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Attachment 2. HRSA’s Response to Public Comments Received in Response to the 60-day Federal Register Notice Published January 7, 2013

The Health Resources and Services Administration (HRSA) received comments from state Title V programs, state Children with Special Health Care Needs (CSHCN) programs, and provider associations in response to the January 7, 2013 Federal Register 60-day notice. This is the reconciliation of the comments grouped by topic area.

Definition of “Service” Must Be Better Defined

Comment. Several commenters expressed that the definition of “service,” as used in the data collection tool, needed to be better defined. In particular, the data collection tool was not clear as to whether or not expenditures for “services” might include funds used to provide salary or infrastructure support to providers that directly provide health care to maternal and child health (MCH) populations. One commenter expressed concern that if the goal of the data collection tool was to gain a better understanding of the extent to which direct medical care services were supported by Title V funding, then excluding these salary and infrastructure funds would not achieve that goal. Another commenter noted that definition of “services” for this data collection tool did not align with the definition of “direct services” defined under the Title V Block Grant. In particular, “services” included enabling services as defined under the Title V Block Grant.

Response. We appreciate the thoughtful comments pertaining to the definition of “service.” We have revised the data collection tool to expand the discussion of what is defined as a “service” for purposes of this data collection effort. Services are defined as the medical, allied health, and support services; medical equipment; and supplies that are typically reimbursed by public or private insurance and that are reimbursed by the Title V program using federal MCH Formula Block Grant funds. We provide examples of services in the revised data collection tool. We have also clarified that the funds used to provide salary or infrastructure support to health care practitioners who provide clinical care will not be captured through this data collection tool.

Definition of “Reimburse” Must Be Better Defined

Comment. Two commenters suggested that the phrase “reimburse direct services” needed to be better defined. One commenter noted that this phrase could mean paying for a clinic that makes services available to children or it could mean providing funding to local public health agencies that make health services available to children. Another commenter noted that it could mean direct payment to a provider for a service, a direct payment to a parent for services that they paid to a provider, or a contractual agreement to "buy" a provider to provide services.

Response. We appreciate the thoughtful comments pertaining to the definition of “reimburse direct services.” We have revised the data collection tool to include an expanded discussion of what is defined as a “service” for purposes of this data collection effort. Included in this discussion, we clarify that the intent of the data collection tool is to capture information about federal MCH Formula Block Grant funds used to pay for services through a formal process similar to paying a medical billing claim. We also clarify that funds used to provide salary or infrastructure support to providers that provide clinical care will not be captured through this data collection tool.

Inclusion of Pregnant Women or “Other” Populations Should Be Considered

Comment. Several commenters noted that the Title V MCH Block Grant addresses the needs of five target populations: pregnant women, infants, CSHCN, children aged 1–22 years, and “other” populations. However, the data collection tool is limited only to infants, children, and CSHCN. This limited focus would underestimate the breadth of the MCH populations served through the Title V program.

Response. HRSA thanks the commenters for noting the differences in population focus between the Title V MCH Block Grant and the data collection tool. On the basis of HRSA’s data needs and the motivation for this data collection effort, we have decided to revise the data collection tool to capture data on pregnant women, in addition to infants, children, and CSHCN. However, to minimize burden, we will not request data on the “other” population served by Title V programs.

Additional Clarification Is Needed on Specific Directions Outlined in the Tool

Comment. One commenter requested that we provide further direction on determining health insurance status in Question 2, as Title V clients’ insurance status may change throughout the year.

Response. We appreciate this commenter’s request for additional clarification. To address this concern, we have revised the directions for Question 2 of the data collection tool to include an example of how to break out expenditures across the type of insurance a child or pregnant woman may have at the time he or she receives services reimbursed using federal MCH Formula Block Grant funds. We have also added guidance for situations in which a child or pregnant woman may have more than one source of insurance coverage.

Comment. One commenter requested additional clarification as to whether the intent of Question 3 of the data collection tool was to request an unduplicated count of children.

Response. We thank the commenter for this request for additional clarification, and we have revised the directions for Question 3 to highlight that we are requesting an unduplicated count of children and pregnant women.

Comment. One commenter noted that Question 3 of the data collection tool asks that states report the number of children who receive services that are reimbursed using federal MCH Formula Block Grant funds. Many states do not pay for these services on the basis of claims but rather provide salary support for the health care practitioners providing clinical care. The service would not be considered a “claim,” yet the patient would be included in the count of individuals served. This contradiction of not counting money but counting individuals served needs to be resolved.

Response. We thank the commenter for noting this. We have revised the data collection tool to clarify that funds used to provide salary or infrastructure support to providers that provide clinical care will not be captured through this data collection tool. Instead, this data collection tool is intended to capture federal MCH Formula Block Grant funds used for services rendered and paid for through a formal process similar to paying a medical billing claim. The expectation is that states can track the number of children and pregnant women for whom a “claim” was paid. We have revised the directions for Question 3 to clarify that states should report the unduplicated number of children and pregnant women who received services reimbursed using federal MCH Formula Block Grant funds reported in Question 2.

Comment. One commenter suggested that HRSA ask the states to provide documentation of policies and procedures that establish the state’s use of Title V funds as a payer last resort for direct clinical care.

Response. HRSA appreciates this comment. Because federal legislation requires that Title V funds can be used only after all other sources of reimbursement have been exhausted, we will not require state documentation of this policy.

Additional Clarification Is Needed on the Inclusion of Funds for Staff Support

Comment. Several commenters observed that the data collection tool was not explicit about including federal MCH Block Grant funds expended to provide salary or infrastructure support to health care practitioners who provide clinical care to MCH populations.

Response. HRSA appreciates the comments related to the inclusion of funds used to provide salary or infrastructure support health care practitioners. On the basis of the motivation for this data collection effort and our data needs, we have clarified in the data collection tool that funds used to provide salary or infrastructure support to health care practitioners who provide clinical care are not to be reported.

Relationship Between This Data Collection Tool and the Title V Annual Report

Comment. Several commenters noted that the relationship between the data collection tool and the Title V Annual Report is not clear. Several commenters were unsure whether the data collection tool represented a one-time data collection effort or if it would be an ongoing supplement or revision to the existing Title V Annual Report.

Response. HRSA appreciates these comments. We have clarified in the data collection tool that this will be a one-time data collection effort. At this time, there are no plans to collect these data in conjunction with the Title V Annual Report.

Comment. One commenter suggested that definitions used in the data collection tool—particularly the definition of “services”—should be used by all Title V programs when reporting Title V-related expenditures, whereas another commenter suggested that HRSA align the data requested in the data collection tool with the data collected in the Title V Annual Report.

Response. HRSA appreciates these comments. The intent of this data collection effort is to capture information not currently reported by states in the Title V Annual Report; therefore, we cannot align requested data in the tool with data reported in the Title V Annual Report. To make this clearer to states, we have clarified in the data collection tool that the data requested differs from what states are currently reporting in the Title V Annual Report. For this data collection effort, the definition of “service” is not the same as the definition of “direct services” under the Title V Block Grant program. In this data collection tool, we have included an expanded discussion of what is defined as a “service” for purposes of this data collection effort. At this time, there are no plans to apply this revised definition of “service” to other components of the Title V Block Grant program.

Paperwork Reduction Act Burden Is Underestimated

Comment. Fourteen commenters expressed that the burden calculation was underestimated.

Response. HRSA appreciates these concerns regarding the burden estimate for this data collection. Based on pretesting with six states, HRSA is aware that some states will have no data to report, so the burden of collection will be less than 1 hour, whereas other states will need significantly more than 8 hours (divided across several staff members) to collect and coalesce the data and complete the data collection tool. HRSA has taken this into consideration and revised the estimated burden from 8 hours per response to 36 hours per response based on the experience of the pretest states. However, based on the pretesting of the data collection tool, this estimated burden could range from less than one hour to 61 hours.

States’ Policies Regarding Implementation of the Affordable Care Act (ACA) Need to Be Addressed in the Data Collection Tool

Comment. Two commenters expressed concern that the data collection tool does not allow for consideration of states’ policies regarding implementation of the ACA. Specifically, some states may not expand Medicaid coverage under the ACA or may not implement their own health insurance exchanges. These decisions will affect how states use Title V dollars, and these issues should be considered when interpreting data provided through this tool.

Response. HRSA appreciates the commenters’ concerns regarding states’ ACA-related decisions. We agree that these policies provide critical context for the data collected in this tool, but we have decided not to use this data collection tool to collect information on states’ policies regarding implementation of the ACA. Should the need arise for this information, we will use publicly available data sources to collect it. However, we have added an additional question (Question 6) to the survey to gather information on states’ expectations related to their Title V program needs after implementation of the ACA.

Allow States to Provide Estimates for Requested Data

Comment. One commenter noted that the data collection tool is asking for retrospective data from federal fiscal year 2011. The commenter noted that states’ data systems may not be able to aggregate retrospective data in the manner needed for this data collection tool, so reasonable flexibility should be provided to permit states to estimate the requested expenditures and enrollment figures using the data they have available.

Response. HRSA thanks the commenter for raising this issue. After considering this, we have decided to allow estimates of the numbers of children and pregnant women receiving services reimbursed by federal MCH Formula Block Grant funds (Question 3 of the data collection tool), and we have revised the data collection tool accordingly. If a state uses an estimate, the directions indicate that the state should briefly explain how the estimate was derived in a footnote. However, we have decided that the expenditure data reported in Question 2 and Question 5 of the data collection tool must reflect actual expenditures made. The directions for Question 2 and Question 5 have been revised to ask states to report actual amounts of block grant funds used to reimburse services.

Support for the Intent of the Data Collection Effort

Comment. Several commenters expressed support for the data collection effort because it provides an opportunity to more accurately document states’ expenditures for clinical care reimbursed using federal MCH Formula Block Grant funds. Other commenters noted that this effort will help address misperceptions that Title V funds are consistently used to pay for direct clinical care and that full implementation of the ACA will obviate the need for Title V funding to states.

Response. HRSA appreciates these comments. We noted in the revised data collection tool that this is currently a one-time data collection effort to provide a baseline for examining how the use of federal MCH Formula Block Grant funds to reimburse services may change after implementation of the ACA.

Title V Block Grant Funds Are Used for Activities Other Than the Provision of Direct Clinical Care

Comment. Several commenters noted that they use Title V Block Grant funds to support broad-based activities, such as infrastructure, systems, and capacity building activities ,that ensure the health of MCH populations. They anticipate that these activities will still need to be funded after implementation of the ACA.

Response. HRSA appreciates these comments and continues to support states in their effort to improve the physical and mental health, safety, and well-being of the MCH population. We are aware that states use Title V Block Grant funds for a range of population-based and infrastructure-building activities. However, these activities are not the focus of this data collection effort. As we note in the revised data collection tool, the intent of this data collection effort is to collect information on how much of the federal MCH Formula Block Grant funds are used to reimburse services through a formal process similar to paying a medical billing claim. Therefore, the focus is on services that might otherwise be reimbursed by public or private insurance and that are reimbursed by the Title V program using federal MCH Formula Block Grant funds.

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