Pennsylvania School-Based ACCESS Program Overview for PASBO Members October 8,

Agenda  Program Overview o Background o Roles and Responsibilities o Participation Requirements o Program Components o Statewide Financial Performance  Business Process & Timeline  Direct Service Claiming  Random Moment Time Study (RMTS)  Medicaid Administrative Claiming (MAC)  Cost Settlement 2

PROGRAM OVERVIEW 3

School-Based ACCESS Program (SBAP) provides Medicaid reimbursement for certain medically necessary health-related services documented in Individual Education Plans (IEPs) for students who are MA-eligible school year marks the 24 th year anniversary of the Pennsylvania SBAP. Over 500 Local Education Agencies (LEAs) currently participate in SBAP: school districts, intermediate units, charter schools and early intervention programs. Background 4

Centers for Medicare & Medicaid Services (CMS) conducted a Financial Management Review of Pennsylvania’s SBAP in 2012 CMS required significant programmatic changes: –Cost-based Payment Methodology including Random Moment Time Study (RMTS) and cost reconciliation –Discontinuance of billing for IEP meetings and collateral services –Discontinuance of Approved Private Schools/Chartered Schools for Deaf and Blind as SBAP providers DHS continues to evaluate SBAP to ensure the program is in compliance Background cont. 5

Roles and Responsibilities 6 Federal Medicaid Oversight Centers for Medicare & Medicaid Services (CMS) -Sets Federal requirements that must be implemented on a state level State Oversight PA Department of Human Services (DHS) & PA Department of Education (PDE) -Determines requirements for Pennsylvania Operational & Project Oversight Public Consulting Group (PCG) -Manages web- based systems used to accurately collect required data -Assists LEAs with program requirements -Submits LEAs’ claims to Medicaid Day-to-Day Operations & Oversight Local Education Agencies (LEAs) -Manages all program requirements at local level -Maintains Compliance -Documents Services, Participates in RMTS, Provides Cost Report

In order to participate in the SBAP program, LEAs are required to:  Enroll in the Pennsylvania MA program as a provider of SBAP services, following the guidelines and agreements to participate; and  Submit direct service claims to Medicaid; and  Participate in the Random Moment Time Study (RMTS) & submit quarterly costs (Medicaid Administrative Claim); and  Complete an annual Cost Report. Participation Requirements 7

Program Components 8 School Based ACCESS Program components that drive reimbursement include: Direct Service Claiming: Interim FAI Payments Cost Settlement: Annual Reconciliation of Direct Service Claiming Random Moment Time Study (RMTS) Quarterly Medicaid Administrative Claiming (MAC): MAC Checks Total LEA Reimbursement

Statewide Financial Performance 9

PROCESS & TIMELINE 10

Program Components & Business Processes 11 Direct Service Claiming MA Eligibility Direct Service and Transportation Logs Compliance data 180-day window LEA Specific Rates Medicaid Administrative Claiming (MAC) Submit and Certify Quarterly Costs RMTS Direct Service Staff Pool Administrative Service Staff Pool School Calendar: Start/End Times Creating shifts Responding to Moments Cost Settlement Capture costs Direct Medical Percentage IEP Ratio Transportation Ratios Unrestricted Indirect Cost Rate Direct Service Staff Pool Lists SBAP Process Timeline Monthly Quarterly Annually Quarterly

SBAP Timeline – FY October 2015 Oct – Dec: Quarter 1 Begins Annual Cost Settlement Trainings for LEAs Certify Costs for July – Sept: Quarter 4 (MAC Checks) Annual Fall Trainings November 2015 Annual Fall Trainings Open Jan – March: Quarter 2 RMTS Staff Pools and School Calendar December 2015 Deadline for LEAs to Certify Cost Reports Certify Jan – March: Quarter 2 RMTS Staff Pools and School Calendar January 2016 Jan – March: Quarter 2 Begins Certify Costs for Oct – Dec: Quarter 1 (MAC Checks) February 2016 Open April – June: Quarter 3 RMTS Staff Pools and School Calendar March 2016 Certify April – June: Quarter 3 RMTS Staff Pools and School Calendar July 2015 July - Sept: Quarter 4 Begins (Inactive Quarter – No RMTS moments) Certify Costs for April-June: Quarter 3 (MAC Checks) August 2015 Open Oct – Dec: Quarter 1 RMTS Staff Pools and School Calendar September 2015 Certify Oct – Dec: Quarter 1 RMTS Staff Pools and School Calendar April 2016 April – June: Quarter 3 Begins Certify Costs for Jan – March: Quarter 2 (MAC Checks) May 2016 Release Reconciliation for LEAs to submit Cost Settlement CPE Forms June 2016 Deadline for LEAs to submit Cost Settlement CPE Forms

DIRECT SERVICE BILLING – Monthly 13

Direct Services 14  Services are provided or purchased by LEAs enrolled in the Medical Assistance (MA) Program to MA-eligible beneficiaries under 21 years of age for whom the service is medically necessary and documented in the IEP.  Services must be face-to-face to be compensable

Direct Services cont. 15 Assistive Devices Audiology Services Hearing-Impaired Services Nursing Services Nurse Practitioner Services Occupational Therapy Services Orientation, Mobility and Vision Services Personal Care Services Physical Therapy Services Physician Services Psychiatric Services Psychological Services Social Work Services Special Transportation Services Speech and Language Services

As claims are processed by Medicaid/PROMISe, LEAs can track approved and denied claims via PCG’s Reports:  Monthly Management Reports o Distributed monthly via PCG’s EasyTrac System o Shows claims submitted/paid/pending on monthly basis o Shows year to date, and year to year performance o Shows Exceptions (missing compliance data)  FAI Summary Report o Shows Payments, Withdrawals, Vendor Fees o Does not currently show LEA current balance o Does not reflect funds held by an IU o Does not reflect MAC claims payments (paper checks are sent directly to LEA) Tracking Reimbursement 16 Claims Processing 4-6 weeks

Important Reminders 17  DHS Requirement for all Providers – 180 days from date of service to bill Medicaid  Capture all services delivered to all eligible students as soon as possible. What is your LEA internal policy?  LEA is responsible to review any third party providers/vendors entering claims “on behalf of” LEA.  The LEA should regularly review service log status: what logs have been captured; imported into PCG’s EasyTrac System; status of exception data? Provide any missing compliance data quickly.  LEA receives interim payments in FAI account for Paid Claims  Services are billed to DHS using each LEA’s gross billing rate. If those claims are approved, they are multiplied by the current FMAP rate to determine the net interim payment that is then deposited into the LEA’s FAI account.

RANDOM MOMENT TIME STUDY (RMTS) – Quarterly 18

What is the purpose of RMTS? The Random Moment Time Study (RMTS) methodology is used to select, capture and code moments in time for determining on a statewide basis how frequently participants are involved in a Medicaid billable activity. RMTS results are used to: Develop the Direct Medical Percentage used in the Cost Settlement Process Develop each participating LEA’s quarterly MAC reimbursement RMTS 19

 Prior to the beginning of each quarter, the RMTS SBAP Coordinator for each participating LEAs must: o Submit a school calendar for the upcoming quarter (for quarters 1 – 3) o Submit (or update) a staff pool list (for quarters 1 – 3) o 4 th Quarter is a “non-active” quarter  Each quarter 3,000 moments are randomly selected (statewide) o Direct Service cost pool o Administrative Support cost pool  All staff receiving a “moment” must respond (5 days) o Participating LEAs’ goal is 100% response rate o Statewide response rate needs to be 85% or greater RMTS cont. 20

 Each LEA’s quarterly Staff Pool List (or, roster) is comprised of two cost pools: o Direct Service cost pool must include: All qualified service providers (e.g. PT, OT, SPL, etc.) who are providing health-related services to your students where these services are billed (or could be billed) to Medicaid for cost reimbursement o Administrative Support cost pool can include: “Rule of thumb” is that any staff who (is NOT a direct service provider) who spends 50% or more of their time (on a typical day) working in or supporting your Special Education program Quarterly Staff Pools 21

MEDICAID ADMINISTRATIVE CLAIMING (MAC) – Quarterly 22

 MAC Claims – Submitted & Paid Quarterly o LEA to enter actual, allowable costs on a quarterly basis o 30 days to submit quarterly costs (cash basis) o Once actual costs have been captured and reviewed, and a MAC claim amount calculated, each participating school receives a Certification of Public Expenditure (CPE) letter that must be signed & returned within 10 days. Any letter received after that deadline would delay payment until the following quarter o Participating schools who are entitled to receive a MAC claim payment will receive a paper check ( Note: MAC payment dollars are never deposited in the school’s FAI account ) MAC 23

COST SETTLEMENT – Annually 24

What is Cost Settlement? Cost settlement is the annual reconciliation of reimbursement of each LEA’s interim payments for direct service claiming as compared to each LEA’s total Medicaid allowable costs. Since SBAP utilizes a cost-based reimbursement methodology, LEAs cannot receive more than their Total Medicaid Allowable Costs. Cost Settlement Process 25

1.District provides their cost data 2.Cost Settlement methodology produces these outcomes : o NET Medicaid Allowable Costs o NET Medicaid Interim Payments 3.Cost Settlement result o When an LEA’s net Medicaid allowable costs exceed its net interim payments, the LEA will receive a payment for the difference o When an LEA’s net interim payments exceed its net Medicaid allowable costs, the LEA must repay the difference NOTE: Cost Settlement does not include quarterly MAC payments that the LEA has received during the school year. Cost Settlement Calculation – How it Works 26

Common reasons for “pay back” result: o The salary and benefit costs for all direct service providers (employees and contractors) have NOT been included on your quarterly Staff Pool Lists, therefore, all eligible costs could not be included in your cost settlement process o Even when the salary and benefit costs for all service providers have been captured in the LEA’s Cost Report, in order for them to be included in your cost settlement process, the LEA must have received reimbursement for each health-related category they bill to Medicaid. Otherwise, those costs are EXCLUDED from your Medicaid cost settlement calculation. Cost Settlement Paybacks 27

Cost Settlement Estimation Tool  Allows LEAs to use its costs, its interim payments and previous year’s statewide ratios, to estimate cost settlement outcome  Provides estimates only – does not provide final cost settlement calculations for LEAs Cost Settlement Annual Training Webinars  Dates of cost settlement webinars: Cost Settlement Tool and Trainings 28 DayDateTime Tuesday10/13/20152:00 pm Wednesday10/21/201510:00 am Monday10/26/20151:00 pm Tuesday11/3/20153:00 pm Friday11/6/201510:00 am Thursday11/19/20151:00 pm Wednesday12/2/20153:00 pm Wednesday12/16/201510:00 am

Becky Ludwick School-Based ACCESS Program Director Department of Human Services Phone: (717) Contact Information 29

SBAP client/paaccess/SBAP101.html SBAP Trainings/Webinars client/paaccess/calendar.html 30 Additional Resources

Questions? 31