Presentation on theme: "SCHOOL BASED SERVICES: THE UNIQUE PARTNERSHIP OF MEDICAID AND EDUCATION Increased financial resources to support students with disabilities."— Presentation transcript:
SCHOOL BASED SERVICES: THE UNIQUE PARTNERSHIP OF MEDICAID AND EDUCATION Increased financial resources to support students with disabilities
Agenda 1. What you would like to know 2. Greetings from DHS Greg DiMiceli, or 3. Brief Overview of Medicaid 2. How School-Based Services Works 3. DHS & DPI – roles and responsibilities 4. Talking it over
28-Apr-15 What is Medicaid? It is not MEDICARE, which Generally is for persons 65 and over (45 million persons!!) Covers hospital costs (45%), some physician, out-pt (35%), HMOs (15%) and now Rx drugs Mostly federally funded. $$ from your earnings taxes, premiums & deductibles, & state Medicaid agencies pay some premiums Does not generally cover check ups, nursing home costs (NHs)
28-Apr-15 What is Medicaid? Jointly funded Federal-State program to finance health coverage (mostly kids) and long term care / nursing home services For low-income individuals and families Costs shared between State and Fed govt Fed pays at least 50% of costs – like a discount—average federal share is 56%
28-Apr-15 What is Medicaid? Has become the largest public health care program in America Coverage for over 58M persons in 2007 44 million people in low-income families— our nation’s sickest and poorest 14 million elderly and/or persons with disabilities and to fill in gaps of Medicare coverage, as safety net 30 million children (1/4 of all kids are on Medicaid) Pays for over 1.5M births annually (37% of all US births) 70% of NH beds Medicaid-financed
28-Apr-15 What is Medicaid? Medicaid has become the financing vehicle for state and local health care (h/c) In 2005 total spent was $329 B Medicare $325B Unparalleled support as health care safety net For those who would have no h/c ins Largest single source of federal grants to states — comprises 44% of all federal funds to states (> $4B / yr comes to Michigan)
28-Apr-15 How Does Medicaid Work? Some mandatory services and populations Basic dental services for kids under 21 yrs, those on SSI (special protected group), foster care kids Income based (% of federal poverty level) Some optional services and populations Pre-and post-natal services, pregnant women, new babies (higher income individuals), dental o21 Discretion for each State results in 50+ “different” Medicaid Programs in U.S., territories
28-Apr-15 Medicaid School Based Services Is NOT one of the Medicaid programs that have contributed to the States’ budget crises over the years Because SBS brings in Federal funds to State, and at virtually no additional cost to the State budget
Where Do Medicaid $$ Go?
28-Apr-15 School Based Services is really about finding Common Ground Medicaid Special Education
11 What is SBS? School-based services (SBS) is a program that allows public school districts to bill Wisconsin Medicaid for medically necessary services provided to Medicaid-eligible children. In turn, the State receives federal reimbursement for medical services performed as reported in Medicaid students' IEPs.
12 SBS Program History The Wisconsin state budget (Act 27) established a School-Based Services (SBS) benefit. The SBS has brought in approximately $33 million of federal dollars annually since 2000.
13 SBS Funding Stream In the SBS program, 60% of the federal funding received goes back to the local schools, and 40% is returned to the state’s general fund.
14 Fiscal Impact of SBS In 2006 Wisconsin received over $41 million in federal SBS reimbursement funds. SBS transportation accounted for $8.4 million in federal funding.
Wisconsin SBS Program What Direct Medical Services are covered by the SBS Program? Physical Therapy Occupational Therapy Speech, Hearing, and Language Services Nursing Services (including delegated nursing services) Attendant Care Services (beginning January 1, 2009) Psychological Services Counseling Services Social Work Services What Other Services are covered by the SBS Program? Special Education Transportation Services
Wisconsin SBS Program (cont’d) What are the requirements for billing Direct Medical Services? The child must be between the ages of 3 and 21, since the services are allowable under the federal EPSDT laws. The child must be Medicaid eligible at the time of the service. The child’s Individualized Education Program (IEP) must document the medical necessity (need) for the service. The district must have a signed Parental Consent form if the district submits interim bills on behalf of the student. The service must be delivered by an approved provider type. The service must be properly documented.
Wisconsin SBS Program (cont’d) What are the requirements for billing Special Education Transportation Services? The child must be between the ages of 3 and 21, since the services are allowable under the federal EPSDT laws. The child must be Medicaid eligible at the time of the service. The child’s IEP must document the medical necessity (need) for the service. The district must have a signed Parental Consent form if the district submits interim bills on behalf of the child. A billable Direct Medical Service must be provided on the same day that the Special Education Transportation Service is provided. The service must be properly documented.
Wisconsin SBS Program (cont’d) The Centers for Medicare & Medicaid Services (CMS) require that school districts, as governmental providers, not be reimbursed more than their Medicaid-allowable costs. To that end, as SBS providers, school districts are required: To participate in time studies for both semesters (fall and spring) each year for the calculation of the direct medical services time study percentage for allocating costs to the Medicaid program; To submit an annual cost report documenting direct costs of providing SBS to determine Medicaid-allowable costs; To have Medicaid-allowable costs from annual cost report reconciled with the district’s Medicaid interim payments; and To cost settle the results of the cost report reconciliation. Cost reports are to be filed on annual basis to DHS by October 31.
Purpose of the Random Moment Time Study - SBS The Department of Health Services has adopted a cost-based reimbursement methodology for the SBS program. To that end, as SBS providers, school districts are required to: Participate in SBS time studies; Submit an annual cost report documenting direct costs to provide SBS toward the determination of Medicaid-allowable costs; Have Medicaid-allowable costs from the annual cost report reconciled with the district’s Medicaid interim payments for SBS; and Cost settle the results of the cost report reconciliation.
Purpose of the Random Moment Time Study – SBS (cont’d) The SBS Random Moment Time Study (RMTS) process results in direct medical services time study percentages, which are applied to direct medical services costs on the annual SBS Cost Report as one allocation method for determining Medicaid-allowable costs for delivering SBS. School districts can only submit Medicaid SBS claims for SBS staff listed on the time study staff pool list and for SBS staff replacing staff listed on the time study staff pool list and only for the time study period listed. School districts can only report costs on the annual SBS Cost Report for SBS staff listed on the time study staff pool list and for SBS staff replacing staff listed on the time study staff pool list and only for the time study period listed.
Quarterly Process The State of WI is moved to the new Quarterly Medicaid MAC reporting and claims payment process for the school year. Why a Quarterly process instead of the semester process? Quarters align with the recommended CMS federal program policy. Quarters will allow providers three opportunities to update and enhance their staff list to make sure all eligible staff are included for MACS claiming and SBS cost-reporting purposes. Quarters will more closely align to provider financial reporting periods to streamline the reporting process for the financial offices. MACS claims can be generated each quarter, after the receipt of financials, resulting in payments to providers each quarter to enhance cash flow. The quarterly MACS financial data submitted will automatically transfer to the web- based annual SBS cost report. This will allow the providers’ financial staff to verify the accurate transfer of the payroll data and make any necessary changes
Program perspectives Compliance perspectives Why is DPI involved in the MA SBS conversation?
Program perspective: covered services Physical Therapy Services are covered when they identify, treat, rehabilitate, restore, improve, or compensate for medical problems.. Occupational Therapy Services are covered when they identify, treat, rehabilitate, restore, improve, or compensate for medical problems that interfere with age-appropriate functional performance. Speech, Hearing, and Language Services are covered for children with speech, language, or hearing disorders that adversely affect the child's functioning. Nursing Services are covered but must be appropriate for the child's medical needs and specifically identified in the child's IEP. Psychological, Counseling, and Social Work Services include diagnostic or active treatments intended to reasonably improve the child's physical or mental condition.
Teletherapy Coordination of school and community services Early Childhood Transition Online program information Program perspective: updates
MA requirement to include in IEP IEP content IDEA requirements DPI long-standing guidance Where do these meet? “attendant care services” NOT required Need for services documented in current IEP (present levels of academic and functional performance; measurable annual goals; summary of services; placement) Compliance perspectives: Attendant care services
IDEA requirement Other state systems Guidance DPI Information Update Bulletin Model form (M-5) DPI/DHS joint memo (Information Update Bulletin 09.01) Oversight Assurance collected via the LPP Additional Data Elements IDEA complaints MA SBS fiscal audit process Compliance perspective: consent to bill Medicaid
Submitted Questions: Questions that were not addressed during the presentation will be answered at this time. See handout Feedback and discussion
What aspects of the new process are working well? What aspects of the new process need modifications? What other feedback do you have? What other questions do you have? Feedback and discussion
Information Update Bulletins and online at Model Form M-5 online at Technical assistance: Courtney Reed Jenkins DPI Contact Information