Medicaid Reimbursement for SchoolBased Health Care Services

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Medicaid Reimbursement for School-Based Health
Care Services
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Overview

• Purpose of the program
• Reasons for the program changes
• Program updates and what they mean to the school
  districts
• Reimbursement
• Rates
• Covered services
• Provider qualifications
• Documentation

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Purpose of the Program

• The purpose of the program is to pay school
  districts for some of the healthcare related
  services included in an IEP.

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Reasons for the program changes

• 2003 OIG Audit
• Non-covered/unauthorized services
• Unqualified providers
• Unsupported services
• CMS Corrective Action Plan
• Ensure costs are allowable adequately supported
• Amend the State Medicaid Plan
• Reimbursement

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Reimbursement

• Effective for dates of services on or after
  September 1, 2007
• School districts bill DSHS/Medical Assistance
• Medical Assistance pays the school districts
  directly
• School districts receive all available state and
  federal dollars
• School districts pay their billing contractor
  directly

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Requirements for Medicaid Reimbursement

• Medicaid enrolled client
• Enrolled in special education
• Services must be in the IEP
• Provided by qualified staff

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Rates

• Prior to September 1, 2007
• Cost-based
• September 1,2007 and after
• Community-based

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How does this impact school district billing?

• An increase in the number of codes the school
  districts will use to bill Medical Assistance
• By definition some codes pay a flat rate
• Some codes pay by units of time
• A unit of time is 15 minutes
• No more rounding up

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Important Points About New Rates

• New rates are all inclusive
• School districts will no longer bill for
  collateral services
• Simplify billing

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Covered Services

• Medical Assistance pays only for services that
  are medically necessary, and
• Address the physical and/or mental disabilities
  of a child, and
• Are prescribed by a physician or recommended by
  another qualified healthcare provider, and
• Included in the IEP

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Covered Services include

• Physical therapy
• Occupational therapy
• Speech-language services
• Audiology
• Nursing services
• Psychological evaluation and testing
• Counseling services and

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Please Remember

• Evaluations and assessments for covered
  services are reimbursable only when the plan of
  care, or treatment plan, is incorporated into the
  IEP

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Provider Qualifications

• Code of Federal Regulations
• Therapist qualifications
• Revised Code of Washington
• Professional licensure
• Washington Administrative Code
• Professional practice standards

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Provider Qualifications, continued

• Providers must meet both federal and state
  education and work experience requirements and
  where applicable, must be licensed by their
  professional licensing board

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Providers requiring a professional license

• Physical therapists
• Occupational therapists
• Registered nurses (RN)
• Licensed practical nurses (LPN)

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Providers Exempt from the State Licensure
Requirements

• Speech-language pathologists
• Audiologists
• Counselors
• Psychologists

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To be exempt providers must

• Meet the education and work experience
  requirements necessary for licensure
• Be ESA certified, and
• Limit their practice to the school setting

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Medical Assistance Policy Exception

• School psychologists who
• Have a masters degree in school psychology
• Are ESA certified, and
• Limit their practice to the school setting

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Under the direction of

• Providers have the clinical and fiduciary
  responsibility for all services provided under
  their direction or supervision
• The nature, frequency and scope of supervision is
  determined by the supervising therapist according
  to their professional practice standards

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Important Information

• Effective September 1, 2007, Medicaid will no
  longer reimburse school districts for healthcare
  related services provided by para-professionals,
  aides or instructional assistants.

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Nurse Delegation Exception

• Non-credentialed school employees may provide
  certain limited health care tasks when delegated
  by a registered nurse and supervised according to
  professional practice standards

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Documentation RequirementsWAC 388-502-0200

• The provider must
• Establish the medical necessity for services
• Develop a treatment plan including amount, scope
  duration of services
• Report on daily progress
• Adjust the treatment plan as indicated
• Report outcomes

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OTHER

• The role of the Medicaid reimbursement
  coordinator
• Medicaid reimbursement policies and procedures
• The billing codes
• Current Procedural Terminology (CPT) 2007
• Professional Addition
• [phone]
• Coverage list and new fee schedule

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Important Information

• Please hold all Medicaid billings until
  November 1, 2007, so the department assures all
  systems are in place to accurately process your
  bills

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Contact Information

• Christine Bess
• Program Manager
• School-Based Health Care Services
• bessce_at_dshs.wa.gov
• [phone]