Attachment A: Subsidy Coverage Limitations

Basic Subsidy Coverage Limitations

The Division has placed certain limitations on those services for which it will pay or which it will provide.

General:

Contact should be made with each adoptive/guardianship family at least annually to insure the best services are being provided to families and children. However, Agreements approved to age 18 will continue until the last day of the month of the child’s 18th birthday, if the family requests no changes in the terms of the Agreement via amendment and no previously authorized services have expired.
All families must sign an Agreement, which is legally binding. These Agreements will only be signed by the family and the Division Director.
All services, including MO HealthNet, for which the Children’s Division has agreed to pay, must be documented in the service section of the Agreement.
Payment will not exceed the authorized amount for the service included in the service section of the Agreement.
For the Division to make payment for those services authorized through a subsidy Agreement, the Division must have a contract with the provider or make payment to the adoptive parent(s) or guardian(s) who then will pay the provider for the non-contracted service. "Paid" receipts or an invoice from the provider must be provided to the Division monthly, or as necessary, by the adoptive parent(s) or guardian(s) for any service provided by a non-contracted provider. The adoptive parent(s) or guardian(s) must provide "paid" receipts to the Division after payment for the services and within two (2) weeks, if payment was made based on an invoice. The Division will pay services provided by a contracted provider directly to the provider. The use of contracted providers is required when a contract may be established. All receipts submitted for reimbursement must be submitted within 6 months of the service being provided.
Payment for nonrecurring adoption expenses is made after the adoption is final. However, these expenses must have been included in the Agreement before final adoption. These expenses are not eligible for payment if applied for after final adoption. However, in the event that expenses exceed the amount approved prior to finalization an amendment may be completed to request payment of the excess amount.
All expenses paid under the legal guardianship Agreement will only be paid after legal guardianship has been granted by the probate court to a qualified relative as defined by Missouri Statute 453.072.
Use must be made of a contracted provider, if available, for any service through children's treatment services, and residential treatment services unless prior authorization is given to use a non-contracted provider. Subsidy will not reimburse the adoptive/guardianship family for payment for services provided by an immediate member of the household.
The resources of the family, other state, national, and community agencies must be reviewed and plans made for the use of these resources before use of subsidy funds may be authorized in the Agreement. The Division will not make payment for services that are a duplication of other available services.
The original copy of the Adoption Subsidy Agreement , CD AD, or the Subsidized Guardianship Agreement, CD SG, must be submitted to the Contract Management Unit (CMU), in Central Office, at the time of the initial agreement. Each time an Agreement needs to be amended, an amendment section should be completed and the entire Agreement submitted to CMU.
If a determination has been made by Regional staff that subsidy is needed to complete an adoption/guardianship and no other family is available, arrangements may be made to transfer the child to the custody of the Children's Division at the time adoption/guardianship becomes the plan and/or a family has given a firm indication by filing an adoption/guardianship petition that they wish to adopt or obtain guardianship of such a child. The child must meet all appropriate subsidy eligibility criteria.

Maintenance:

At the time of placement, no payment may exceed the maintenance rate paid if the child had remained in out-of-home care, even when used in combination with other benefits available to the child. Standard maintenance Agreements should be written to expire on the last day of the month of the child's 18th birthday. Medical and Behavioral maintenance are approved according to the Above Base Maintenance Section in this chapter.
At the time of placement, the amount paid is determined by information obtained from the family as to what financial assistance they need to meet the needs of the child and the resources available to the child such as OASDI, VA or SSI, etc.
The purpose of maintenance is to contribute toward those items as defined in Section 4 Chapter 11 (room and board, clothing and incidentals). The definition of maintenance should be explained to the adoptive or guardianship family at the time of negotiation of a new subsidy.
In the event that a child becomes eligible for OASDI due to the adoptive parent's/guardian’s disability after adoption or guardianship, the family may receive both.

Medical and Dental Care:

A child, eligible for adoption subsidy IV-E, adoption subsidy-HDN, SSI, or guardianship subsidy is automatically eligible for MO HealthNet within the policy and procedural requirements of this program. This eligibility is included in the Agreement. Services covered by MO HealthNet do not require special approval in the service section of the Agreement.

In the MO HealthNet program, a child who has an adoption/legal guardianship subsidy monthly maintenance payment may be eligible for a MO HealthNet vendor payment (which includes daily living expenses and an allowance for personal incidentals). Vendor payments are made to a facility providing 24-hour care, such as a regional diagnostic center, nursing home, convalescent center, etc. If so, the maintenance payment from adoption/legal guardianship subsidy will be counted against the MO HealthNet vendor payment on a dollar-for-dollar basis. It is to the family's advantage to allow MO HealthNet to use the entire vendor payment and drop maintenance from the Agreement. Families may have expenses relating to support of a child's placement in a MO HealthNet contracted facility. These may be negotiated and included in the Adoption Subsidy Agreement, CD AD, or the Subsidized Guardianship Agreement, CD SG as a special expense to support the family relationship.
Payment will not be made from Division funds to supplement payment made from MO HealthNet, except in certain extreme circumstances, determined on a case-by-case basis.
Important MO HealthNet procedural requirements include:

A Third Party Resource Form, TPL-1, must be submitted to MO HealthNet Division (MHD) by the worker as soon as the child is eligible for coverage under the adoptive parent(s) or guardian(s)’ private insurance. The information needed for this form is located on the family's insurance card.

The child's inclusion in the family's private insurance will usually occur at the time of the final decree of adoption or granting of the guardianship. Some policies may exclude eligibility for the child with a pre-existing condition. In this instance, the child's needs will be covered by MO HealthNet within the limitations of this program.

Families are not required to add their adopted or guardianship children to their private insurance, although it is encouraged. Payment for an insurance deductible as prescribed by their private health insurance plan is the responsibility of the adoptive parent(s)/guardian(s), as private insurance is not a requirement for subsidy.

If a family has added the adopted or guardianship child to their private health insurance, they must use their private health insurance, if the child is covered in their policy, before using MO HealthNet. However, the family must indicate to the provider that the child is also eligible for MO HealthNet. Showing the card and informing the provider of MO HealthNet eligibility should prevent the provider from charging for services above the MO HealthNet rates.

Providers will bill the adoptive parent(s)’ or guardian(s)' insurance company for payment before they bill MO HealthNet for payment. If full payment is not made by the private insurer, MO HealthNet may be billed. MO HealthNet will then pay any balance of service charges within their allowable rates for the specific service. If a balance of charges remains, the provider may not bill the adoptive parent(s)/guardian(s) for the service, except in certain allowable circumstances.

Adoptive parent(s) and guardian(s) should be made aware of the HIPP-Health Insurance Premium Payment Program through the MO HealthNet Division. This program pays the cost of health insurance premiums, coinsurances and deductibles. The program pays for health insurance for MO HealthNet eligible persons when it is cost effective for the state. Information about this program or the HIPP-1 application may be obtained from Family Support Division, or by calling the HIPP Unit at (573) 751-2005. You may write to them at:

Third Party Liability Unit
HIPP Section PO Box 6500
Jefferson City, MO 65102-6500

MO HealthNet providers must be utilized whenever possible. The Division acknowledges that specific circumstances/conditions may arise that require payment to be made for care not covered by MO HealthNet.

However, adoptive parent(s) or guardian(s) who elect not to use MO HealthNet providers should understand that the Children's Division will not pay for any medical/dental services in whole or in part received from non MO HealthNet providers without prior authorization by signature of the Division Director to the subsidy Agreement or amendment.

The following circumstances may be considered for payment not covered under MO HealthNet:

Medically necessary orthodontic services when a MO HealthNet provider is not geographically accessible (over 100 miles round trip), or not paid entirely by private insurance may be included in an Agreement and approved up to the amount MO HealthNet would pay for the same service. These approvals are obtained through a prior authorization process through the MO HealthNet Division and a MO HealthNet consultant.

The following information is required for prior authorization through a MO HealthNet consultant in the approval of orthodontia:
1. A letter from the physician recommending the procedure with documentation regarding the medical necessity of the work;
2. Documentation regarding the lack of accessible MO HealthNet orthodontic providers within the area where the family resides;
3. Orthodontic records that consist of a cephalometric x-ray, panoramic x-ray or full-mouth survey and dental study models, properly occluded and trimmed; and
4. Documentation of all other sources explored: the family’s insurance and community resources.
  This information should be sent to the Adoption/Guardianship Program Development Specialist in Central Office, who will forward the information to the MO HealthNet Division. The MO HealthNet Division will have the information reviewed by an orthodontic consultant, who will determine if the procedure is medically necessary and would be reimbursable through MO HealthNet, if a MO HealthNet provider were available. Notice of this review, the consultant’s worksheet, will be sent back to local staff.
  
  If the request for orthodontics is denied, the orthodontist may bill for an office visit, x-rays, and diagnostic casts. These costs may be approved for reimbursement by amendment to the subsidy Agreement.
  
  If the request for orthodontics is approved, the amount indicated as acceptable through the MO HealthNet program and as indicated on the consultant's worksheet may be added to the subsidy Agreement by amendment.
Families should be advised that "Orthodontics is only for the most handicapping malocclusions. A handicapping malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the patient by causing impaired mastication, dysfunction of the temporomandibular articulation, susceptibility to peridontal disease, susceptibility to dental caries and impaired speech due to malposition of the teeth."
"Assessment of the most handicapping malocclusion is determined by the magnitude of the following variables: degree of malalignment, missing teeth, angle classification, overjet, overbite, openbite and crossbite."

Requests for services for cosmetic purposes will not receive authorization.

b. Emergency care not covered under MO HealthNet or private insurance which is less than $500.00 may be included on an amendment to the contract without prior authorization.

The evaluation and recommendation of MO HealthNet Division must be secured for charges over $500.00. This approval is obtained by submitting the invoice and treatment summary to the Adoption/Guardianship Program Development Specialist in Central Office who will forward the information to the MO HealthNet Division for review, evaluation and recommendation. Upon receipt of the recommendation, the local office will be notified and if approved the amount may be included on an amendment to the Agreement and approved by the Division Director.

Childcare

Child Care Services are Regulated by the Office of Early Childhood. Child care policy is available at the Child Care Policy Manual Web site on the Children’s Division Intranet.

A subsidy Agreement may include childcare services as a part of the basic subsidy package for children up to age thirteen (13) when both parent(s)/guardian(s) are working. Childcare is to be included on the Adoption Subsidy or Subsidized Guardianship Agreement as service code DAYC. In the maximum amount box the words, “State Contracted Rate" are to be entered. In the explanation section the statement, ”Childcare may be approved at the state contracted rate to age 13 when both parents/guardians are working. Payment may only be made to licensed/contracted or registered providers" is to be included.

Contracted childcare facilities receive financial incentives for providing care to special needs children. These incentives are automatically generated to the provider when a child is authorized through the SEAS system, or when a Children’s Services Integrated Payment System Invoice, CS-65, is entered using childcare service codes. These incentives and their service codes are as follows:

SPND - Special Needs. This incentive is paid whenever a child has been in the custody of the Division. All children who are adopted/under a guardianship Agreement qualify for this incentive payment if they are being cared for by a licensed/contracted or registered provider. The payment system automatically generates a payment which is 25% over the total cost for the month the child was in childcare. For instance, if the child's total childcare bill is $300.00, the provider will automatically receive a payment of $75.00 in addition to the $300.00 they charged.
Other incentives may be available to the childcare facility based on their qualifications. These incentives will be automatically calculated into the “State contracted rate.”

Contracted services are authorized using the SEAS Request and Eligibility Form, CS-67, and SEAS Authorization Form, CS-67A, completed in the county/circuit of the child's residence by the authorizing worker. Approval from the authorizing designee must be received.

The CS-67 and CS-67A will be completed and entered into SEAS after a provider is located and a referral completed. After entry of the CS-67 and CS-67A, both the provider and the adoptive or guardianship family will receive system-generated notifications detailing the childcare authorized.
The Services Eligibility and Authorization Provider Invoice, CS-65A, will be generated by the system directly to the provider(s) for all authorized services.
Upon receipt of the Services Eligibility and Authorization Provider Invoice, CS-65A, it will be the responsibility of the county payment designee to check the invoice for completeness, reasonableness, and accuracy.
The system will not allow payment for rates that exceed those specified in the provider's contract.
Childcare expenses reimbursed on a Children’s Services Integrated Payment System Invoice, CS-65, for registered childcare must use the service codes ASDC (Adoption Subsidy childcare) and LGDC (Legal Guardianship Childcare) and will not be affected by the incentive payments, DISP and ACRD.
1. When reimbursing families for childcare expenses paid to a registered provider, the childcare provider's taxpayer identification number and the dates and hours the services provided, as well as proof of payment must be on the receipt and attached to the CS-65 being submitted for payment.

Nonrecurring Adoption or Legal Guardianship Expenses

These different types of nonrecurring expenses should be listed individually. The expenses should be reasonable and customary. All receipts submitted for reimbursement must be submitted within 6 months of the service being provided:
1. Nonrecurring placement related expenses (NROT) may be reimbursed up to $1,000.00 and are limited to:
  1. Pre-placement transportation: This expense is paid at the current customary rate established by the Children’s Division for use of a personal automobile, or the charge of air or ground transportation; and
  2. Lodging and food: Reimbursed using Division travel guidelines for both in-state and out-of-state travel.
2. Legal (NRLG) fees include attorney, court, publication and GAL costs.
  
  Attorney fees may be reimbursed up to $100.00 per hour to a maximum of $1,500.00 in non-contested adoption cases and up to $3,000.00 in contested matters. Legal fees for guardianship subsidies may be reimbursed up to $100 per hour to a maximum of $500.00 in non-contested guardianship cases, and up to $1,500.00 if the guardianship is contested.
  
  According to 453.020 RSMo, the GAL may be awarded a reasonable fee for such services to be sent by the court. The court, in its discretion, may award such fees as a judgment to be paid by any party to the proceedings or from public funds. Such an award of GAL fees shall constitute a final judgment in favor of the GAL.
3. Private agency fee reimbursement up to $3,500.00 is allowed. Such costs may include the adoption study, including health and psychological examination, and supervision of the placement prior to adoption finalization.
  
  Payment for nonrecurring expenses does not include those paid for or provided through resources available to the adoptive parent(s) or guardian(s), court or the agency facilitating the placement. Examples of these resources include:
  - A private agency waives the cost of the family assessment (home study) or the placement support services;
  - The family claimed the Missouri adoption tax credit for nonrecurring adoption expenses;
  - The family has private insurance providing payment for certain services included in an adoption/guardianship; and
  - A service provider has waived the cost for the service.

Additional Services

Above Base Maintenance:
1. In the case of Medical or Behavioral Foster Care (BFC) payments, the child must meet the criteria set forth in Section 4 Chapters 14 and 15 of this manual in the same manner as a child in alternative care. The worker shall arrange a team meeting and obtain the required documentation according to policy for children in care. Staff are encouraged to utilize the behavioral consultants to assist in determining eligibility.
  
  Children in foster care, who receive BFC or Medical maintenance, are required to have regular six-month reviews. If a regular review is overdue, or if a review is due within 60 days, the review must be completed within one month upon the determination that adoption or guardianship is the goal for the child. The purpose of this staffing is to verify a continued need for above base maintenance. The child must then be staffed every six months until adoption or guardianship is finalized. The subsidy worker must submit the approved staffing results with the request for above base maintenance, in order for the child to be approved for and receive behavioral or medical maintenance.
  1. The Medical Foster Care Assessment, CS-10, and Residential Treatment Referral, CS-9, are to serve as referral forms for above base maintenance. Children who are referred for BFC maintenance will follow the local procedures that apply when foster children are referred to this program. These forms are to be completed by the adoptive/guardianship family, with help from staff if needed, and signed by a supervisor. The Division Director will need to approve all above standard maintenance payments via the subsidy Agreement, prior to any payment being authorized.
  2. When children need a BFC maintenance rate to meet their special needs, the adoptive parent(s)/guardian(s) are required to attend behavioral foster parenting classes. Training must be completed prior to payment of the above standard rate. No back payments to the date of placement will be approved.
    
    For families who live out of state, 18 hours of equivalent training may be substituted. The family will need to provide the worker with the curriculum from the training they plan to receive. The worker will review this information with their supervisor to determine the appropriateness of the training.
    
    Adoption/guardianship subsidy will reimburse the out-of-state adoptive parent(s)/guardian(s) for training up to $90.00 per hour if there is a charge. This charge must be approved on the subsidy Agreement prior to reimbursement and a receipt provided.
    
    Children receiving above base maintenance rates are not eligible for the incentive payment for charting that is provided through the Behavioral foster care program.
  3. Families of children receiving the medical maintenance rate must undergo individualized medical training by the child’s health care provider, which is individualized to the child’s specific health care needs. The health care provider who provides the training must provide documentation of this training.
  4. As of July 31, 2002, career rates were no longer approved in new subsidy Agreements. Families who are currently receiving Career maintenance on their subsidy contract as approved prior to July 31, 2002, are not required to undergo yearly reviews, and may be automatically approved to age 18, unless the parent/guardian agrees to reduce the maintenance amount.
2. Above Base Maintenance may be approved for up to two years at a time or up to the child's 18th birthday, if it is determined that the child's condition will not improve and/or that the adoptive/guardianship family will not be in agreement to lowering the maintenance amount as the maintenance rate may not be reduced without the consent of the adoptive parent(s)/guardian(s).
  In the case of medical subsidy where the medical condition of the child is permanent as indicated by documentation from medical professionals, medical subsidy should be approved to age 18 as the condition is not expected to improve.
Intensive In-Home Services (IIS)
Intensive In-Home Services (IIS) may be offered to the family who is in need of intervention that may reduce the risk of the child entering out-of-home care. Referrals are to be made according to the guidelines set forth in Section 3 Chapter 7 of this manual.
Residential Care Services (All Levels):
1. An amendment to the subsidy Agreement must be completed if the adoptive parent(s) or guardian(s) request residential services. The amendment must be signed by the Division Director before residential services may begin and payment for such services made.
2. Any time the subsidy worker receives a request to place a child in residential treatment, the worker shall make a referral to IIS as an attempt to divert placement out of the home. This is to be treated as any other IIS case, and to be paid for out of county funds. If the IIS intervention is unsuccessful, or the parent(s)/guardian(s) refuse to use IIS, the worker is to begin working with the family towards other alternatives such as the use of community resources or residential treatment.
3. Community resources are to be researched by the parent/guardian, with assistance from the worker, and efforts documented, prior to making a residential treatment referral. The worker shall notify the parent(s)/guardian(s) of services that are available within the community which might prevent the child from being removed from their community and being placed in residential treatment. The worker shall ensure the parent(s)/guardian(s) tried to access these services before seeking residential care.
4. The parent(s)/guardian(s) must complete the Residential Treatment Referral, CS-9, with the assistance of the worker. Documentation of the child's condition from appropriate professionals (psychological, psychiatric, etc.) is required and must be obtained by the parent(s)/guardian(s).
  The CS-9 must be sent through the appropriate channels to the Regional Office Residential Care Screening Team (RCST) Coordinator. The RCST Coordinator will determine the child's need for residential treatment; the level of care needed, and assist the parent(s)/guardian(s) in obtaining a residential treatment facility for the child in close proximity to their home to allow involvement by the parent(s)/guardian(s) in the child's treatment. The parent should be provided with a letter of approval indicating the amount which will be paid. The parent/guardian is responsible for making arrangements for actual placement into the residential facility. The letter to the parent(s)/guardian(s) should also include information as a reminder that:
  1. Residential level changes require a new approval.
  2. Documentation provided by the facility on behalf of the parent/guardian must support the level being requested and be no more than 90 days old and include an estimated discharge date and prognosis, a monthly treatment summary, why a continued need for residential respite exists, and a description of parental involvement with the facility/treatment plan.
5. Once a child has been approved for residential treatment, the family shall be referred to the out-of-home care program. A voluntary Family Centered Services (FCS) case is to be opened, and services will be offered to work towards reintegration. Counties may use their discretion in selecting a case manager dependent upon program specialization. However, the subsidy worker shall be a member of the Family Support Team (FST).
6. If the family is unwilling to be a part of this process and has no desire for the child to be returned to their home, residential treatment may not be authorized through subsidy and the subsidy worker is to discuss other permanency options with the family. If the child enters the custody of the Children's Division, the Division will pursue child support from the adoptive parent(s)/guardian(s).
  
  The worker shall implement a FST meeting with the family, child, adoption/guardianship specialist, community representative, and the facility either prior to or upon placement of the child in residential treatment. The team must complete a plan for reintegration. If the facility holds an initial treatment staffing, the staffing may count as the FST meeting, if the worker and family are involved in the team meeting. Subsequent FST meetings are to be held on the same time schedule as children in the custody of the Children’s Division. This applies to all children entering residential care as well as all children currently in residential care.
  
  If, after placement, the parent(s)/guardian(s) refuse to be involved in the treatment of the child and in the FST meetings, agency staff must work with other FST members to develop another permanency plan for the child. The need for this plan must be discussed with the family. If the parent(s)/guardian(s) have withdrawn from the child and this is, for all intents and purposes, a disruption, the FST should recommend to the court that the child be placed in the custody of the Children’s Division (CD). This would then put the child under ASFA (Adoption and Safe Families Act) requirements.
7. Subsidy may be authorized for the cost of residential treatment at the level determined by the RCST Coordinator. As with all services, payment for residential treatment will not be made until the service has been approved by the CD Director and shall not be backdated.
  
  Payment for these services must be made under the terms of the contracts the Division has with Missouri providers. Whether in state or out of Missouri, the Missouri contract rate will apply. Placements for children who are residents of Missouri will only be sought with Missouri residential facilities or facilities in bordering states because of the proximity to the adoptive home, or when the necessary treatment cannot be provided by a Missouri facility.
8. Residential placements may be authorized for only six months at a time. Upon the sixth month, the documentation supporting the need for placement and level of care must be reviewed in a FST meeting and the documentation provided to the RCST coordinator. The review team should consist of the family, child, worker, supervisor, facility and any other persons involved in the treatment of the child. These reviews, along with the approval of the RCST, are to be submitted to Central Office with the amendment indicating a continued need for funding for residential treatment. No payment should be made until the amendment is approved by signature of the Division Director and approval should be given at least 30 days prior to expiration of the prior amendment to avoid any interruption in services.
9. Requests for out-of-state residential treatment are to be reviewed by the Regional Office RCST in consultation with Central Office, if necessary. The RCST Coordinator must have already determined a level of care. Residential treatment will be reimbursed at the rates of contracted providers located within Missouri.
  
  When using out-of-state residential or Missouri non-contracted facilities, the worker is to contact Contract Management in order to request that a child-specific-contract be sent to the vendor. The worker and Regional Office designee are to work together with the vendor in order to negotiate the monthly rate. Contract Management Unit (CMU) is available for technical assistance while completing this process.
10. According to your regional practices, the completed CS-67 and CS-67A for residential treatment with a contracted provider are to be entered into the SEAS system. Out-of-state providers being utilized for families who reside out of state must have a child-specific contract with the Division in order to receive payment. The provider must submit a child-specific contract to the CMU for negotiation.
11. Update Alternative Client Information screen in FACES new placement by leaving the adoptive parent(s)/guardian(s) Departmental Vendor Number (DVN) and placement type, but entering the sub-placement code of "S", and changing the maintenance code to no maintenance. In the sub-placement type indicate the residential facility where the child is residing.
12. In certain circumstances use may be made of residential treatment services which are not currently covered by a contract with the Division. A contract must be developed between the facility and the Division by the facility, proposing a child-specific contract regarding the proposed care for the child. Payment shall not be made directly to the adoptive parent(s) or guardian(s).
13. A CS-65A will be generated automatically to contracted providers. The CS-65A will then be submitted by the provider to the RCST Coordinator requesting payment.
14. In the case of children attending different school districts, the school district where the parent(s)/guardian(s) reside should be charged for any special education services needed.
15. The subsidy worker shall meet with the adoptive or guardianship family to discuss the child's needs while in residential treatment, and explore the possibility of reducing the maintenance payment while the child is in treatment determining only the amount necessary while the child is in residential care (i.e. toiletries, clothing, and travel for visitation and therapy.) If the family agrees to suspend maintenance while the child is in the facility, this should be indicated in the narrative of the subsidy file and the maintenance code should be changed to no maintenance.
  
  According to federal policy (ACYF-CB-PA-O1-01) the agency cannot lower an adoptive family's amount of maintenance without the family's concurrence. If the family does agree to lower their maintenance, this is to be documented in the narrative section of the subsidy record and the reduced amount indicated on the alternative care client information record.
16. Day treatment services may be considered on a child-specific, time-limited basis. Adequate documentation must support the need for day treatment. The adoptive or guardianship family must first inquire as to the ability of their private insurance to pay for all or part of this treatment prior to the agency approving this service through subsidy. In addition, a self-referral to the Department of Mental Health (DMH) may be appropriate to determine if they can assist in funding any or all of the day treatment services. Based upon their assessment, DMH may be able to provide services to the family which are not available through the Division. Services may only be approved for up to six months at a time, and the use of the FST must occur.
Career Foster Care Placement:
1. Although career payments cannot be approved to be paid to the adoptive parent(s)/guardian(s), a child may be placed in a Career Foster Home if this treatment is determined necessary for the child. The career foster home program is for the purpose of treating a child's behavioral issues so they can be successfully placed in a permanent home. If a child enters a Career Foster Home, the family is to be referred to the out-of-home care program, a voluntary case is to be opened, and services are to be offered in order to work towards reintegration into the adoptive or guardianship home. Case opening and the use of the Family Support Team are to be used as described above.
  The CS-9 is to serve as the referral form for placement in Career Foster Care. Supporting documentation from appropriate professionals is also required. The parent(s)/guardian(s) are to complete the CS-9 and provide documentation, obtaining assistance from the worker as needed.
2. Career Foster Care placements may be authorized for only six months at a time. Upon the sixth month, the need for placement and level of care must be reviewed in a FST meeting. The review team should consist of the family, child, worker, supervisor, Career Foster Parents and any other persons involved in the treatment of the child. These reviews are to be submitted to Central Office with an amendment requesting funding for Career Foster Care. This funding will be approved by signature of the Division Director. No payments should be made until approval is given.
3. Update the Alternative Client Information screen in FACES for the new placement leaving the adoptive parent(s)
  /guardian(s) DVN and placement type, but entering the sub-placement code of "S" and entering the career placement as the sub placement, as well as changing the maintenance code to no maintenance, if the parent(s)
  /guardian(s) agree to suspend their maintenance payments.
  With regard to agency liability of an adopted/guardianship child voluntarily placed in a Career foster home, any legally recognized parent (biological or adopted/guardianship) is liable for the actions of his/her child as long as that parent/guardian has not been relieved of legal custody. If the Division does not have legal custody of a child, we are not liable for the child. The Career home may be liable for the actions of the child, at least in the negligent supervision area.
4. Payment must be made to the Career foster home via a CS-65 each month. When changing the amendment to Career Foster Care, use the service code, "MAIN". The adoptive/guardianship family's maintenance code of ‘MAIN’ will remain on the amendment. If the adoptive/guardianship family refuses to suspend their payment, the maintenance code will remain the same, however, if they agree to suspend their payment, the maintenance code will be ‘3’ indicating no maintenance. All of these actions should be documented in the narrative section of the subsidy record.
  The subsidy worker shall meet with the adoptive/guardianship family to discuss the child's needs while in Career Foster Care and explore the possibility of reducing the maintenance payment while the child is in treatment (i.e. toiletries, clothing, and travel for visitation and therapy.) Update the Alternative Client Information screen in FACES regarding change in maintenance and document all changes in the narrative section of the subsidy file remembering that the maintenance amount cannot be reduced without the concurrence of the adoptive/guardianship family.
Respite:
1. Adoptive or guardianship families may receive respite as a special service on a case-by-case basis through subsidy when a documented need exists. Documentation for this need requires a letter requesting this service by the adoptive or guardianship family, stating the child's need for respite. A letter supporting this need must also be completed by the worker and be submitted with the subsidy amendment. All paid receipts submitted for reimbursement must be submitted within 6 months of the service being provided.
2. Respite units may only be approved according to the child's level of maintenance. One unit is a time period of between 12 – 24 hours. The following eligibility rates apply:
  1. Base Maintenance = 12 units at $20.00 per unit.
  2. Above Base Maintenance = 19 units at approximately $21.00 per unit. (The daily rate of maintenance they receive.)
3. Respite may be approved up to age 18.
  
  Career respite units may only be approved for contracts that have career maintenance that was approved prior to July 31, 2002. Respite on these contracts is approved for 24 units at $40.00 per unit. There are no two-week vacations approved through subsidy as are available to Career Foster Parents. Career respite will not be approved as a new service.
Integrative Expenses:
1. Only under extreme circumstances will an integrative expense be considered under subsidy. Extreme circumstances include situations where the adoptive parent(s)/guardian(s) home or vehicle may need to be adapted to meet the Americans with Disabilities Act (ADA) requirements in order to meet the needs of the child with a disabling condition. The adoptive parent(s)/guardian(s) are expected to seek other community resources in obtaining the needed service prior to the subsidy request and provide documentation regarding their findings. Subsidy may assist in the cost of the service. No payments will be made for expenses incurred prior to approval by the Division Director to the agreement.
  
  EXPENSES NOT ELIGIBLE FOR APPROVAL THROUGH SUBSIDY
  
  Housing additions, vehicles, clothing allowances, integrative expenses such as furniture and linens, special education services, sports/dance/ music/art lessons, tutoring, private school tuition, diapers, day-to-day transportation, child care above locally contracted rate, mentoring, computers, home schooling materials, extracurricular activities, club memberships, summer camp/day camps, school expenses, telephone calls, attachment therapy centers not covered by MO HealthNet, insurance premiums, or deductibles in states that are ICAMA member states.
  
  Providers will be reimbursed directly if they have a contract with the Division. Adoptive parent(s) or guardian(s) will be paid for the service after an invoice or a "paid" receipt has been submitted. All receipts submitted for reimbursement must be submitted within 6 months of the service being provided.
Special Education Services Costs:
1. The responsibility of providing for special education costs remains with the local school districts. Staff should assist adoptive parent(s) or guardian(s) and school officials in obtaining the assistance of the Missouri Department of Elementary and Secondary Education (DESE) in meeting the cost of a child's special education needs.
2. Special education services must be met by the local school district except for:
  1. Tutorial plans which are intended to support a child’s special education plan (must be met by the parent/guardian or community resources); or
  2. Payment for special education services for a child in residential placement is authorized as follows:
    - The Adoption or Subsidized Guardianship Agreement provides for payment of residential treatment services;
    - The residential placement is outside the domicile school district of the adoptive parent(s) or guardian(s);
    - The child requires special education services; and
    - There are no other resources available to meet the costs of these services.
Continuing Subsidy beyond the Child's 18th Birthday Utilizing an 18+ Agreement:

Only Adoption Subsidy Youth May be Considered for an 18+ Agreement. No Guardianship Agreement will be Continued Beyond Age 18 Under Any Circumstance.
1. The child's physical, dental or mental health condition must be of such a degree that the child continues to require extraordinary specialized care beyond the age of 18. Documentation of the degree of the child's condition and the recommended treatment is required. Often, MO HealthNet may be all that is necessary to meet the child's needs. Maintenance does not automatically continue if it is not identified as a need:
  1. The 18+ Adoption Subsidy Agreement, CD AD 18, may only be approved for one year. The subsidy must be renegotiated and a new Agreement signed every year in the case of a child over the age of 18 that continues to have a documented need for subsidy to continue. Each year Children's Division staff should be working with the parents to make referrals to allow the family to access services to transition the youth to adult services, reducing the need for subsidy each year between ages 18 and 21.
  2. Documentation of the need to extend the subsidy due to the child's physical, mental health or dental needs must accompany the Agreement to Central Office for approval. Such documentation must come from a physician, dentist, therapist or other professional involved in the ongoing treatment of the youth. Documentation should include a long-term plan for the child when subsidy is no longer available (i.e. MO HealthNet, Department of Mental Health services, Social Security Disability, etc.). Documentation must always be placed in the case file and be written into the case plan.
  3. Approval must be obtained from the Division Director by signature to the 18+ Adoption Subsidy Agreement at least 30 days prior to the end of the month of the child's 18th birthday.
  4. The authorized funding category must be adoption subsidy-HDN when an 18+ Adoption Subsidy Agreement is in place.
  5. Subsidy shall not be continued for a child who is able to work after graduation, or who has enrolled in college; nor does subsidy assist with college tuition or books.

Attachment A: Subsidy Coverage Limitations

Basic Subsidy Coverage Limitations

Additional Services

Chapter Memoranda History: (prior to 1/31/07)

Memoranda History: