Family First Prevention Services and Programs – Reimbursement for Culturally Adapted Services and Programs for Native Children and Families

Background

Historically, Title IV-E of the Social Security Act has provided entitlement funds for foster care, adoption assistance, and relative guardianship payments and grant funds for services for children aging out of foster care. Title IV-E also provides funding for administration, data systems, and training costs connected with providing services to Title IV-E eligible children. Title IV-E funding, with the exception of the grant funds provided to children aging out of foster care, is a reimbursement for a portion of the total costs of providing eligible services to children and families who are Title IV-E eligible. The reimbursement rate for each eligible service or activity is identified under the statute.

Since 2008, with the enactment of the Fostering Connections to Success and Increasing Adoptions Act (P.L. 110-351), Tribal Nations have been eligible to directly operate the Title IV-E program. Currently, 22 Tribal Nations have an approved Title IV-E plan, although only 13 Tribes have moved forward with the implementation of their approved plan.

Tribal Nations can also operate Title IV-E through an agreement with a state. States have an obligation to negotiate a Title IV-E agreement with a Tribe in good faith if requested by the Tribe, and the agreement can cover all or part of the program. The most recent study of Tribal-State agreements revealed that there were 98 agreements involving 277 Tribal Nations in 17 states, but that information is from 2014 and thus somewhat dated.¹ The number of agreements has increased since 2014, but no official number is available. Many of the agreements are comprehensive, including operation of and reimbursement for all Title IV-E eligible services, while some are more limited.

Family First Prevention Services Act (P.L. 115-123)

Overview

In 2018, the Family First Prevention Services Act (FFPSA) (P.L. 115-123) amended Title IV-E of the Social Security Act to provide the option for states and Tribal Nations with an approved plan to use Title IV-E entitlement funds to support prevention services and programs. An individual family is eligible for covered services and programs for up to 12 months. Parents and/or kin caregivers are eligible for services, in addition to the child. Unlike other parts of Title IV-E, eligibility for prevention services is linked to the child’s status, not the income of the family. Specifically, a child must be a “candidate” for foster care who is identified to be at imminent risk of entering care and able to safely remain at home or with kin caregivers if preventive services are provided. It also includes a child whose adoption or guardianship arrangement is at risk and a child in foster care who is pregnant or parenting.

Currently, the federal government provides funding for prevention services under FFPSA at a 50 percent match (50 percent of the total cost of eligible services will be reimbursed). Beginning in October 2026, however, the match rate will be based upon the Federal Medical Assistance Percentage (FMAP) of the Tribal Nation or state, which will significantly increase reimbursement for many states and the vast majority of Tribal Nations providing these services. Tribes have to have a direct Title IV-E agreement to be eligible to submit a prevention plan and get it approved. As of December 2025, four Tribes have approved prevention plans: Cherokee Nation, Eastern Band of Cherokee Indians, Port Gamble S’Klallam Tribe, and Salt River Pima-Maricopa Indian Community.

Eligible Prevention Services

Evidence-Based Programs (EBPs)

The types of prevention services that may be provided are:

• Mental health prevention and treatment services,
• Substance abuse prevention and treatment services, and
• In-home parent skill-based programs.

In general, FFPSA-funded programs must be EBPs. This means that programs must be either:

• Promising: At least one well-designed, well-executed study exists that used some form of control group (e.g., a waitlist, a placebo group) to determine the effect of the program or service.
• Supported: At least one well-designed, well-executed study exists that used a random control or quasi-experimental trial to determine a sustained effect for at least six months after the end of treatment.
• Well-Supported: At least two well-designed, well-executed studies exist that used a random control or quasi-experimental trial to determine a sustained effect for at least a year after the end of treatment.

The Title IV-E Prevention Services Clearinghouse reviews applications for the approval of programs. The Clearinghouse has developed criteria for the approval of EBPs covered by FFPSA. Thus far, the Clearinghouse has approved 95 programs.

Seven of the approved EBPs have been used and shown to be effective with Native communities:

• Homebuilders—Intensive Family Preservation and Reunification Services
• Motivational Interviewing
• Multisystemic Therapy
• Parent-Child Interaction Therapy
• Parents as Teachers
• SafeCare
• Trauma-Focused Cognitive Behavioral Therapy

In some cases, EBPs have developed protocols that are targeted toward specific sub-groups, including Native people and Tribal communities. The Clearinghouse has a process for determining whether an adaptation makes substantial changes to the EBP or whether it is not substantial, meaning that the adaptation can be implemented without further research. The Title IV-E Prevention Services Clearinghouse Handbook of Standards and Procedures, Version 2.0 gives examples of what is substantial and not substantial. Among those changes considered not substantial are modifying examples or illustrations, providing the intervention in a different language, and updating activities or exercises to increase the relevancy of the program in a particular cultural setting. However, making more substantive changes to the protocols of the EBP would be considered substantial, meaning that the changed service or program would require its own approval in order to be supported with FFPSA funds.

While there is potential for cultural adaptations to make some EBPs appropriate for Native children and families, the overwhelming majority of EBPs do not have culturally based adaptations and have not been used, or have not been shown to be effective, in Native communities. While the seven EBPs identified above have been used and shown to be effective with Native communities, only one program that is specifically based upon Native culture—Family Spirit, an in-home parenting skills program—has been approved by the Clearinghouse. At least one other Native-based program—Positive Indian Parenting, developed by the National Indian Child Welfare Association—is currently the subject of research studies that may lead to recognition as an EBP, although it is likely to be several years before those studies are completed.

Culturally Based Programming

The FFPSA specifically exempted Tribes from the EBP requirement, allowing Tribes to receive reimbursement for “prevention services that are adapted to the culture and context of the Tribal communities served,” which is a recognition that it is not always realistic for Tribes to meet the same practice criteria as states.²

Originally, the Children’s Bureau interpreted this requirement (in its program instruction ACYF-CB-PI-18-10) to apply only to Tribes that were operating Title IV-E directly through the federal government. As mentioned above, 4 of the 22 Tribal Nations approved for direct Title IV-E funding have approved Family First plans. Those plans include a combination of EBPs and culturally based programs.

In July 2024, this interpretation was changed by amendments to the Children’s Bureau Child Welfare Policy Manual, Section 8.6, Questions 1 and 2. The Children’s Bureau determined that Tribes accessing Title IV-E through Tribal-State agreements could also utilize programs and services adapted to the culture and context of the Tribal Nations; in these agreements, States must include the Tribal culturally based programs in their five-year Title IV-E prevention plans.

The criteria for approval of culturally based programs are based upon community-driven, practice-based evidence,³ as opposed to research studies. The criteria in ACYF-CB-PI-18-10 include the following elements:

• Longevity of the practice in Indian Country
• Teachings on which the practice is based
• Values incorporated in practice
• Principles incorporated in practice
• Community leader/elders’ approval of practice
• Community feedback and evaluation of practice

All the culturally based programs that have been submitted thus far by the four directly funded Tribal Nations with approved FFPSA programs (Cherokee Nation, Eastern Band of Cherokee Indians, Port Gamble S’Klallam Tribe, and Salt River Pima-Maricopa Indian Community) have been approved as eligible for reimbursement.

Tribal Nations accessing Title IV-E through Tribal-State agreements now have a mechanism for obtaining reimbursement for culturally based prevention services for children who are under Tribal jurisdiction. The steps for doing so would be as follows:

1. The Tribal Nation develops a description of how the program meets the criteria for using cultural services.
2. The Tribal Nation and state negotiate appropriate amendments to their Tribal-State agreements.
3. The state submits for federal approval an amendment to its Family First prevention plan that includes the Tribal Nation cultural programs and services.⁴

A couple of questions have come up regarding the relevant processes.

• First, the question has been raised as to whether FFPSA-only Tribal-State agreements are allowed. Thus far, the Children’s Bureau has indicated that such agreements are not permitted, although efforts to revisit this opinion are underway.
• A second question concerns what funding mechanism would be available to Tribal Nations that want to provide culturally based prevention services through Title IV-E Tribal-State agreements for children under state jurisdiction. States can and sometimes do contract with Tribal Nations and Native organizations to provide services to Native children and families under state jurisdiction. In addition, some Tribal Nations have approved Title IV-E programs with service areas that include areas near Tribal lands as defined by the Tribal Nation.

Clearly, if there is an EBP that the Tribal Nation uses—either without a specific cultural protocol or with a cultural adaptation that the Clearinghouse considers not substantial—reimbursement would be possible under FFPSA. Whether a culturally based program that is not an EBP would be reimbursable is an open question that will require further guidance from the Children’s Bureau.

Another option is using state funding. With the increase in the Federal Medical Assistance Percentage (FMAP) scheduled to occur in October 2026, states will be receiving additional reimbursement for their prevention programs and services. It is possible that states could use some of that money to negotiate contracts or provide grants to Tribal Nations to provide culturally based programs and services to their children and families. In fact, the active efforts requirement in the Indian Child Welfare Act (25 U.S.C. 1901 et seq.) requires states to provide culturally based services to the maximum extent possible, and this can be a mechanism to meet that requirement.

There is precedent in a related context for a state to use “additional FMAP” funds to increase the capacity of Tribal Nations to provide prevention services to their children and families. In 2019, North Dakota and four Tribal Nations renegotiated their Title IV-E Tribal-State agreements. One of the key provisions of the renegotiation was a change in State procedures whereby North Dakota would use Tribal FMAPs (as they were entitled to do under the law but had not been doing) to determine reimbursement for foster care payments made for Native children placed under the Tribal-State agreements. This was a change from the previous agreement that used the State FMAP. The Tribal FMAPs were 83%, whereas the State FMAP was 50%. This change generated a significant amount of additional funding for North Dakota. In the revised agreements, the State would utilize 50% of the new funds to establish a new grant program for the Tribal Nations. The four Tribal Nations have been sharing approximately $1.5 million per year under this FMAP grant program. North Dakota committed that the remainder of the additional funds would be used to improve its services to Native children and families.

Based on the North Dakota example, there may be new opportunities for Tribes to provide culturally based prevention programming to their children and families through Tribal-State Title IV-E agreements and by accessing additional funds that will be generated through FFPSA in October 2026.

We thank NICWA Government Affairs Director David Simmons and former Casey Family Programs Senior Director Jack Trope for co-writing this piece.

1. Trope, J. F. and O’Loughlin, S.K. (2014). A Survey and Analysis of Select Title IV-E Tribal-State Agreements including Template of Promising Practices. Association on American Indian Affairs. https://www.indian-affairs.org/uploads/5/4/7/6/54761515/fulltitleiv-ereport.pdf ↩︎
2. 42 U.S.C. 679c(c)(1)(E) ↩︎
3. Practice-based evidence is the knowledge and insights gained from real-world experience with programs and services, without the need for academic research or studies to show impact. ↩︎
4. It should be noted that only 42 states have received approval of their FFPSA plans. Tribes in states without approved plans should seek to have these programs included in plans that have been or will be submitted for approval. ↩︎

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