Medicaid and Education
June 13, 2012
www.cms.gov
State Plan
Each state
determines its State
Plan within the
general guidelines
of the federal CMS.
Medicaid and Education Timeline
1989
1990
2000
U.S.
Congress
IDEA
Medicaid
State Plan
Amended
Medicaid
reimbursement
for children
with IEPs
WV Code
18-2-5b
Added
Only OT, PT,
Speech,
Nursing, and
Psychology
IEPs, Care Coor,
Sp. Trans.
Personal Aides
IDEA
Reduction of Other Benefits.--Nothing
in this part shall be construed to
permit the State to reduce medical or
other assistance available or to alter
eligibility under title V of the Social
Security Act… or title XIX of the Social
Security Act (relating to Medicaid for
infants or toddlers with disabilities)
within the State.
1990
Each School District – 1st #
Therapy Provider #
0 00XXXXXXXX
2000
Each School District – 2nd #
Cost-Based Provider #
15XXXXXXXX - New
NPI # - 2009
Audiology #
Initial/Triennial IEP
OT #
Annual IEP
PT #
SLP #
RN #
Psychology #
Personal Care (full)
Personal Care (part)
Sp. Trans. Vehicle
Sp. Trans. Aide
Care Coordination
Code
Description
Frequency Federal
match
T1001 Nursing Assessment/Evaluation
2x/year
$99.66
T1000 Nursing Services (Specialized
Procedures)
15 min.
$6.02
WVEIS #
Diagnosis Code
County
Beginning Date
School
Ending Date
Procedure
Units
T1001
Ind. Provider #
Beginning Date
Ending Date
Procedure
Units
T1000
Private Duty Nursing Services: Written physician’s orders with diagnosis and specialized care
required. Must be identified on IEP (Care plan may be attached).
Code
T1001
Service
Unit
1 per year
Procedure
Nursing Assessment/Evaluation
T1000
Nursing Services, Individual services (including the planning for the delivery
of care in consultation with the parent, physician, school personnel, private
duty nurse and delivery of actual specialized health procedures and evaluation
of the student’s response to the treatments summarized below.)
15 minutes
Authorized Individual Nursing Services/Treatments:
Anaphylactic Reaction
Manual Resuscitator
Postural Drainage and Percussion
Catheterization: Clean-SelfSterile
Crede’s Method
Mechanical Ventilator
Seizure Management
Measurement of Blood Sugar with
a Glucometer
Oral Suctioning
Subcutaneous Insulin Infusion
Pump/Bolus
Subcutaneous Insulin by Injection
Ostomy Care: Emptying/Changing
of Ostomy Pouch
Oxygen Administration
Peak Flow Meter
Tracheostomy Care
Emergency Medication
Administration
Enteral Feeding (tube feeding)
Epinephrine Auto-Injector
Inhalation Therapy by Machine
Long-Term Medication
Administration
Vagus Nerve Stimulator
Administering Medications through
Gastrostomy/N-G Tube
Epinephrine Twinject
Phrenic Nerve Stimulator
Special Dietary Needs Medical
Statement
Date
Proc.
Time
1
2
3
4
5
Date
Proc.
Time
16
17
18
19
20
6
21
7
22
8
23
_____________________________________
Signature
9
24
10
25
11
26
27
12
28
_________________
Date
13
29
14
30
15
31
15
minute
=1
billing
unit
7.5 min.
may
round
up
Menu
LEA
Supporting Documentation:
IEP
Progress Notes
Attendance Records
Care Coordination form
Billing
Form or
WVEIS
Entry
Electronic
claim
RESA
Payment –
Direct
Deposit
Remittance Advice
Denial/pending
WVDHHR Molina
Processing
Agency;
Bureau of
Medical
Services
BMS
Documentation
• Student Related Documentation
Included in IEP services – related service
Notes/log
• Billing Documentation - WVEIS
The federal CMS is requiring
states to adopt a cost settlement
approach for school-based
Medicaid reimbursement
beginning July 1, 2012.
Cost Report Process
 Cost Reports will be submitted through a web
based software system

WV: Introduction to Medicaid
Cost Based School Based
Health Services
More comprehensive cost report training will be provided in the future
21
Cost Settlement Calculation Example
1.0
Total Costs of Eligible SBHS Provider Costs (County’s costs)
2.0
Indirect Cost Rate
3.0
Total Costs of Eligible SBHS Provider Costs
4.0
RMTS Direct Medical Percentage Results (Statewide results)
5.0
Direct Medical Services Costs
6.0
Application of Medicaid Eligibility Rate (IEP Ratio) (County’s)
7.0
Medicaid Direct Medical Services Costs (for the quarter)
$373,750
8.0
Medicaid Interim Payments Received (for the quarter)
$200,000
9.0
Medicaid Cost Settlement (at the end of the year – July 2013)
$173,750
WV: Introduction to Medicaid
Cost Based School Based
Health Services
$1,000,000
115.00%
$1,150,000
65.00%
$747,500
22
50.00%
Cost Settlement Calculation 2nd
Example – Pay Back
1.0
Total Costs of Eligible SBHS Provider Costs (county’s cost)
2.0
Indirect Cost Rate
3.0
Total Costs of Eligible SBHS Provider Costs
4.0
RMTS Direct Medical Percentage Results (Statewide results)
5.0
Direct Medical Services Costs
6.0
Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)
7.0
Medicaid Direct Medical Services Costs (for the county)
$373,750
8.0
Medicaid Interim Payments Received (by the county)
$500,000
9.0
Medicaid Cost Settlement (at the end of the year – July 2013)
-$126,250
WV: Introduction to Medicaid
Cost Based School Based
Health Services
$1,000,000
115.00%
$1,150,000
65.00%
$747,500
23
50.00%
Cost Settlement Calculation 3rd
Example – Neutral
1.0
Total Costs of Eligible SBHS Provider Costs (county’s cost)
2.0
Indirect Cost Rate
3.0
Total Costs of Eligible SBHS Provider Costs
4.0
RMTS Direct Medical Percentage Results (Statewide results)
5.0
Direct Medical Services Costs
6.0
Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)
7.0
Medicaid Direct Medical Services Costs (for the county)
$373,750
8.0
Medicaid Interim Payments Received (by the county)
$373,750
9.0
Medicaid Cost Settlement (at the end of the year – July 2013)
WV: Introduction to Medicaid
Cost Based School Based
Health Services
$1,000,000
115.00%
$1,150,000
65.00%
$747,500
24
50.00%
$0
$ County’s
costs for
billable services
– excluding IDEA
Match
Results of
RMTS
(statewide)
#Medicaid
Eligible/
#Special Ed.
Rate billed for
SLP, PT, OT, PSY,
RN, AUD
Rate billed for
Care
Coordination
Rate billed for
Personal Care
Aides
$
County’s
costs for
Medicaid-covered services
billable
services –
excluding
IDEA
•Audiological Services
•Speech therapy services
•Physical therapy services
•Occupational therapy services
•Psychological evaluation
•RN – Specialized Procedures
Results of
RMTS
(Direct billable)
Care Coordination
activities
Personal care activities
#Medicaid
Eligible/
Special
Education
•Communication;
•Safety;
•Mobility;
•Behavior;
•Medical/health
RMTS Site Preview
WV: Introduction to Medicaid
Cost Based School Based
Health Services
27
RMTS Site Preview
WV: Introduction to Medicaid
Cost Based School Based
Health Services
28
RMTS Site Preview
WV: Introduction to Medicaid
Cost Based School Based
Health Services
29
RMTS Site Preview
WV: Introduction to Medicaid
Cost Based School Based
Health Services
30
For Additional Support
 LEA contact will e-mail files to
wvsbhs@pcgus.com
 No later than January 2012
 Staff Roster – LEA contact to CREATE
 Calendar – LEA contact to CREATE
 Reminder
 PCG will code using a centralized standard coder
 Training will be embedded in the RMTS
 For additional assistance, please contact the
Public Consulting Group’s West Virginia Hotline
at
 E-Mail Address: wvsbhs@pcgus.com
WV: Introduction to Medicaid
Cost Based School Based
Health Services
31
RMTS Responses (Direct Services)
Inappropriate Response: I was not providing
direct services to students.
Appropriate Response: I was working on
writing new IEP goals regarding transition for a
student.
Inadequate Response: Who was with you?
Some students and an adult.
Appropriate Response: Five students and an
aide.
PCG’s Advice
When indicating that you were participating in
or preparing for an IEP Meeting,
please indicate the portion of the IEP on which
you were working during your moment
(i.e., health related services goals, transition,
state assessments, etc.).
$ County’s
costs for
billable
services
Results of
RMTS
#Medicaid
Eligible/
#Special
Education
Drawing from Basic
Information Page –
Special Education
screen WVEIS
Important LEA Data Collection Needs
 IEP Ratio must be maintained and tracked for Medicaid cost
allocation purposes
 Medicaid-allowable costs are determined by
multiplying total direct medical services times the
IEP ratio.
Total Number of Medicaid Eligible FFS
IEP
Ratio
Students Receiving Direct Medical Services
with an IEP
=
WV: Introduction to Medicaid
Cost Based School Based
Health Services
Total Number of Students Receiving
Direct Medical Services with an IEP
35
Medicaid Administrative Claiming (MAC)
Additional $
MAC
WV: Introduction to Medicaid
Cost Based School Based
Health Services
36
Medicaid Administrative Claiming (MAC)
•Medicaid Outreach
•Facilitating Medicaid Eligibility Determination
•Direct Medical Services
•Translation Related to Medicaid Services
•Program Planning, Policy Development and
Interagency Coordination Related to Medicaid
Services
•Medicaid related training
•Referral, Coordination, and Monitoring of
Medicaid Services and Documentation
$ County’s
costs for
billable services
– excluding IDEA
Results of
RMTS
(statewide) –
% #Medicaid
Eligible/
#Special Ed.
Same
participants
Rate billed for
SLP, PT, OT,
PSY, RN, AUD
Rate billed for
Care Coor. –
(Treatment
Planning?)
Rate billed for
Personal Care
Aides
COUNTY BUDGET FOR IDEA and State Aid - FY 2012_ _
ENTER ALLOCATIONS
5 Digit
Program
Function
Code
3 Digit
Object
Code
IDEA School Age (321)
Description
S PECIAL EDUCATION - PERS ONNEL
List each position by FTE and type of position, including exceptionality if
applicable; and program function code. Fixed charges may be aggregated.
21210
21210
21210
21210
21282
21271
22721
22134
22142
5 Digit
Program
Function
Code
111
121
121
121
121
111
121
111
111
Don’t bill Med.
1.0 multi-catagorical teacher
5 1.0 primary paraprofessionals
5 1.0 middle paraprofessionals
3 1.0 high school paraprofessionals
1.0 pre-school special needs paraprofessionals
.5 1.0 teacher of the gifted
1.0 bus aide
.10 school nurse
3 0.50 school psychologists
S ub Total S pecial Education Personnel
3 Digit
Object
Code
$997,309.00
43-2-1
IDEA Preschool
(3-5)
43-2-2
$103,471.00 $1,145,995.00
State Aid
$28,255.00
$34,000.00
$34,130.00
$5,065.00
$97,845.00
$545,055.00
$28,255.00
IDEA Preschool
(3-5)
Total Budget for
This Line Item
02-2-1
$54,584.00
$143,916.00
$124,315.00
$85,200.00
IDEA School Age (321)
Description
$45,215.00
$34,000.00
State Aid
$54,584.00
$143,916.00
$124,315.00
$85,200.00
$28,255.00
$34,000.00
$34,130.00
$5,065.00
$97,845.00
$607,310.00
Total Budget for
This Line Item
S PECIAL EDUCATION - S ERVICES
2xxxx
22150
21273
21223
22161
22162
21219
151
341
341
341
341
112
contracted speech
orientation & mobility trainer
vision specialist
occupational therapy services
physical therapy services
extended school year services
Don’t bill Med.
REMAINING IN ALLOCATION
$15,000.00
$2,000.00
$10,000.00
$70,135.60
$15,000.00
$8,000.00
#REF!
$2,536.71
#REF!
$16,890.00
#REF!
$0.00
$15,000.00
$2,000.00
$10,000.00
$89,562.31
$15,000.00
$8,000.00
$0.00
$0.00
$0.00
#REF!
Online Strategic Plan
Maintenance Of Effort (MOE)
State/Local
In a cost-based system,
Medicaid reimbursement will
cover the costs of providing
special education and healthrelated services to Medicaid
eligible students.
http://wvde.state.wv.us/osp/medicaid.html