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

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

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%
Key Medicaid Statistics
State Population:  19,651, estimate  (
Percent of Population Receiving Medicaid:  27%
[5,303,375 total enrollees 2013/19,651,127] (
Overall Medicaid Budget:  
                              Medicaid Expenditures Calendar Year               $46,660,714, (
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. 50,000
Percent of Students Receiving SSHSP Services: _<2__%
                                        2,680,303 students enrolled in public school in NYS in school year
                                                            (

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

5. SSHSP – Present Day
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.

6. SSHSP – Present Day
Submitted 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 Timeline
Federal Audits
Compliance Agreement
Today

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)

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

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)

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

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

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

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…

16. SSHSP Policy Changes - Highlights
SPA 09-61
Encounter-based claiming
SSHSP claims present
Guidance issued to SSHSP providers

17. SPA 09-61 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

18. SPA 09-61
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, 2010

19. SSHSP Claims Present
Claims Paid for SSHSP from September to Present*
*Not all claims have been received for current year
School Year
Paid Amount
Number of Claims
Number of Unique Recipients
9/09 – 6/10
$1,098,973
29,411
471
7/10 – 6/11
$59,231,489
1,785,749
29,292
7/11 – 6/12
$98,761,787
2,968,653
42,329
7/12 – 6/13
$110,846,498
3,445,903
50,494
7/13 – 6/14*
$77,180,501
2,343,770
47,310

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:

21. State Plan Process - Implementation of Certified Public Expenditure Reimbursement Methodology
SPA submission
Introduction of CPE Reimbursement Methodology
Requirements 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 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

23. Introduction of CPE Reimbursement Methodology
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

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

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 11-39

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:
Salary costs for eligible SSHSP service providers employed by school districts and counties
Benefit costs for eligible SSHSP service providers employed by school districts and counties
Contract costs for eligible SSHSP service providers contracted by school districts and counties by outside agencies
Approved direct medical service material, supply, and equipment costs
Depreciation costs for approved direct medical service equipment
Annual tuition costs for private schools and other non-public entities
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.

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:
Random Moment Time Study (RMTS) percentage or Direct Medical Service (DMS) percentage results
School District and County Indirect Cost Rates (ICR)
Health Related Tuition Percentages
Individualized Education Program (IEP) Ratio
Each 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 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

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
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?

32. Requirements for Participating School Districts

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:
Salary costs for eligible specialized transportation service providers
Benefit costs for eligible specialized transportation service providers
Approved Specialized Transportation Non-Personnel costs
Depreciation costs for Approved Specialized Transportation Non- Personnel costs
School District and County Indirect Cost Rates (ICR) (pre-populated by PCG)
Specialized Transportation Ratio
One Way Trip Ratio

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
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
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?

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?

39. SSHSP Resources
Online Resources
PCG Support

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:

41. Toll Free SSHSP Hotline: 1-866-912-2974
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: