Medicaid School Based Services Update

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Medicaid School Based Services Update

• MAASE
• October 15, 2008

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Presenters

• Thomas Koepke Director, Special Education
  Management Services, Macomb ISD
• Jane Reagan Department Specialist, Medicaid,
  OSE-EIS, Michigan Department of Education
• Liz Patrick Supervisor, Instructional Data
  Management Special Education Finance, Ingham
  ISD
• Members, Medicaid School Based Services Workgroup

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Outline

• Overview
• Backcasting
• Moratorium
• State Plan Amendment Changes
• Outreach
• Fee for Service
• Personal Care Services
• Reimbursement methodology
• New Time studies

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Medicaid Overview

• Largest payor of health care in US
• In 2007, 340 billion for over 62 million
  individuals (30 million children)
• Two types of reimbursement in school settings
  Fee for Service and Outreach

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Medicaid Overview

• Outreach
• Provides funds to districts that are working to
  identify children that are uninsured and may
  qualify for Medicaid involve ALL students
• Fee for Service
• Reimbursement for certain health related services
  (PT, OT, Nursing, etc) provided to Medicaid
  eligible children with IEP or IFSP

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Backcasting Overview

• May 2002 Settlement Agreement between Feds
  State
• Prompted by a disagreement regarding Michigans
  Outreach claiming methodology
• Methodology used was State approved
• Feds did not provide formal guidance on
  acceptable claiming methodologies until the
  issuance of the May 2003 Medicaid School-Based
  Services Administrative Claiming Guide

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Backcasting Overview

• Settlement required new program design
  effective January 2004
• Results of 1st 4 quarters under new plan applied
  to previous 16 quarters Jan/Mar 2000 through
  Oct/Dec 2003

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Backcasting Overview

• 10/22/07 CMS Final Report
• 89,848,860 Overpayment
• ISD 60 53,909,316
• State 40 35,939,544
• CMS expects the State to refund the financial
  amount identified

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Backcasting Current Status

• ISD Reserves
• ISD s held by State 20,737,997
• ISD s held by ISD ??
• ISD Max repayment
• ISD Overpayment 53,909,316
• ISD Reserve-held by State - 20,737,997
• ISD Reserve-held by ISD - ???
  
• 33,171,319

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Backcasting Current Status

• Breakdown of total by ISD
• CMS report only addressed total overpayment
• MDCH responsible for calculating breakdown
• State has appealed CMS decision
• ISDs - wait and see

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Congress Moratorium on Proposed Regs until
April 1, 2009

• Federal CMS proposed in 2007 to
• Eliminate reimbursement for Outreach (AOP) and
  Transportation
• Redefine/limit targeted case management
• Redefine/ limit rehabilitative services to
  exclude reimbursement for intrinsic elements of
  education programs
• Limit reimbursement to governmental providers
  costs by narrowing definitionimpacted schools

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Outreach Current Status

• 2006-07 Total Statewide Reimbursement
  19,000,000
• ISD 60 11,400,000
• State 40 7,600,000
• Statewide Vendor - Public Consulting Group (fees
  paid by ISDs State)
• No changes for 2008-09

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FFS Current Status

• 2006-07 Total Statewide Reimbursement
• Program Transportation Total
• ISD (60) 64,600,000 2,300,000
  66,900,000
• State (40) 43,100,000 1,600,000
  44,700,000
• 107,700,000 3,900,000
  111,600,000

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FFS ReimbursementBefore 7/1/08

• Service documentation logs
• Reimbursement rate per service type and statewide
  fee
• Claim submitted to MDCH
• ISD Reimbursement based on what was
  provided/billed

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FFS Reimbursement After 7/1/08

• Cost-based
• Provider (ISD)-specific
• Annually reconciled
• Cost settlement process
• Service documentation and claim submission is
  still required

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New Reimbursement Methodology

• Total Allowable Costs
• Indirect Cost Rate (MDE)
• x Direct Service (annual avg from RMTS)
• x ISD SE Med Elig Rate, Hlth Svcs (Dec1)
• x Fed Medical Assistance (0858.1)
• x ISD Reimbursement Rate (60)
• Net Dollars to ISD

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Random Moment Time Study (RMTS)

• Previously 1 RMTS for Outreach 800
  moments/quarter
• Now 4 RMTS 3,000 moments/qtr each
• Outreach Only Staff
• Direct Medical Service Providers
• Case Managers
• Personal Care Providers
• Only staff on staff pool lists can be included as
  part of Medicaid Allowable costs

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Interim Payment Process

• Estimated based upon prior year
• 2008-09 75 of 2006-07
• ISDs may adjust payment
• MDCH will monitor claim volume
• If claiming drops significantly be prepared for
  questions and/or payment adjustment

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SE Medicaid Eligibility Rate for Health Related
Services
Medicaid Eligible SE Students with a
health-related support service in the IEP
__________________________________________________
_____ Total SE Students with a health-related
support service in their IEP
Based on December 1 count
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Allowable Direct Service Providers

• ASHA certified speech language pathologist
• TSLIs under the direction of an ASHA certified
  SLP or audiologist
• Audiologist
• LPN/RN
• OT/COTA
• PT/PTA
• Orientation Mobility Specialist
• Psychologist (full license only or limited under
  the direction of a fully licensed psychologist)
  (Not School Psychs)
• Licensed Masters Social Worker

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Under the Direction of

• Supervising the individuals care
• Face to face contact initially and periodically
• Prescribing the type of care
• Reviewing the need for continued services
  throughout treatment
• Assuring professional responsibility for services
  provided
• Ensuring all services are medically necessary

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Personal Care Services

• Range of human assistance services provided to SE
  students, enables them to accomplish tasks that
  they would normally do for themselves if not for
  the disability
• Eating/Feeding/meal preparation
• Toileting/maintaining continence
• Personal Hygiene/grooming
• Transferring/mobility/positioning

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Personal Care Services

• Providers - Health aides, Instr aides, Parapros,
  Program assts, Teacher aides, Trainable aides
• Require authorization
• Need for service documented in IEP
• Service documentation

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Financial Reporting Changes

• Cost Reporting
• Current
• Outreach Quarterly financials
• FFS n/a
• New Methodology
• Outreach Only Quarterly financials
• Direct Medical Addendum to 4096
• Personal Care Quarterly financials
• Case Management Quarterly financials

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Fiscal Impact of Changes

• Will vary from ISD to ISD based on
• Actual state-wide direct service compared to
  of direct services per ISD that are typically
  logged
• Costs mainly salary benefits
• Medicaid eligibility rate
• Indirect cost rate

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2008-09 Budget Impact

• Medicaid Outreach 4 quarters
• Medicaid FFS
• - Estimate based on 75 of 2006-07 revenue
• - 2007-08 claiming
• - Personal care no payment in 08-09 (will be
  part of cost settlement process in 2010)

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2008-09 Timeline Cost Reports

• June 30, 2009end of first year
• Oct 15, 2009ISDs access Medicaid cost reports
  via web, w/ pre-populated fields (time studies,
  Medicaid elig rate, indirect cost rates)
• Oct 31, 2009LEA and PSA Medicaid cost reports
  due to their ISD
• Dec 31, 2009ISDs submit summary cost reports to
  Medicaid

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2008-09 Timeline Cost Reports, contd

• Jan 2010Initial settlement of ISD costs and
  adjustments of interim payments begin
• Revisions to Medicaid Cost Report may occur until
  July 2010
• July 2010Final ISD settlement process begins

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More Discussion if time

• Resources Medicaid SBS Work Group
• At Medicaid agency
• Linda Sowle, Medicaid Policy Specialist,
• Michigan Department of Community Health
• 517-241-8398
• SowleL_at_Michigan.gov