HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE Medicaid Coverage and Other Health Care Resources The information in this document is intended primarily to provide people working in subsidized housing and homeless assistance systems basic information about available health care resources. It is also intended to provide context for a discussion on gaps in needed health care services and treatment. The following resources are covered: § Federally Qualified Health Centers: Community Health Centers; Health Care for the Homeless; Migrant Health Centers § Rural Health Services § Native American Health Resources § Veteran Health Resources § HIV/AIDS Health Resources § Behavioral Health Resources § Other Resources for the Uninsured in North Dakota § Medicaid § Managed Care

HEALTH CARE RESOURCES AND MEDICAID COVERAGE A variety of health care resources for low-income people exist at the federal and state level. These resources can take the form of health care directly accessible by individuals or funding that flows through organizations that provide health care and related services. Accessing certain resources requires enrollment (and re-certification) based on specific, documented eligibility criteria. As with housing resources, many health care resources focus on particular populations, such as people experiencing homelessness, people living with HIV/AIDS, veterans, or people with disabilities.

Federally Qualified Health Centers (FQHCs)1

The Federal Health Center Program serves medically underserved populations or areas, works with special populations, and provides for enhanced Medicaid reimbursement. The four types of health centers are: (1) Community Health Centers; (2) Health Care for the Homeless; (3) Migrant Health Centers; and (4) Public Housing Primary Care Health Centers. Details about Community Health Centers and Health Care for the Homeless Programs are below. According to the Community HealthCare Association of the Dakotas, there are 5 FQHCs in North Dakota.

Community Health Centers2

Community Health Centers (CHCs) deliver comprehensive, high-quality preventative and primary health care to patients regardless of their ability to pay. They also provide oral health and behavioral health care tailored to the needs of the communities they serve. CHCs offer a sliding fee discount to based on income. According to HRSA, there are 4 CHCs in North Dakota: • Coal Country CHC • Family HealthCare Center • Northland Health Partners CHC • Valley CHC

1 Community HealthCare Association of the Dakotas, “Find a Community Health Center in the Dakotas,” http://www.communityhealthcare.net/find-a-chc-site 2 HRSA Health Center Program, “2014 Health Center Program Grantee Profiles: North Dakota,” http://bphc.hrsa.gov/uds/datacenter.aspx?q=d&year=2014&state=ND#glist

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources Health Care for the Homeless (HCH) Programs3

HCH Programs emphasize a multi-disciplinary approach to delivering care to homeless persons, combining aggressive street outreach with integrated systems of primary care, mental health and substance abuse services, case management, and clinical advocacy. Emphasis is placed on coordinating efforts with other community health providers and social service agencies.

There is one federally-funded HCH Program in North Dakota: Homeless Health Services in Fargo.

Homeless Health Services4

Homeless Health Services (HHS) is a program of the Family HealthCare Center in Fargo. The project maintains a primary care clinic in the downtown area at St. Mark's Lutheran Church. Services include management of acute and chronic health problems, preventive care, HIV/AIDS screening, and patient education. Patients receive case management services, including referrals for mental health and substance abuse services. Outreach is provided by staff at area shelters and other community sites serving people who are experiencing homelessness. Family HealthCare has in-house enrollment specialists to assist uninsured patients with Medicaid applications.

Linkages: Homeless Health Services has linkages with Fargo Cass Public Health, Merit Care Medical Center, Southeast Human Service Center, Lakeland Mental Health, area shelters, and transitional housing sites.

Statistics: Estimated homeless population: 5,000; Patients served annually: 1,020

Migrant Health Centers5

The Migrant Health Center Program provides support to health centers to deliver comprehensive, high quality, culturally-competent preventive and primary health services to migratory and seasonal agricultural workers and their families with a particular focus on the occupational health and safety needs of this population. There is one Migrant Health Center program in North Dakota: Community Health Services Inc., which operates in Grafton.

Rural Health Services

Critical Access Hospitals (CAHs) and Rural Health Clinics (RHCs) are the safety net providers for rural and remote communities in North Dakota. Critical Access Hospitals (CAHs)6 “Critical Access Hospital” is a designation given to certain rural hospitals by the Centers for Medicare and Medicaid Services (CMS). The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. This is accomplished through cost-based Medicare reimbursement.

To ensure that CAHs deliver services to improve access to rural areas that need it most, restrictions exist concerning what types of hospitals are eligible for the CAH designation. The primary eligibility requirements for CAHs are:

3 National Healthcare for the Homeless Council –North Dakota Profile, https://www.nhchc.org/hchdirectory/nd/ 4 National Healthcare for the Homeless, “Homeless Health Services,” https://www.nhchc.org/directory/homeless-health-services-2/ 5 Community HealthCare Association of the Dakotas, “Find a Community Health Center in the Dakotas,” http://www.communityhealthcare.net/find-a-chc-site and Community H ealth Services, Inc., http://chsiclinics.org/ 6 University of North Dakota Center for Rural Health, “North Dakota Hospitals,” https://ruralhealth.und.edu/projects/flex/hospitals

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources • 25 or fewer acute care inpatient beds • Location more than 35 miles from another hospital • Maintained annual average length of stay of 96 hours or less for acute care patients • 24/7 emergency care services

According to the University of North Dakota Center for Rural Health, there are 36 CAHs in the state. [For a list of CAHs in North Dakota, please see Appendix A at the end of this Worksheet.] Rural Health Clinics (RHCs)7 A Rural Health Clinic is a federally qualified health clinic (but not a part of the FQHC Program) that is certified to receive special Medicare and Medicaid reimbursement. CMS provides advantageous reimbursement to increase rural Medicare and Medicaid patients' access to primary care services.

CMS reimburses RHCs differently than it does other facilities. CMS is required to pay RHCs using a prospective payment system (PPS) rather than a cost-based reimbursement system. RHCs receive an interim payment from Medicare, and at the end of the year, this payment is reconciled using the clinic's cost reporting. For services provided to Medicaid patients, states can reimburse using PPS or by an alternative payment methodology that results in a payment equal to what the RHC would receive under PPS. Regardless of whether the patient sees a mid-level provider or a physician, the RHC must receive the same amount for its services.

As of 2015, there were 55 Rural Health Clinics in North Dakota. [For a list of Rural Health Clinics in North Dakota, please see Appendix B at the end of this Worksheet].

Native American Health Resources Native American Development Center8 The Native American Development Center (NADC) works to connect Native Americans relocating to the Bismarck-Mandan community to find services, including behavior health services and mentorship programs. NADC provides referrals to a supportive professional network of psychologists, behavior health providers, attorneys, and medical doctors to serve Native American individuals and families. Indian Health Service – Area Office9 Indian Health Service’s Great Plains Area Office in Aberdeen, , works in conjunction with its 19 Indian Health Service Units and Tribal-managed Service Units to provide health care to approximately 122,000 Native Americans located in North Dakota, South Dakota, Nebraska, and Iowa. The Area Office's service units include seven hospitals, eight health centers, and several smaller health stations and satellite clinics. Each facility incorporates a comprehensive health care delivery system. The hospitals, health centers, and satellite clinics provide inpatient and outpatient care and conduct preventive and curative clinics.

7 North Dakota Department of Rural Health, “Health Facilities: North Dakota Rural Health Clinics,” https://www.ndhealth.gov/HF/North_Dakota_Rural_Health_Clinics.htm 8 Native American Development Center, “Services,” http://nativeamericandevelopmentcenter.com/services/ and Ashley W right, “Native American Development Center Forming,” The Bismarck Tribune , Jan 9, 2014, http://bismarcktribune.com/news/local/bismarck/native-american- development-center-forming/article_fa7e9ce2-78b3-11e3-83d4-0019bb2963f4.html 9 U.S. Department of Health and Human Services – Indian Health Services, Great Plains Area, https://www.ihs.gov/greatplains/

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources Spirit Lake Health Center10 The Spirit Lake Health Center, located in Fort Totten, North Dakota, is staffed by three physicians in an ambulatory care facility. Complex outpatient services or inpatient care are referred to a contract facility. Fort Totten operates a dental clinic and a diabetes program with comprehensive screening, education, and treatment. Fort Yates Hospital11 The Fort Yates Hospital, located near the at Fort Yates, North Dakota, is a fully accredited 12-bed hospital staffed by three permanent physicians and two nurse practitioners. Comprehensive services include inpatient, outpatient, emergency, dental, behavioral health, optometry and a dialysis unit (8 stations). Dental care is provided in the main clinic at the hospital by two dental officers. There are also health stations at Cannonball, Bullhead, and Wakpala. The health stations provide minimal outpatient care and are staffed by a physician's assistant, a public health nurse, and a community health representative. The health stations are visited at least once a week by a physician from the Fort Yates Hospital. Quentin N. Burdick Memorial Health Care Facility12 The Quentin N. Burdick Memorial Health Care facility located in Belcourt, North Dakota, serves a population of approximately 13,100, has 27 beds and 11 physicians (Inpatient and Outpatient). In addition to inpatient care, the hospital provides general surgery, podiatry, ENT surgery, obstetrics, and CAT scan. The outpatient department offers basic service and specialty clinics with contracted specialists. The dental program has a full clinic at the hospital. The facility also includes a mental health department, which consists of one full-time consulting clinical psychologist, one staff psychologist, a psychiatric nurse, and a psychiatrist. Veteran Health Resources Fargo VA Health Care System13 Veterans’ Affairs Medical Center (VAMC) Fargo strives to be a patient-centered, integrated health care organization for veterans. In addition to the main VA facility in Fargo, VAMC Fargo offer services in eight community-based outpatient clinics in North Dakota in Bismarck, Devils Lake, Dickinson, Grafton, Grand Forks, Jamestown, Minot, and Willston. Health Care for Homeless Veterans (HCHV) Program VAMC Fargo operates an HCHV program, which serve as the hub for a myriad of housing and other services which provide the VA a way to outreach and assist homeless Veterans by offering them entry to VA care. The central goal is to reduce homelessness among veterans by conducting outreach to those who are the most vulnerable and are not currently receiving services and engaging them in treatment and rehabilitative programs. HCHV’s Contract Residential Treatment Program ensures that Veterans with serious mental health diagnoses can be placed in community-based programs that provide quality housing and services.

10 U.S. Department of Health and Human Services – Indian Health Services, Great Plains Area, “Spirit Lake Health Center,” https://www.ihs.gov/greatplains/index.cfm/healthcarefacilities/spiritlake/ 11 U.S. Department of Health and Human Services – Indian Health Services, Great Plains Area, “Standing Rock Service Unit,” https://www.ihs.gov/greatplains/healthcarefacilities/standingrock/ 12 U.S. Department of Health and Human Services – Indian Health Services, Great Plains Area, “Turtle Mountain Service Unit,” https://www.ihs.gov/greatplains/healthcarefacilities/turtlemountain/ 13 U.S. Department of Veterans Affairs, “Fargo VA Health Care System,” http://www.fargo.va.gov/about/index.asp

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources Homeless Patient Aligned Care Teams (H-PACTs) Program The Fargo VA Health Care System operates a Homeless Patient Aligned Care Teams (H-PACTs) Program, which implements a coordinated homeless primary care model that focuses on improving the access, care coordination, and quality of treatment of alcohol and other substance use for veterans experiencing or at risk of homelessness. H-PACTs provides a coordinated "medical home" specifically tailored to the needs of homeless Veterans that integrates clinical care with delivery of social services with enhanced access and community coordination. Health Care for Re-Entry Veterans Program The Health Care for Re-Entry Veterans Program helps incarcerated Veterans successfully rejoin the community through supports including those addressing mental health and substance use problems. Homeless Veterans Dental Initiative The Homeless Veterans Dental Initiative provides dental treatment for eligible Veterans in a number of programs: Domiciliary Residential Rehabilitation Treatment, VA Grant and Per Diem, Compensated Work Therapy/Transitional Residence, Healthcare for Homeless Veterans (contract bed), and Community Residential Care. The Fargo VA Health Care System is working to expand dental care to all eligible Veterans within its programs.

HIV/AIDS Health Resources Ryan White HIV/AIDS Part B Program14 The Ryan White HIV/AIDS Program (RWHAP) provides a comprehensive system of care that includes primary medical care and essential support services for people living with HIV who are uninsured or underinsured. The Program works with cities, states, and local community-based organizations to provide HIV care and treatment services to more than 512,000 clients each year. Part B of the program particularly provides grant funding to states and territories timprovo e the quality, availability and organization of HIV health care and support services. The North Dakota Department of Health HIV Program is the Ryan White Part B grantee in North Dakota. Case managers are available in 13 counties throughout North Dakota to assist residents in enrolling in the Ryan White programs. AIDS Drug Assistance Program (ADAP)15

The Ryan White HIV/AIDS Program Part B program also includes grants for the AIDS Drug Assistance Program (ADAP). The ADAP program is a state-administered program that provides FDA-approved medications to low-income individuals with HIV who have limited or no coverage from private insurance or Medicaid. Any resident of North Dakota who has been infected with HIV/AIDS and has a gross income below 300% of the federal poverty level (FPL) may be eligible to receive services through the ADAP Program. North Dakota residents can enroll in the ADAP by contacting the Ryan White Case Manager in their area.

14 North Dakota Department of Health HIV Program, “Ryan White HIV/AIDS Program,” https://www.ndhealth.gov/HIV/HIV%20Care/HIV%20Care.htm 15 North Dakota Department of Health HIV Program, “AIDS Drug Assistance Program (ADAP),” https://www.ndhealth.gov/HIV/HIV%20Care/ADAP/ADAP.htm

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources Behavioral Health Resources

North Dakota Behavioral Health Division16

The North Dakota Behavioral Health Division provides leadership for the planning, development, and oversight of a system of care for children, adults, and families with severe emotional disorders, mental illness, and/or substance abuse issues. The Behavioral Health Division provides behavioral health services (mental health and substance abuse services) through eight Regional Human Service Centers: • Northwest Human Service Center: Divide, McKenzie, Williams Counties; Trenton Indian Service Area; part of Fort Berthold Indian Reservation • Badlands Human Service Center: Adams, Billings, Bowman, Dunn, Hettinger, Golden Valley, Slope, Stark Counties • North Central Human Service Center: Bottineau, Burke, McHenry, Mountrail, Pierce, Renville, Ward Counties • West Central Human Service Center: Burleigh, Emmons, Grant, Kidder, McLean, Mercer, Morton, Oliver, Sheridan, Sioux Counties; Standing Rock Indian Reservation; part of Fort Berthold Indian Reservation • Lake Region Human Service Center: Benson, Cavalier, Eddy, Ramsey, Rolette, Towner Counties • South Central Human Service Center: Barnes, Dickey, Foster, Griggs, LaMoure, Logan, McIntosh, Stutsman, Wells Counties • Northeast Human Service Center: Grand Forks, Walsh, Pembina, Nelson Counties • Southeast Human Service Center: Cass, Ransom, Richland, Sargent, Steele, Traill Counties The North Dakota Behavioral Health Division also provides behavioral health services through the North Dakota State Hospital in Jamestown. Coal Country Community Health Centers (CCCHC)17 CCCHC provides assistance to individuals and families who experience emotional and coping problems and those who have serious, persistent mental illness. CCCHC provides services to help clients dealing with mood disorders, personality disorders, anxiety, stress, grief, suicidal thoughts, relationship difficulties, anger, and drug and alcohol abuse. CCCHC also offers 16-hour DUI seminars, adult and youth programs on mental health and first aid, and employee assistance programs. CCCHC is licensed to provide Drug and Alcohol Evaluations as well as Outpatient Substance Abuse Treatment and Aftercare. Prairie St. John’s18 Founded in 1997, Prairie St. John’s is a fully-licensed and accredited 110-inpatient bed facility offering services for children, adolescents and adults to address mental health issues, substance use addiction or co-occurring disorders. Prairie offers a full psychiatric and addiction continuum of services. This continuum of services includes inpatient hospitalization, partial hospitalization (day treatment), residential treatment, intensive outpatient services and clinic services. While many

16 North Dakota Department of Human Services, “Behavioral Health Services,” https://www.nd.gov/dhs/services/mentalhealth/ and https://www.nd.gov/dhs/info/pubs/docs/hsc-contact-info.pdf 17 Coal County Com munity H ealth Ce nters, “Behavioral Health,” http://www.coalcountryhealth.com/behavhealth.html 18 Prairie St. John’s, http://prairie-stjohns.com/

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources patients are from the Fargo, ND, Moorhead, MN, and surrounding areas, Prairie St. John’s also serve individuals and their families from throughout Minnesota, North Dakota and other states. Dacotah Foundation19 The Dacotah Foundation is a community-based mental health system for children and adults with mental illness and/or chemical dependency. The Foundation operates residential programs in Bismarck and Fargo for adults with mental illness and/or chemical dependency, as well as a Recovery Center and independent living units for individuals with mental illness in Bismarck. The Dacotah Foundation also operates Community Based Services to adult mentally ill and/or chemically dependent individuals in Bismarck and Fargo, including but limited to representative payee services, community mental health technicians/case aides, and medication monitoring. Other Health Resources for Uninsured North Dakotans North Dakota Health Tracks20

North Dakota Health Tracks is a preventive health program that is free for children ages 0 to 21 who are eligible for Medicaid. Health Tracks pays for screenings, diagnosis, and treatment services to help prevent health problems from occurring or help keep health problems from becoming worse. Health Tracks also pays for orthodontics, glasses, hearing aids, vaccinations, counseling, and other important health services. Health Tracks helps schedule appointments for services and will also help with finding transportation to the services.

Free Clinics21

Free health and medical clinics offer services free of cost or for a nominal fee to persons who have limited income, no health insurance, or do not qualify for Medicaid or Medicare. There are a total of 28 free clinics in the state of North Dakota. City & Country Health Clinic (CCHC)22 CCHC provides outpatient care, basic medications, health education and referrals at First Lutheran Church in Minot. Appointments are provided free of charge on a "first come, first served" basis. CCHC has 12 physicians, nurse practitioners, and physician assistants providing services as volunteers, as well as medical residents from UND Center for Family Medicine. The clinic also welcomes nursing students from Minot State University serving their community health practicums. Joanne’s Clinic23 Joanne’s Clinic provides basic and preventative medical services at no cost to those living in a Ruth Meiers facility. Services include immunizations, wound care, cold and flu care, and other basic services. Referrals can be made to medical providers in the community.

19 Dacotah Foundation, “Services,” http://www.dacotahfoundation.org/mission.html 20 North Dakota State Government, “Health Tracks,” https://www.nd.gov/dhs/services/medicalserv/health-tracks/ 21 Free Clinic Directory, “Free and Income Based Clinics in North Dakota,” http://www.freeclinics.com/sta/north_dakota 22 First Lutheran Church Minot, “City & Country Health Clinic,” http://www.flcminot.com/ministry-outreach/city-country-clinic 23 Ruth Meiers Hospitality House, “Service and Assistance Programs: Joanne’s Clinic,” http://www.savannahgraphics.com/ruthmeiers/programs/

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources Third Street Clinic (TSC)24 TSC seeks to improve the health and well-being of underserved residents of Grand Forks by partnering with the greater Grand Forks community as a resource for timely access to healthcare, medicine, and other vital services. Eligible clients are residents of the greater Grand Forks Community who have no insurance for the requested health service, have an income below 200% of the Federal Poverty Level, and have a medical condition or dental emergency in need of treatment. TSC does not have providers on-site; the clinic offers referrals, vouchers, and financial assistance for patients seeking primary care, vision, and emergency dental services. TSC also offers prescription medication assistance through a partnership with Inspire Pharmacy, with co-pays ranging from $5-8.

YWCA Cass Clay25

Through a Partnership with , YWCA Cass Clay has hired a Shelter Faith Community Nurse to bring health education to shelter residents and empower women to better manage their health through a holistic approach. The Nurse functions as a health educator, advocate, spiritual liaison, and referral resource for women and their families. In 2015, 1,250 referrals were made by the Shelter Faith Community Nurse; 218 women required no further referrals and 10 emergency room visits were averted.

NORTH DAKOTA HEALTH CARE FUNDING AND MANAGEMENT Medicaid

North Dakota State Medicaid Plan26

Overview: Historically, Medicaid eligibility was restricted to specific categories of low-income individuals, such as children, their parents, pregnant women, the elderly, or individuals with disabilities. In most states, adults without dependent children were ineligible for Medicaid, regardless of their income, and income limits for parents were very low. The Affordable Care Act (ACA) extended Medicaid to nearly all nonelderly adults with incomes at or below 138% of poverty (about $32,500 for a family of four in 2013). All states had previously expanded eligibility for children to higher levels than adults through Medicaid and the Children’s Health Insurance Program (CHIP). North Dakota has implemented Medicaid expansion under the ACA; enrollment began in October 2013, with coverage effective January 2014. As of May 2015, Medicaid and CHIP cover 89,001 North Dakota residents. From fall 2013 to May 2015, the number of people covered by Medicaid/CHIP increased by 19,021 and the state saw a 24% reduction in the uninsured rate from 2013 to 2014.

How Care is Delivered in North Dakota Medicaid: In North Dakota, the North Dakota Department of Human Services, Medical Services Division is responsible for Medicaid. Sanford Health Plan was awarded the state contract to provide health coverage to the newly-eligible population under the Medicaid expansion.

On October 1, 2011, North Dakota Medicaid began transitioning their disease management program to a Health Management Program. Services of this program include patient-centered care

24 Third Street Clinic, http://www.thirdstreetclinic.org/ 25 YWCA Cass Clay, “Shelter Faith Community Nurse,” http://www.ywcacassclay.org/what-we-do#shelter-faith-community-nurse 26 North Dakota Department of Human Services, “Medicaid Managed Care,” https://www.nd.gov/dhs/services/medicalserv/medicaid/managedcare.html and HealthInsurance.Org , “North Dakota Medicaid,” https://www.healthinsurance.org/north-dakota-medicaid/

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HEALTHCARE AND HOUSING (H2) SYSTEMS INTEGRATION INITIATIVE NORTH DAKOTA Medicaid Coverage and Other Health Care Resources coordination, telephone contact with a care coordinator or nurse within the clinic, involvement from a team of medical professionals as needed, and patient education. Providers, practitioners, clinics, or Disease Management Organizations (DMOs) may be eligible to provide additional health management services to certain, eligible Medicaid recipients with chronic diseases.

North Dakota Home and Community Based Services Waiver Programs27

North Dakota has six Medicaid 1915(c) HCBS Waivers: ND Medicaid Waiver HCBS (0273.R04.00) Provides adult day care, adult residential care, case management, homemaker, respite care, supported employment, adult family foster care, chore, emergency response, environmental mods, extended personal care, family personal care, home delivered meals, non-medical transportation, specialized equipment and supplies, and transitional living for aged North Dakotans. Children's Hospice (0834.R01.00) Provides case management, respite, hospice, skilled nursing, bereavement counseling, equipment and supplies, expressive therapy, and palliative care for medically fragile individuals ages 0 – 21, individuals ages 65 and older, and physic