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RALEIGH — Changes proposed to the Medicaid program are at best confusing and at worst could make certain services for those with mental illness hard to come by, local providers and national advocates said last week. At issue is a category of treatments known as rehabilitative services that includes therapeutic foster care for troubled children and day programs for the developmentally disabled.

Advocates say that Medicaid funding for these services could be eliminated or severely curtailed under the proposed Medicaid rule changes.

"We have found that many of these services are not available in some states to begin with," said Mary Giliberti, director of public policy and advocacy for the National Alliance on Mental Illness.

Medicaid is the health insurance program for the poor and disabled jointly funded by the federal and state governments. The changes to the program's rehabilitative services rules were proposed by the Centers for Medicare and Medicaid Services in August.

According to a summary of the rules, they are designed to keep Medicaid from paying for services that other state and federal programs should fund. Doing so would save $2.2 billion over five years.

The children's health insurance bill passed by Congress in September would have kept the new rules from going into effect for six months. But that measure was vetoed by President Bush.

With a public-comment period on the proposed rules set to expire Friday, they could be put into place this year.

The proposed rules have the potential to affect a number of services provided to North Carolina residents. One example is therapeutic foster care, a service provided to more than 11,000 North Carolina children, according to the Methodist Home for Children, a group that provides the service.

"I don't think anyone is really clear on what they mean," said Chuck Hodierne, executive director of Youth Focus in Greensboro. Besides other services, his agency provides therapeutic foster care to local children. "I think if it does mean it's the end of using Medicaid dollars for therapeutic foster care, it would be a disaster."

A spokesman for the Centers for Medicare and Medicaid Services was unable to provide an answer to the question as to how much therapeutic foster care would be restricted. However, therapeutic foster care is specifically named in a part of the proposed rules that would limit what Medicaid would pay for.

Foster care is familiar to many as a temporary living arrangement for children and teens who either lose their parents or are taken away from abusive caretakers. Therapeutic foster care differs markedly.

It is a kind of treatment in which the foster parents are specially trained to guide the behaviors of children with a severe mental health diagnosis such as post-traumatic stress disorder or bipolar disorder.

There is a big difference in the reimbursements given to those families. A family foster care provider will get about $500 a month, Hodierne said. Because therapeutic foster care parents must spend so much time with their children — some have no other jobs — the reimbursement rate is about $100 a day, he said.

"We really regard them as professional parents," Sandy Mastin Cook, executive director of Greensboro-based Children's Home Society, said of therapeutic foster parents. "I can't imagine where else we would get the funding to do it."

Contact Mark Binker at (919) 832-5549 or mbinker@news-record.com