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NYSASBO Conference, December 2014 Megan Morris, PCG Constance Donohue, NYSDOH Medicaid Policy New York School Supportive Health Services Program 1.

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Presentation on theme: "NYSASBO Conference, December 2014 Megan Morris, PCG Constance Donohue, NYSDOH Medicaid Policy New York School Supportive Health Services Program 1."— Presentation transcript:

1 NYSASBO Conference, December 2014 Megan Morris, PCG Constance Donohue, NYSDOH Medicaid Policy New York School Supportive Health Services Program 1

2 Agenda Introduction to NY Medicaid Introduction to SSHSP NY SSHSP Timeline – Federal Audits to Today SSHSP Policy Changes – Highlights State Plan Process toward Implementation of CPE Methodology Lessons Learned/Summary/Wrap-up 2

3 3 Introduction to New York Medicaid Key Medicaid Statistics State Population: 19,651,127 (2013 estimate) Percent of Population Receiving Medicaid: 27% 2013 Medicaid Expenditures: $46.6 billion (CY 2013) Key SSHSP Data 600 School Districts 50 Counties 50,000 Students (est.) Percent of Students Receiving SSHSP Services: <2%

4 Introduction to New York’s Preschool/School Supportive Health Services Program (SSHSP) 4 SSHSP – Present Day

5 Operating under State Plan amendment 09-61, approved April 26, 2010 retroactive to September 1, 2009 Changed the reimbursement methodology for SSHSP from previous monthly billing to encounter-based claiming Covered 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. 5

6 SSHSP – Present Day Submitted SPA to CMS on December 14, 2011 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) 6

7 NY SSHSP Timeline Federal Audits Compliance Agreement Today 7

8 8 NY SSHSP Timeline Audits – Compliance Agreement – SPA – Pending SPAs 11-39A and 11-39B 2001 DOJ and OIG Initiate Audits 2009 Compliance Agreement between NY and CMS 2010 CMS Approval of SPA Implement Encounter- Based Claiming 2011 Submission of SPA to Implement CPE Reimbursement Methodology 2014 SPAs 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 referral Lack of qualified provider Inadequate documentation Minimum number of speech services (under the then-monthly billing methodology) not provided No individualized education program (IEP) 9

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 documentation No service other than transportation furnished on the day transportation was claimed Transportation not included in the student’s IEP Fewer than 2 services furnished other than transportation within the month billed Student was not actually transported 10

11 Settlement Agreement Agreement was reached in July 2009 Allowed the SSHS Program to continue in NY The 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) 11

12 Compliance Agreement Requirements Compliance Officer and Committee Audit Requirements - providers OMIG payment reviews of all SSHSP services Separate 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 SSHSP Annual written reports 12

13 Compliance Agreement Requirements New York State SSHSP compliance policy Commitment to ensure compliance Training of relevant employees Ensure 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 requirements Confidential disclosure program 13

14 Compliance Agreement Requirements State Plan and SSHSP reimbursement methodology Required 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 approval Implementation Plan – due 90 days after the start of the Agreement Certification of annual State reports required by the Agreement by the Compliance Officer 14

15 Compliance Agreement Status The State requested of CMS - and was granted - two extensions of the Agreement The Compliance Agreement final report was submitted in January 2014 In 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… 15

16 SSHSP Policy Changes - Highlights SPA Encounter-based claiming SSHSP claims present Guidance issued to SSHSP providers 16

17 SPA Encounter-based claiming Moved SSHSP services from the Rehabilitation Section of the State Plan to the EPSDT Section Key features: 10 SSHSP services Requires written orders/referrals as appropriate Services included in student’s IEP Specifies practitioner qualifications required under the Medicaid program Includes “under the direction of” and supervision requirements Each encounter must be documented in accordance with State Medicaid regulation requirements 17

18 SPA Fee-for-service reimbursement is benchmarked at 75% of the Medicare rate for the Mid-Hudson region of the State Many SSHSP providers were unable to claim or submitted a limited number of claims for the school year Targeted Case Management (TCM) claims continued to be paid through June 30,

19 SSHSP Claims Present Claims Paid for SSHSP from September 2009 to Present* *Not all claims have been received for current year School YearPaid Amount Number of Claims Number of Unique Recipients 9/09 – 6/10$1,098,97329, /10 – 6/11$59,231,4891,785,74929,292 7/11 – 6/12$98,761,7872,968,65342,329 7/12 – 6/13$110,846,4983,445,90350,494 7/13 – 6/14*$77,180,5012,343,77047,310 19

20 Guidance Issued to SSHSP Providers Since 2009: Handbook 7, Handbook 8 41 Medicaid Alerts 226 Questions and Answers Guidance is posted on the State Education Department’s website at: 20

21 State Plan Process - Implementation of Certified Public Expenditure Reimbursement Methodology SPA submission Introduction of CPE Reimbursement Methodology Requirements for Participating School Districts 21

22 SPA 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 districts SPA 11-39B – “Rest of State” counties (preschool) SPA 11-39C – New York City school district SPA 11-39D – New York county (preschool) SPAs A-D call for the implementation of a Certified Public Expenditure (CPE) reimbursement methodology for SSHSP The SSHSP Annual Cost Settlement Cycle is illustrated on the following slide 22

23 Introduction of CPE Reimbursement Methodology 23 Quarterly Staff Pool List Quarterly Random Moment Time Study Districts & Counties submit SSHSP Annual Cost Report PCG Conducts Desk Review of Annual Cost Reports PCG Calculates Ratios and Percentages used to calculate settlements PCG Calculates the SSHSP Annual Cost Settlement DOH Reviews Cost Settlement Results Districts & Counties Verify SSHSP Annual Cost Settlement Results DOH 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 students The CPE reimbursement methodology relies on an annual cost report to determine the Medicaid allowable costs for each participating school district and county The Medicaid allowable costs are then compared to the Medicaid interim FFS payments received through the annual cost settlement process 24

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 schedule School Districts which employ direct medical clinicians who provide Medicaid billable services are responsible for including those clinicians on the quarterly RMTS rosters Following 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 25

26 Requirements for Participating School Districts Participating school districts must complete an annual Medicaid cost report The annual Medicaid cost report requires participating school districts to report specific cost and statistical data for direct medical services and for specialized transportation services The allowable cost categories and required statistical data are defined in SPA

27 Requirements for Participating School Districts Medicaid Allowable Costs and Cost Report Data Elements for Direct Medical Services The 7 CMS-approved cost elements used to determine Medicaid costs for Direct Medical Services include: 1. Salary costs for eligible SSHSP service providers employed by school districts and counties 2. Benefit costs for eligible SSHSP service providers employed by school districts and counties 3. Contract costs for eligible SSHSP service providers contracted by school districts and counties by outside agencies 4. Approved direct medical service material, supply, and equipment costs 5. Depreciation costs for approved direct medical service equipment 6. Annual tuition costs for private schools and other non-public entities 7. Annual intergovernmental agreement costs for contract and tuition arrangements between public schools and counties Districts 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. 27

28 Requirements for Participating School Districts Medicaid Allowable Costs and Cost Report Data Elements for Direct Medical Services The 4 CMS-approved data elements used to determine Medicaid costs for Direct Medical Services include: 1. Random Moment Time Study (RMTS) percentage or Direct Medical Service (DMS) percentage results 2. School District and County Indirect Cost Rates (ICR) 3. Health Related Tuition Percentages 4. Individualized Education Program (IEP) Ratio Each direct service data element applied to the cost report is populated by PCG. 28

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 Study When the results of the RMTS are coded, specific codes identify, on average, how much time direct medical service providers spend performing direct medical services The direct medical percentage is a statewide average rate and is not specific to a school district or county The 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 29

30 Requirements for Participating School Districts Individualized Education Program (IEP) Ratio The ratio is calculated and reported annually on the Medicaid SSHSP Cost Report Direct medical services are defined as those services billable under the SSHSP program The purpose of the IEP ratio is to allocate direct medical service costs to the Medicaid program In 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 services IEP 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 Cost 30 IEP Ratio = Total Number of Medicaid Eligible IEP Students with a Direct Medical Service in their IEP Total 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? 31

32 Requirements for Participating School Districts 32

33 Requirements for Participating School Districts Medicaid Allowable Costs and Cost Report Data Elements for Specialized Transportation Services The 7 CMS-approved cost and data elements used to determine Medicaid costs for Specialized Transportation Services include: 1. Salary costs for eligible specialized transportation service providers 2. Benefit costs for eligible specialized transportation service providers 3. Approved Specialized Transportation Non-Personnel costs 4. Depreciation costs for Approved Specialized Transportation Non- Personnel costs 5. School District and County Indirect Cost Rates (ICR) (pre-populated by PCG) 6. Specialized Transportation Ratio 7. One Way Trip Ratio 33

34 Requirements for Participating School Districts Specialized Transportation Ratio What is the Specialized Transportation Ratio? The Specialized Transportation Ratio is used to break out specialized transportation costs from general transportation costs The ratio is calculated by the district or county and reported annually on the Medicaid SSHSP Cost Report 34 Specialized Transportation Ratio = Total Number of Medicaid Eligible Special Education Students Receiving Specialized Transportation Services per their IEP Total Number of ALL Students Receiving Transportation Services (Specialized or Non Specialized)

35 Requirements for Participating School Districts One Way Trip Ratio What is the One Way Trip (OWT) Ratio? The ratio is calculated and reported annually on the Medicaid SSHSP Cost Report A 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 data The purpose of the One Way Trip ratio is to allocate specialized transportation costs to the Medicaid Program In 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 services 35 OWT 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? 36

37 Requirements for Participating School Districts 37

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? 38

39 SSHSP Resources Online Resources PCG Support 39

40 Online Resources Information 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/nyhttps://costreporting.pcgus.com/ny 40

41 PCG Support PCG offers ongoing technical support to all school districts participating in SSHSP through a dedicated account and hotline SSHSP Toll Free SSHSP Hotline:


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