Presentation on theme: "NEW YORK STATE EDUCATION DEPARTMENT (NYSED)"— Presentation transcript:
1 NEW YORK STATE EDUCATION DEPARTMENT (NYSED) Preschool/School Supportive Health Services Program: SSHSP – Medicaid in EducationNEW YORK STATE EDUCATION DEPARTMENT (NYSED)
2 Topics SSHSP Overview Program information resources Updates to the SSHSP Medicaid claim requirements
3 School Supportive Health Services Program (SSHSP)
4 SSHSPMedicaid reimbursement program available to school districts and countiesServices must be included in a student’s IEPServices have required Medicaid documentation for medical necessity and provider qualificationNYS Department of Health – Medicaid Policy and paymentNYS Education Department – Special Education policy and billing assistanceOver $100 Million per year in fee for service encounter claiming
5 What is the Role of the CSE/CPSE? The Committee on Special Education will always develop and review the Individualized Education Program, but may also perform SSHSP administrative functions (just like CSE/CPSE chairs may perform STAC functions). Examples:Secure parental consent authorizing district to access Medicaid participation in fundingMake referral for Psychological Counseling Services, Psychological or Medical EvaluationMedicaid training- documentation, collection and retentionMonitor service delivery for compliance with professional and SSHSP standards
7 Policy, Guidance and Support Resources Medicaid in Education WebsiteMedicaid Handbook Update #8Posted Questions and AnswersMedicaid AlertsTraining PowerpointsTraining HandoutsRegional Information CentersMedicaid 101 TrainingDocumentation TrainingDirect supportUpdates are available from LISTSERV
8 Policy ResourcesSpecial Education Policy – NYSED SEQA Regional AssociateProfessional Scope of Practice – NYSED Office of the ProfessionsMedicaid Policy – Regional Information Center, NYSED Medicaid in Education Staff, NYS DOH Office of Health Insurance ProgramsRules for each program area may vary; Medicaid- billable services comply with all three!
9 Updates to Medicaid Claim Requirements What would you have heard about over the last year by monitoring the SSHSP website, receiving ListServ s, attending SSHSP trainings
10 Clarified Medicaid Policy SSHSP - Same Day, Same CPT Code Billing for Medicaid ReimbursementMedicaid Alert #14-04 (Issued 8/15/2014) Clarification of Medicaid Claim Form and Supporting Documentation Requirements: Billing PT and OT Services (same day, same CPT code billing)When 2 SSHSP Medicaid are claimed (1 PT & 1 OT ) for the same CPT code and service date. The 1st claim will be processed but the second will be denied as a duplicate claim.Fix: see Alert #14-06, Starting in Cycle 1952, CNYRIC will add a OT/PT/Speech (97000 code) modifier to all claims based on the servicing profession’s code submitted in the claim.
11 Clarified Medicaid Policy SSHSP – Evaluation Clarification for Medicaid ReimbursementMedicaid Alert #14-08 (11/26/2014) Clarification on SSHSP Medicaid Reimbursement for EvaluationsMedicaid reimbursement is available for PT, OT, Speech and Psychological evaluation ONLY when the IEP includes a recommendation for ongoing services based on the this (or prior) evaluation results.The evaluation must also have an written order or appropriate referral dated prior to the evaluation (or an ongoing service order/referral), be documented in a report and be completed by a Medicaid qualified provider.
12 Clarified Medicaid Policy SSHSP – Clarification of Skilled Nursing Wording IEP Location for Medicaid ReimbursementMedicaid Alert #15-02_ (3/04/2015) Including Medicaid-reimbursable Skilled Nursing Services in the Student’s IEPDepending on the nature of the skilled nursing services, the documentation in the student’s IEP could, as appropriate to the individual student’s needs, be included as follows:The IEP may specify school health services or school nurse services as a related service with further clarification under the column “Service delivery recommendations” that such services are “skilled nursing services.”Alternatively, as appropriate to the student’s need for certain skilled nursing services, IEP recommendations for skilled nursing services could be noted as supplementary aides and services
14 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s , Claimable Age Limits& NYS Medicaid Enrollment RequirementNYSDOH Response to Question #16: In order for children to receive Medicaid reimbursable services under SSHSP/PSSHSP, they must be Medicaid eligible, be between the ages of 3 to 21 years , have been determined to have a disability through the IEP process and have an IEP. Please note that when a student turns 21 they are no longer reimbursable in the SSHS Program. In addition, the service must be ordered/referred by a NYS Medicaid enrolled practitioner
15 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s, PT Provider RequirementsNYSDOH Response to Question #24: Effective July 24, 2013, all New York State licensed and currently registered physical therapists are qualified physical therapy providers under the New York State Medicaid program, including SSHSP. Therefore, each school district/county must maintain documentation of New York State licensure for their physical therapist. (Graduation from a CAPTE approved program is no longer a requirement.)
16 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s, Written Orders/Referral ElementsNYSDOH Response to Question #32: The written order(/referral) must (now) include: The frequency and duration of the ordered (referred) service must either be specified on the order (referral) itself OR the order (referral) must explicitly adopt the frequency and duration of the service in the IEP by reference (‘per the IEP’).
17 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s , Written Order/Referral ElementsNYSDOH Response to Question #32 (continued):Stamped signatures are not allowable.The written order/referral must be in place prior to the initiation of service prospectively, including evaluation.Referral for psychological evaluations and counseling service may be made by ‘an appropriate school official or other voluntary health or social agency’. School officials are not allowed nor required to enroll as NYS Medicaid providers. (November 24, 2014] therefore the SSHSP biller’s NPI would need to be included on these claims.
18 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s, Special Transportation Requirement ChangesNYSDOH Response to Question #43:Medicaid reimbursement for special transportation is limited to those situations where the child receives transportation TO/FROM a provider in the community for the exclusive purpose of accessing an SSHSP Medicaid covered serviceORBoth the Medicaid covered service and how the transporting vehicle is (specifically) modified to meet the needs of the individual student are included in the student’s IEP.
19 Clarified Medicaid Policy SSHSP Special Transportation Criteria for Medicaid ReimbursementTwo exceptions to the rule:Special transportation is Medicaid reimbursable, regardless of the type of vehicle used, under the following special circumstances:A student resides in an area not having school bus transportation, but has a medical need for that transportation and is traveling to/from a Medicaid reimbursable service; or whenA student is transported from school or home directly to and/or from a provider in the community for the exclusive purpose of accessing an SSHSP service.
20 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s, Evaluation SSHSP Reimbursable ChangeNYSDOH Response to Question #57: The evaluation would only be reimbursable under SSHSP if the existing or new service is subsequently included as an ongoing service in the student’s IEP. [November 24, 2014]
21 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s, Out of State Ordering Providers PolicyNYSDOH Response to Question #91: In accordance with Article 31 section #6526 of the State Education Law, the only out-of state practitioners that may prescribe medically necessary care/treatment are physicians licensed in a bordering state and who reside near the border of this state. The border vicinity is usually defined as less than 25 miles. In addition, the out-of-state ordering practitioner must be enrolled in the NYS Medicaid program. [November 24, 2014]
22 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s, Medicaid does not have a Re-Evaluation RequirementNYSDOH Response to Question #117: Time frames pertaining to CSE/CPSE meeting for re-evaluation for special education services are required by special education law and regulation. There is no required re-evaluation schedule for Medicaid covered SSHSP services. To be Medicaid reimbursable an evaluation (or re-evaluation) must be: Medically necessary, documented with a written report, be included in the student’s IEP as an ongoing service and is appropriately ordered/referred and delivered by a qualified provider.
23 Clarified Medicaid Policy 4/13/2017Clarified Medicaid PolicySSHSP – Q & A’s, Ordering/Referring NPI when completed by an Appropriate School/County OfficialNYSDOH Response to Question #159: Effective April 1, 2013, All SSHSP claims must contain the NPI of the NYS Medicaid enrolled ordering referring provider. The Psychological Evaluation or Counseling Service billing, the school district’s or county’s NPI must be include on the claim in place of a ‘referring school district or county official’s NPI’ since enrollment by these individual is not required.
24 Existing Medicaid Policy Documentation Requirements Summary Verification of current certification, licensure, and/or registration, as relevant, of clinician providing the service must be available upon request.Provider Agreement and Statement of Reassignment completed by outside contractors, if applicable.Written Orders/Referrals.“Under the Direction of” or “Under the Supervision of” documentation, if applicable. (FYI-the #1 reason for OMIG audit disallowance).Documentation of each billable service:Evaluation reportSession noteMedication Administration Record (MAR)Special transportation logs
25 Certified Public Expenditures (CPEs) Random Moment Time Study (RMTS)
26 Clarified Medicaid Policy SSHSP – Certified Public Cost Amendments Have Been ApprovedMedicaid Alert #15-01 (1/16/2015) Medicaid State Plan Amendments for Certified Public Expenditures have been ApprovedDistricts will continue to submit Medicaid fee-for-service claims for each encounter, providing interim reimbursement for SSHSP services.After the school year is over, the Certified Public Expenditure (CPE) process will adjust that interim Federal Medicaid reimbursement to reflect the district’s Medicaid allowable costs for providing SSHSP services.The calculation of those Medicaid allowable costs requires the district to submit cost reports and participate in random moment time studies.Any district billing for the SSHSP services in school year or thereafter must complete this CPE cost settlement process
27 Revised Medicaid RMTS Policy Medicaid Alert (12/23/2014) Random Moment Time Study (RMTS) Moment Expiration UpdateMoments assigned to RMTS participants throughout the January-March 2015 quarter are required to be submitted within three (3) school days from the time of the moment.Effective April 1, 2015, moments assigned to RMTS participants are required to be submitted within two (2) school days from the time of the moment.In addition to the changes in the moment expiration process, RMTS participants (and RMTS Coordinator) will no longer be notified in advanced of a moment, but rather, will receive notification at the exact time of their moment.
28 SSHSP Billing/Claiming 4/13/2017Medicaid Alert # (posted 5/1/14) International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)ICD-9-CM will be replaced by ICD-10-CM (October 1, 2015)68,000 codes in ICD-10-CM (only 13,000 in ICD-9-CM)Free ICD-10-CM official guidelines and code sets online at:
29 IDEA Parental ConsentParental Consent Requirement for Release of InformationOne time consent with an annual notification is required to bill Medicaid for SSHSP services. The written notice must explain all the of the protections available to parents under Part B of IDEA to ensure parents are fully informed of their rights.The written notice must be written in language understandable to the general public and in the native language of the parent, unless it is clearly not feasible to do so.The NYS Office of Special Education Services has issued guidance on the implementation of these regulations:publicbenefits.htmThe Federal Department of Education has also issued guidance:
31 SSHSP ContactsNYSED Medicaid Unit (Medicaid in Education) SED: , SED SSHSP Website: PCG, Random Moment Time Study (RMTS) and Annual Cost Reporting: PCG Hotline: , SSHSP Medicaid Policy and Medicaid Claims: NYSDOH: Computer Sciences Corporation (CSC): , #1 (Billing), then #2 (CLINIC) or #2 (Enrollment), w/your NPI# NERIC: Vernea Diehl, , Heather Schubert, ,
32 Additional ContactsNYSED Office of Special Education SED P-12 Website: Regional Associates: NYS Office of the Medicaid Inspector General (OMIG) NYSED Office of the Professions: NYSED Office of Teaching Initiatives: NPI (Federal) Website: