal, we help sLaLes reform and
resLrucLure Lhelr enLlre healLh and human servlces sysLems. ueploylng cosL-effecLlve savlngs
meLhodologles Lo ensure a value-, LransparenL-, and efflclency-based sysLem, our reforms drlve
lnnovaLlon, lmprove servlce quallLy and performance, lncenLlvlze accounLablllLy and consumer
engagemenL, modernlze operaLlons, and rooL ouL fraud, wasLe, and abuse.