What Every Administrator Should Know
about Medicaid
November 2013
RITAP November 2013
Medicaid
 Federal/State Program

Federal: Centers for Medicare and Medicaid
Services (CMS)
www.medicaid.gov/
 State: Executive Office of Health and Human Services
(OHHS) in Rhode Island
 www.eohhs.ri.gov/
RITAP November 2013
LEAs as Medicaid Providers
 RIGL 40-8-18 authorizing statute (1992/2000)
 Two types of Claiming Opportunities
 Direct Services (related to special education)




Individual Provider Number: school staff/employees
Group Provider Number: contractors, including private schools
Submit claims any time (electronically)
Provide Quarterly Certification of Funds
 Administrative Claiming
 Submit Claims Quarterly
 100% Federal reimbursements  LEAs
 Most recent reimbursement reports:
www.ritap.org/medicaid
RITAP November 2013
Basic Requirements to Implement
 The LEA needs to pay for any services for which
reimbursement is sought
 Direct Services must be funded with state/local $$
 Administrative Claiming activities may be funded with a
blend of federal and state/local $$
 LEAs are the responsible entity for any claims
submitted on their behalf
 All documentation requirements must be met
(Guidebooks)
 LEAS must receive a one-time parental consent in
order to seek reimbursement for direct services
RITAP November 2013
Basic Requirements to Implement
Excerpts From RIGL 40-8-18
Voluntary participation as an EPSDT provider shall require the
local education agency to provide the state match to obtain
federal financial participation for EPSDT services and
associated administrative costs by certifying to the
department of human services that sufficient qualifying local
funds (local certified match) have been expended for such
services and administrative costs;…
Payments made to the local education agency pursuant to this
section shall be used solely for educational purposes and shall
not be made available to local communities for purposes other
than education.
RITAP November 2013
Medicaid Parental Consent 2013
IDEA 34 CFR 300.154(d)
 IDEA Parental Consent Requirements for accessing
Medicaid funds: Revised 2013, Effective 10/9/13
 Must give prior notice
 Must give annual notice
 Must receive one-time informed parental consent to access
Medicaid benefit (if consent not received do not submit a
claim)
 Parents may revoke at any time: revocation effective date LEA
receives it
 www.ritap.org/medicaid: Model Form (English/Spanish),
Parent Brochure, and Implementation Guidance
RITAP November 2013
Medicaid Direct Services
Guidebook
 www.eohhs.ri.gov/Portals/0/Uploads/Documents/GB
%20BODY%2007-29-2010_1.doc.pdf
 Connection between Special Education and Medicaid
 Certification of Funds
 Direct Services Claiming
 Quality Assurance
 Claims Reconciliation
 Services Description
 Roles and Responsibilities School Administrators
RITAP November 2013
Medicaid Direct Services
Guidebook Addenda
 www.eohhs.ri.gov/Portals/0/Uploads/Documents/
GB%20Addenda%2007-29-2010_1.doc.pdf
 Addendum D: Quality Assurance-Matrix
 Addendum G: Sample Certification Funds Letter
 Addendum I: Claims Reconciliation
 Addendum J: Diagnosis & Procedure Codes
 Addendum J: Services descriptions
 Addendum K: Expanded Behavioral Health Treatment
Plan
RITAP November 2013
Childhood Medicaid Eligibility in
Rhode Island
www.eohhs.ri.gov/Consumer/ConsumerInformation.aspx
 RIte Care and RIte Share
 Supplemental Security Income (SSI)
 Katie Beckett
 Foster Care
 Adoption Subsidy
One Stop for Families with Children
www.eohhs.ri.gov/Consumer/FamilieswithChildren/One
StopforFamilieswithChildren.aspx
RITAP November 2013
Medicaid Administrative
Claiming Guidebook
www.eohhs.ri.gov/Portals/0/Uploads/Documents/admi
n_clm_guide.pdf
 Claims submitted quarterly
 Typically overseen by special education: selected staff
time studies
 Typically overseen by business/finance: selected staff
salary and fringe data; other financial data
RITAP November 2013
LEA Oversight Claiming
 Executive Office of Health and Human Services-
EOHHS (state Medicaid agency) conducts biennial
reviews of each LEA
 Review includes claims for Direct Services and
Administrative Claiming
 Guidebooks
 www.eohhs.ri.gov/ProvidersPartners/GeneralInformatio
n/ProviderDirectories/LocalEducationAgency.aspx
RITAP November 2013
Direct Services Billing Options
 District may self-bill
 District staff maintains documentation, prepares
claims, submits claims, reconciles claims-RA- process
 District may contract with a billing vendor
 District staff maintains documentation, prepares claims,
may reconcile claims; vendor may prepare, reconcile and
submits claims
Regardless of method, District is responsible for claims
submitted!
RITAP November 2013
Administrative Claiming Billing
Options
 District may self-bill (train staff, oversee time studies,
collect fiscal records, enter data into formula to formulate a
claim, review processed claim, forward to EOHHS for
processing)
 District may contract with a vendor
 District oversees time studies, collects fiscal records
 Vendor trains staff, may oversee time studies process, receives
documentation (staff and fiscal) from district, enter data to
formulate a claim, review processed claim, forward to EOHHS
for processing
Regardless of method, District is responsible for claims
submitted!
RITAP November 2013
On-Line Resources
 RIDE: www.ride.ri.gov
 Special Education
www.ride.ri.gov/StudentsFamilies/SpecialEducation.aspx
 Office of Student Community and Academic Supports (OSCAS)
www.ride.ri.gov/InsideRIDE/RIDEOffices/StudentCommunityAcademi
cSupports.aspx
 RITAP: www.ritap.org (Autism, ELL, IEP, Medicaid, RTI, Transition)
 Federal Medicaid: www.medicaid.gov/
 Centers for Medicare and Medicaid Services (CMS) www.cms.gov/
 Health Source RI: www.healthsourceri.com/
 Kids Count: www.rikidscount.org/matriarch/default.asp
 Economic Progress Institute at RIC: www.economicprogressri.org/
RITAP November 2013
On-Line Resources
 EOHHS: www.eohhs.ri.gov
 Families with children www.eohhs.ri.gov/Consumer/FamilieswithChildren.aspx
 CEDARR Family Centers & Katie Beckett
www.eohhs.ri.gov/Consumer/ConsumerInformation/Healthcare/PeoplewithSpeci
alNeedsandDisabilities/Children.aspx
 Health Care (children and adults)
www.eohhs.ri.gov/Consumer/ConsumerInformation/Healthcare/HealthcareOver
view.aspx
– LEA Medicaid Guidebooks
www.eohhs.ri.gov/ProvidersPartners/GeneralInformation/ProviderDirectories/
LocalEducationAgency.aspx
– The Departments (DCYF, DHS, BHDDH, DOH)
www.eohhs.ri.gov/Home/EOHHSDepartments.aspx
RITAP November 2013
Key Medicaid Contacts
 RITAP/Special Education: Denise Achin
 401-222-8997, denise.achin@ride.ri.gov
 EOHHS/Medicaid: Shauna Jackson
 401-462-6351, sjackson@ohhs.ri.gov
 Hewlett Packard/Billing Issues: Karen Murphy
 401-784-8004, karen.murphy2@hp.com
RITAP November 2013