Presentation on theme: "New York School Supportive Health Services Program"— Presentation transcript:
1 New York School Supportive Health Services Program NYSASBO Conference, December 2014Megan Morris, PCGConstance Donohue, NYSDOH Medicaid Policy
2 Agenda Introduction to NY Medicaid Introduction to SSHSP NY SSHSP Timeline – Federal Audits to TodaySSHSP Policy Changes – HighlightsState Plan Process toward Implementation of CPE MethodologyLessons Learned/Summary/Wrap-up
3 Introduction to New York Medicaid Key Medicaid StatisticsState Population: 19,651,127 (2013 estimate)Percent of Population Receiving Medicaid: 27%2013 Medicaid Expenditures: $46.6 billion(CY 2013)Key SSHSP Data600 School Districts50 Counties50,000 Students (est.)Percent of Students Receiving SSHSP Services: <2%Key Medicaid StatisticsState Population: 19,651, estimate (http://quickfacts.census.gov/qfd/states/36000.html)Percent of Population Receiving Medicaid: 27%[5,303,375 total enrollees 2013/19,651,127](http://www.health.ny.gov/statistics/health_care/medicaid/eligible_expenditures/el2013/2013-cy_enrollees.htm)Overall Medicaid Budget: Medicaid Expenditures Calendar Year $46,660,714, (http://www.health.ny.gov/statistics/health_care/medicaid/quarterly/aid/2013/cy/expenditures.htm)Key SSHSP Data (650 schools/counties billed for school year – from Salient file from Maria saved here Z:\SSHSP\Data\Claims – Reports)____ School Districts 600____ Counties 50____ Students approx. 50,000Percent of Students Receiving SSHSP Services: _<2__% 2,680,303 students enrolled in public school in NYS in school year (http://www.p12.nysed.gov/irs/statistics/enroll-n-staff/home.html)
4 Introduction to New York’s Preschool/School Supportive Health Services Program (SSHSP) SSHSP – Present Day
5 SSHSP – Present DayOperating under State Plan amendment 09-61, approved April 26, 2010 retroactive to September 1, 2009Changed the reimbursement methodology for SSHSP from previous monthly billing to encounter-based claimingCovered services include: physical therapy, occupational therapy, speech therapy, psychological evaluations, psychological counseling, medical evaluations, medical specialist evaluations, skilled nursing services, audiological evaluations, and special transportation.
6 SSHSP – Present DaySubmitted SPA to CMS on December 14, to change the SSHSP reimbursement methodology to certified public expenditures (CPEs)Responded to RAIs on SPA 11-39A and 11-39B in:2012 (3/13 and 8/30)2013 (1/15, 4/24 and 8/30)2014 (2/10, 4/2, and 7/23)
7 NY SSHSP TimelineFederal AuditsCompliance AgreementToday
8 NY SSHSP TimelineAudits – Compliance Agreement – SPA – Pending SPAs 11-39A and 11-39B2001DOJ and OIG InitiateAudits2009Compliance Agreement between NY and CMS2010 CMS Approval of SPA Implement Encounter-Based Claiming2011Submission of SPA to Implement CPE Reimbursement Methodology2014SPAs 11-39A and 11-39B Pending Approval
9 Federal Audit Findings Office of the Inspector General review of Medicaid speech claims made by NYS school health providers between 9/1/93 and 6/30/2001 showed 56 of 100 speech claims were unallowable.Deficiencies included:Lack of appropriate referralLack of qualified providerInadequate documentationMinimum number of speech services (under the then-monthly billing methodology) not providedNo individualized education program (IEP)
10 Federal Audit Findings Office of the Inspector General review of Medicaid transportation claims made by 695 NYS school health providers between 9/1/93 and 6/30/2001 showed 97 of 100 transportation claims were unallowable.Deficiencies included:Lack of date-specific documentationNo service other than transportation furnished on the day transportation was claimedTransportation not included in the student’s IEPFewer than 2 services furnished other than transportation within the month billedStudent was not actually transported
11 Settlement Agreement Agreement was reached in July 2009 Allowed the SSHS Program to continue in NYThe State and the City of New York entered into an agreement with the Centers for Medicare and Medicaid Services (CMS), the Office of the Inspector General (OIG), and the Department of Justice (DOJ) that called for restitution of approximately $540 million ($100 million to be paid by New York City and the rest by the State)
12 Compliance Agreement Requirements Compliance Officer and CommitteeAudit Requirements - providersOMIG payment reviews of all SSHSP servicesSeparate payment audits for SSHSP claims from the New York City Department of Education (NYCDOE) and from the Rest of the State (ROS)Independent audits of State internal controls for SSHSPAnnual written reports
13 Compliance Agreement Requirements New York State SSHSP compliance policyCommitment to ensure complianceTraining of relevant employeesEnsure SSHSP providers (LEAs and counties) are aware of all applicable laws and regulations and standards of conduct for federal participation in the Medicaid program and consequences for violation of these requirementsConfidential disclosure program
14 Compliance Agreement Requirements State Plan and SSHSP reimbursement methodologyRequired the State to submit to CMS a revised State Plan amendment; effective July 1, 2009, Federal matching funds would only be available for SSHSP under the terms of the revised SPA, which had to receive CMS approvalImplementation Plan – due 90 days after the start of the AgreementCertification of annual State reports required by the Agreement by the Compliance Officer
15 Compliance Agreement Status The State requested of CMS - and was granted - two extensions of the AgreementThe Compliance Agreement final report was submitted in January 2014In July 2014, the State received a letter from CMS acknowledging the sunset of the Compliance Agreement …and reminding the State that there is still work to be done…
17 SPA 09-61 Encounter-based claiming Moved SSHSP services from the Rehabilitation Section of the State Plan to the EPSDT SectionKey features:10 SSHSP servicesRequires written orders/referrals as appropriateServices included in student’s IEPSpecifies practitioner qualifications required under the Medicaid programIncludes “under the direction of” and supervision requirementsEach encounter must be documented in accordance with State Medicaid regulation requirements
18 SPA 09-61Fee-for-service reimbursement is benchmarked at 75% of the Medicare rate for the Mid-Hudson region of the StateMany SSHSP providers were unable to claim or submitted a limited number of claims for the school yearTargeted Case Management (TCM) claims continued to be paid through June 30, 2010
19 SSHSP Claims PresentClaims Paid for SSHSP from September to Present**Not all claims have been received for current yearSchool YearPaid AmountNumber of ClaimsNumber of Unique Recipients9/09 – 6/10$1,098,97329,4114717/10 – 6/11$59,231,4891,785,74929,2927/11 – 6/12$98,761,7872,968,65342,3297/12 – 6/13$110,846,4983,445,90350,4947/13 – 6/14*$77,180,5012,343,77047,310
20 Guidance Issued to SSHSP Providers Since 2009:Handbook 7, Handbook 841 Medicaid Alerts226 Questions and AnswersGuidance is posted on the State Education Department’s website at:
21 State Plan Process - Implementation of Certified Public Expenditure Reimbursement Methodology SPA submissionIntroduction of CPE Reimbursement MethodologyRequirements for Participating School Districts
22 SPA 11-39 Submission to CMS Initial submission on December 14, 2011 CMS required that the statewide SPA be split into four separate SPAs:SPA 11-39A – “Rest of State” school districtsSPA 11-39B – “Rest of State” counties (preschool)SPA 11-39C – New York City school districtSPA 11-39D – New York county (preschool)SPAs A-D call for the implementation of a Certified Public Expenditure (CPE) reimbursement methodology for SSHSPThe SSHSP Annual Cost Settlement Cycle is illustrated on the following slide
23 Introduction of CPE Reimbursement Methodology Quarterly Staff Pool ListQuarterly Random Moment Time StudyDistricts & Counties submit SSHSP Annual Cost ReportPCG Conducts Desk Review of Annual Cost ReportsPCG Calculates Ratios and Percentages used to calculate settlementsPCG Calculates the SSHSP Annual Cost SettlementDOH Reviews Cost Settlement ResultsDistricts & Counties Verify SSHSP Annual Cost Settlement ResultsDOH submits CPE claim to CMS
24 Introduction of CPE Reimbursement Methodology The CPE reimbursement methodology is designed to reimburse school districts and counties participating in SSHSP up to their cost of providing SSHSP services to Medicaid eligible studentsThe CPE reimbursement methodology relies on an annual cost report to determine the Medicaid allowable costs for each participating school district and countyThe Medicaid allowable costs are then compared to the Medicaid interim FFS payments received through the annual cost settlement process
25 Introduction of CPE Reimbursement Methodology School districts and counties participating in SSHSP are responsible for submitting claims to Medicaid throughout the year as services are provided and receive interim payments based on a fee scheduleSchool Districts which employ direct medical clinicians who provide Medicaid billable services are responsible for including those clinicians on the quarterly RMTS rostersFollowing the close of each Fiscal Year, all districts and counties participating in SSHSP are required to submit an Annual Medicaid Cost Report by December 31
26 Requirements for Participating School Districts Participating school districts must complete an annual Medicaid cost reportThe annual Medicaid cost report requires participating school districts to report specific cost and statistical data for direct medical services and for specialized transportation servicesThe allowable cost categories and required statistical data are defined in SPA 11-39
27 Requirements for Participating School Districts Medicaid Allowable Costs and Cost Report Data Elements for Direct Medical ServicesThe 7 CMS-approved cost elements used to determine Medicaid costs for Direct Medical Services include:Salary costs for eligible SSHSP service providers employed by school districts and countiesBenefit costs for eligible SSHSP service providers employed by school districts and countiesContract costs for eligible SSHSP service providers contracted by school districts and counties by outside agenciesApproved direct medical service material, supply, and equipment costsDepreciation costs for approved direct medical service equipmentAnnual tuition costs for private schools and other non-public entitiesAnnual intergovernmental agreement costs for contract and tuition arrangements between public schools and countiesDistricts and counties are required to report gross expenditures as well as any funding from federal sources (other than Medicaid) so that they may be netted out of overall cost.
28 Requirements for Participating School Districts Medicaid Allowable Costs and Cost Report Data Elements for Direct Medical ServicesThe 4 CMS-approved data elements used to determine Medicaid costs for Direct Medical Services include:Random Moment Time Study (RMTS) percentage or Direct Medical Service (DMS) percentage resultsSchool District and County Indirect Cost Rates (ICR)Health Related Tuition PercentagesIndividualized Education Program (IEP) RatioEach direct service data element applied to the cost report is populated by PCG.
29 Requirements for Participating School Districts Random Moment Time Study (RMTS) results (also known as the Direct Medical Service Percentage)The direct medical service percentage is calculated by PCG based on the results of the quarterly Random Moment Time StudyWhen the results of the RMTS are coded, specific codes identify, on average, how much time direct medical service providers spend performing direct medical servicesThe direct medical percentage is a statewide average rate and is not specific to a school district or countyThe average from the three quarterly time study periods that occurred throughout the school fiscal year (October - December, January - March, and April - June) (no time study for July – September) are used to calculate the DMS%The DMS% is applied to all reported Salary, Benefit, Materials, Supplies, and Equipment Costs
30 Requirements for Participating School Districts Individualized Education Program (IEP) RatioThe ratio is calculated and reported annually on the Medicaid SSHSP Cost ReportDirect medical services are defined as those services billable under the SSHSP programThe purpose of the IEP ratio is to allocate direct medical service costs to the Medicaid programIn other words, it is used to determine Medicaid’s portion of direct medical service costs incurred by school districts and counties for the provision of SSHSP direct medical servicesIEP Ratios will be uploaded by PCG into the Medicaid Cost Report and Claiming System (MCRCS) and applied to each cost report in order to determine the Medicaid Allowable Direct CostIEP Ratio=Total Number of Medicaid Eligible IEP Students with a Direct Medical Service in their IEPTotal Number of ALL IEP Students with a Direct Medical Service in their IEP
31 Requirements for Participating School Districts Now that we know about the SSHSP Medicaid Cost Report process, how do the pieces fit together?
32 Requirements for Participating School Districts
33 Requirements for Participating School Districts Medicaid Allowable Costs and Cost Report Data Elements for Specialized Transportation ServicesThe 7 CMS-approved cost and data elements used to determine Medicaid costs for Specialized Transportation Services include:Salary costs for eligible specialized transportation service providersBenefit costs for eligible specialized transportation service providersApproved Specialized Transportation Non-Personnel costsDepreciation costs for Approved Specialized Transportation Non- Personnel costsSchool District and County Indirect Cost Rates (ICR) (pre-populated by PCG)Specialized Transportation RatioOne Way Trip Ratio
34 Requirements for Participating School Districts Specialized Transportation RatioWhat is the Specialized Transportation Ratio?The Specialized Transportation Ratio is used to break out specialized transportation costs from general transportation costsThe ratio is calculated by the district or county and reported annually on the Medicaid SSHSP Cost ReportSpecialized Transportation Ratio=Total Number of Medicaid Eligible Special Education Students Receiving Specialized Transportation Services per their IEPTotal Number of ALL Students Receiving Transportation Services (Specialized or Non Specialized)
35 Requirements for Participating School Districts One Way Trip RatioWhat is the One Way Trip (OWT) Ratio?The ratio is calculated and reported annually on the Medicaid SSHSP Cost ReportA Medicaid one-way trip is defined as a trip in which a Medicaid enrolled student who has specialized transportation services in their IEP and received another Medicaid- covered service provided by the school district or county on the day of the trip. The numerator will be completed by PCG based on paid claims dataThe purpose of the One Way Trip ratio is to allocate specialized transportation costs to the Medicaid ProgramIn other words, it is used to determine Medicaid’s portion of specialized transportation costs incurred by School districts and counties for the provision of SSHSP specialized transportation servicesOWT Ratio=Total Number of Medicaid Paid One Way Trips (per MMIS)Total One Way Trips for Medicaid eligible students with specialized transportation in their IEP (from bus logs)
36 Requirements for Participating School Districts Now that we know about the SSHSP Medicaid Cost Report process for Specialized Transportation, how do the pieces fit together?
37 Requirements for Participating School Districts
38 Requirements for Participating School Districts Now that we know how the SSHSP Medicaid Direct Medical Service and Specialized Transportation Costs are calculated, how is the settlement determined?
40 Online ResourcesInformation regarding SSHSP CPE program requirements can be found through the Medicaid in Education website at:Annual cost report information can also be found in PCG’s web-based financial reporting system, MCRCS, at: https://costreporting.pcgus.com/ny
41 Toll Free SSHSP Hotline: 1-866-912-2974 PCG SupportPCG offers ongoing technical support to all school districts participating in SSHSP through a dedicated account and hotlineSSHSPToll Free SSHSP Hotline:
Your consent to our cookies if you continue to use this website.