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  State by State Commonality = Federal Regulations and Guidance  1988; Congress amended the Social Security Act to allow Local Education Agencies (LEA)

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Presentation on theme: "  State by State Commonality = Federal Regulations and Guidance  1988; Congress amended the Social Security Act to allow Local Education Agencies (LEA)"— Presentation transcript:

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2   State by State Commonality = Federal Regulations and Guidance  1988; Congress amended the Social Security Act to allow Local Education Agencies (LEA) to access Medicaid federal funds for some “health related services”  Services that are reimbursed by Medicaid must be listed in the Medicaid statute (section 1905(a) of the Social Security Act) and must be included in the state plan  Schools can receive Medicaid payment for medical services provided to children under Individuals with Disabilities Education Act (IDEA) through a child’s Individualized Education Plan (IEP).  Federal guidance: Health related services included in an Individual Education Plan (IEP) can be reimbursable if all state and federal statutory and regulatory requirements are met, the services are identified in the state plan, and the services are medically necessary  To receive federal matching dollars for medical services the state must have a federally approved state plan  There is no benefit category in the Medicaid statute or state plan titled “school health services”; services, regardless of location, must be identified in the state plan  State plan includes:  Eligibility groups and standards  Services provided  Service requirements  Payment rates  Amount  Duration  Scope  *Resources for this information can be found in the *CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997) Link can be found at Once You Know One Medicaid Program………. You Know One Medicaid Program

3   The school-based committee spent several years collaborating to identify Medicaid reimbursed services in the school that meet the needs of the children on IEP’s in Idaho. The following is a condensed list of collaborative activities regarding school-based services (SBS) and rules: How We Got Here DateTarget GroupActivity August, 2010School-based Medicaid Committee Discussed the impact to school-based services due to children’s system redesign School districts/Special Education Directors Webinar posted on how children’s system redesign impacts to schools January, 2011School-based Medicaid Committee Identified SBS workgroup members to work on changes to services/IDAPA February, 2011School-based Medicaid WorkgroupBegan workgroup to develop proposal for Centers for Medicare and Medicaid Services (CMS). The workgroup met 6 full days School-based Medicaid Committee SBS workgroup presented the draft proposal, Received feedback from the committee School-based Medicaid Committee Committee approved SBS proposal / Submitted SBS proposal to CMS School-based Medicaid Committee Discuss CMS feedback and service options to the committee March, 2012School-based Medicaid Committee Shared research from other states School-based Medicaid Committee Discuss new service options and timelines based on CMS feedback April, 2012School-based Medicaid Workgroup Developed behavioral intervention/consultation services School-based Medicaid Committee Workgroup presented recommendations for intervention/consultation to the committee June, 2012Families, providers, and community Negotiated Rulemaking Meeting: School-based replacement services Idaho Association of Special Education Administrators (IASEA) Presentation of the proposed school-based service rules at the annual IASEA conference January, 2013 Legislature / Public Idaho Administrative Code proposed changes presented by Medicaid: State Department Of Education spoke in support of proposed rules

4   Idaho Medicaid encourages public and charter schools to become Medicaid providers so that they can receive Medicaid reimbursement for health related services they are providing to children who are eligible  Idaho Medicaid also wants to assure that schools who are receiving reimbursement for health related services are in compliance with federal and state regulations WHY…………..? Federal and State Rule Compliance

5   US Department of Health and Human Services’ concern of school- based services billings On March 9, 2011, Inspector General testified before a US Senate subcommittee that series of audits over past decade identified improper federal Medicaid payments for school-based health services.  FFY 2013 Work Plan - will review Medicaid payments for school- based services in selected states to determine whether costs claimed for services are reasonable and properly allocated.  Idaho’s CMS Regional Auditor identified school-based services as a priority  Special Study: School-based Services Overview: Medicaid Program Integrity March 5, 2013 Federal Concerns over School-based Services

6   Maine (4/2013)  Recommended Repayment of $667,569  Claims were not in accordance with Federal & State Requirements  Lack of adequate documentation to support services provided  Unqualified providers  New Hampshire (10/2012)  Recommended Repayment of $2,700,000  Transportation services * Resources for OIG Reports can be found at: Office of Inspector General Audit Reports

7   Colorado (4/2012)  Recommend Repayment of $871,246  Claims were not reasonable, allowable and/or adequately supported.  New Hampshire (1/2012)  Recommended Repayment of $494,738  Providing Health services that were not reimbursable  Overbilling for services  Lack of adequate documentation to support services provided * Resources for OIG Reports can be found at: Office of Inspector General Audit Reports

8   New Jersey (4/2010)  Recommended Repayment of $8,079,312  Lack of documentation to support services provided  Lack of referral or prescription for services  Unqualified Providers  Services provided not documented in IEP  Arizona (3/2010)  Recommended Repayment of $21,288,312  Overbilling  Lack of documentation  Unqualified Providers  Unallowable Transportation  Lack of referral for services  Eligibility not met * Resources for OIG Reports can be found at: Office of Inspector General Audit Reports

9  Services ProvidedIdahoKansasOregonColoradoWashingtonMontanaIowaUtahNevadaWyomingAlaskaTexasKentuckyMaryland OTXXXXXX X XXXXXX PTXXXXXX X XXXXXX SLPXXXXXX X XXXXXX AudiologyXXXXXX X X XX Personal CareX X X X X XX NursingXXXXXX X XX XXX TransportationXXXX X X XX Interpretive ServicesX X Medical EquipmentX X X Behavioral Therapy/Intervention X X X Behavioral Health Services XXXXXX X X XXXX Psychological/ Counseling XXXXXX X X XXXX Targeted Case Management XX X X Physician Services X X Orientation and Mobility Services X X Other Services: X XX X EPSDT XXXXXXXXXXXXXX Medicaid Reimbursable Services Provided in Schools by State

10  Approximate annual cost of School Based Services Approximate number of students Approximate annual cost per student Iowa $36,000,0004,500$8,000 Rhode Island $22,000,0009,500$2,315 Idaho $26,400,00013,231$1,993 Kansas $24,500,00012,500$1,960 Oregon $5,800,0007,000$828 New York $44,000,00075,000$587 Arizona $22,500,00039,000$577 California $124,000,000225,000 $551 New Jersey $21,500,00043,000$500 Colorado $5,600,00011,310$494 Indiana $2,900,0008,000$363 Washington $5,500,00018,031$303 Nevada $1,050,0003,998$263 Montana $2,600,00013,500$193 Virginia $8,200,000120,000$68 SBS Medicaid State Comparison

11  Annual Average Cost Per Student By Comparison, Idaho ranked 3 rd out of 15 states for the highest annual average cost per student

12  Approximate annual cost of School Based Services Approximate number of students Approximate annual cost per student Idaho $23,303,10913,676 $1,704 Colorado $8,105,64212,328 $658 Washington $8,119,19217,765$ State Comparison

13  FEDERAL CITATION SERVICEDESCRIPTION 42 CFR physicians’ services and medical and surgical services of a dentist “services furnished by a physician (or a doctor of dental medicine or surgery for a dentist) within the scope of practice of medicine or osteopathy as defined by state law and by or under the personal supervision of an individual licensed under state law to practice medicine or osteopathy” 42 CFR medical or other remedial care provided by licensed practitioners “any medical or remedial care or services provided by licensed practitioners within the scope of practice under state law.” This category is used by states to cover such services as psychologist services and nursing services other than those nursing services specifically identified in the Medicaid statute and regulations (such as private duty nursing, home health nurses or nurse practitioners). 42 CFR clinic services“preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished by a facility that is not a part of a hospital but is organized and operated to provide medical care to outpatients.” The services must be furnished under the supervision of a physician or dentist, in a facility which meets the state’s definition of a clinic.” 42 CFR dental services“diagnostic, preventive or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession.” 42 CFR physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders. “Physical and occupational therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under the state’s law and must be provided by or under the direction of a qualified licensed physical therapist or occupational therapist. Services for individuals with speech, hearing or language disorders means diagnostic, screening, preventive or corrective services provided by or under the direction of a speech pathologist or audiologist, for which the patient is referred by a physician or other licensed practitioner of the healing arts. It includes any necessary supplies or equipment.” 42 CFR (a) diagnostic services“any medical procedures or supplies recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under state law, to enable him or her to identify the existence, nature or extent of illness, injury or other health deviation in a recipient.” 42 CFR (c) preventive services“provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability, and other health conditions or their progression; to prolong life and promote physical and mental health and efficiency.” Federal Regulations for Services *This chart is not necessarily all-inclusive, and while it indicates the general Federal Medicaid regulatory requirements, schools should check with their state Medicaid agency to determine any additional or specific state requirements. *Resources for this information can be found in the CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)

14  FEDERAL CITATION SERVICEDESCRIPTION 42 CFR (d)rehabilitative services “any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his or her best possible functional level.” This optional benefit category is used to cover both mental health and substance abuse services and may include assessments, individual, group and family counseling, therapies, psychosocial rehabilitation services, living skills training, drug abuse treatment, medication monitoring and crisis intervention.” 42 CFR (a)transportation services (Please see the Transportation section of the guide for more specific information on transportation and school-based services). 42 CFR nurse practitioner services “furnished by a registered professional nurse who meets the state’s advanced educational and clinical requirements, if any, beyond the 2 to 4 years of basic nursing education required.” 42 CFR Private duty nursing services “for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or skilled nursing facility.” These services are provided by a registered nurse or licensed practical nurse under the direction of a physician, usually in the beneficiary’s home. However, the nurse is permitted to be taken into the community (such as when the child attends school) with the beneficiary if his or her normal life activities take the beneficiary out of the home and the services have been prescribed by the physician for primary use in the home.” Section 1905(a)(24) of the Act (soon to be published ate 42 CFR ) personal care services “These services are authorized for an individual by a physician in accordance with a plan of treatment or otherwise authorized by the state in accordance with a service plan approved by the state, and may be provided in a home or other location (however, not in a Medicaid-funded inpatient facility) by an individual qualified to provide such services, who is not a member of the individual’s family.” Section 1905(a)(4) (c) of the Act and 42 CFR family planning services “supplies for children who are of childbearing age, including minors who can be considered to be sexually active and desire such services and supplies. These include services to aid those who voluntarily choose not to risk an individual pregnancy or who wish to control family size. Federal Medicaid law limits coverage of abortion. In general, family planning services are matched at a higher FFP rate of 90%.” Federal Regulations for Services *This chart is not necessarily all-inclusive, and while it indicates the general Federal Medicaid regulatory requirements, schools should check with their state Medicaid agency to determine any additional or specific state requirements. *Resources for this information can be found in the CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)

15  Managed/ Oversight ALL services are managed by Licensing Rules Physician Recommendation Idaho Desk Reviews (optional in 2014); MPI Audits; Medicaid technical assistance; Statewide trainings every 2 years; No Yes Washington Managed Care: Minimum of 10 school-based Medicaid program reviews annually. Schools must submit the following annually: All health care professionals, copies of new health care professionals licenses YesNo Texas Managed Care : Commission-administered time study; schools submit expenditure reports quarterly; schools submit annual cost reports YesYes (for OT, PT, SLP) Kentucky Managed Care : Schools must apply to be providers annually; all schools receive an annual review; Site surveys; all schools must conduct a peer review (10% of students) annually Yes Must have Physician involvement Utah Periodic time/cost studies NoYes Nevada Fiscal agent provides trainings, medical review, audit and handling disputed payments Yes Oregon The department has 2 school based policy staff that provide annual trainings and extensive reviews: YesNo Alaska Managed Care : Facility site reviews and develops corrective action plans No Montana Managed Care : Fiscal and clinical compliance audits Yes (for unlicensed professionals and nursing ) California Managed Care: Trainings and audits Yes (for OT, PT, SLP and Nursing) Colorado The Department has 2 school based policy staff that provide annual audits of all school districts Yes No Kansas Monitor through the fiscal agent surveillance review (Physician’s orders and supporting documentation) Yes Medicaid Reimbursed School Based Services

16   Federal Guidance: Providers must follow federal and state regulations to receive federal matching dollars.  School-based Medicaid services has been identified as high priority by CMS  Compliance is necessary to avoid outcomes as identified in OIG audit reports  Extensive amount of collaboration took place prior to the final rules effective date of July 1,  State Comparison: Apples to Oranges: Each state has their own federally approved state plan that identifies the standards and requirements for the services that are reimbursable in their schools.  Financial Comparison: Idaho Medicaid continues to demonstrate a high level of annual cost per student as compared to other states. In Summary….

17   Frede’ Trenkle-MacAllister Alternative Care Coordinator, BDDS, Medicaid (208)  Shannon Dunstan Early Childhood and Interagency Coordinator Idaho State Department of Education (208) 332 – 6908 (office) We are here for you!

18   CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)   Kansas:  Kansas Health Policy Authority    NAME survey/education and Research Committee  https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/LEA_ _14010.pdf https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/LEA_ _14010.pdf  Montana:  Montana Department of Public Health and Human Services:   NAME survey/education and Research Committee  Oregon:  Linda Williams, Division of Medical Assistance Programs, Policy Analyst  NAME survey/education and Research Committee  Colorado:  Shannon Huska, Colorado Department of Health Care Policy and Financing, School Health Services Program Administrator  The Department of Health Care Policy and Financing, Colorado, Annual Report   Washington:  Jim Harvey, Washington State Health Care Authority, School-Based Health Care Services Program Specialist  Washington State health care authority:  Resources/References

19   Indiana:  NAME survey/education and Research Committee  Virginia:  NAME survey/education and Research Committee  New Jersey:  NAME survey/education and Research Committee  Iowa:  NAME survey/education and Research Committee  :  Rhode Island:  NAME survey/education and Research Committee   Arizona:  NAME survey/education and Research Committee  California:  NAME survey/education and Research Committee    New York:  NAME survey/education and Research Committee Resources/References


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