Medicaid Reimbursement


CT School-Based Medicaid Billing “Past, Present and the Future”

March 1, 2013

Presented by Pam Katz, CompuClaim Mid-Atlantic Regional Director

Presentation Overview

Opening remarks

History of Medicaid School Based Child Health Program

CT SBCH Program

Maximizing Reimbursement Opportunities

Medicaid Compliance

Cost Reports

Reconciliation and Settlement

Recent Changes to SBCH program

Five Keys to Success

History of the Medicaid School Based Child Health Program

Medicaid was signed into law on July 30,1965.

• • • • In 1975 IDEA was passed to ensure children with disabilities receive a (FAPE) free appropriate public education in the least restrictive environment .

Students received medical services in school by qualified health professionals.

Initially Medicaid did not pay for IEP related services, as they fell under educational services.

1988 Congress recognized the fiscal burden placed on schools and passed a law to make Medicaid funds available for certain health care services for students with disabilities. This law created what is now known as the School Based Child Health program (SBCH).

CMS SBCH Guidelines

At the National level, CMS (Centers for Medicare and Medicaid) oversees, reviews and assesses States SBCH Administrative and Direct Claiming programs in accordance with applicable federal Medicaid law and regulations. • CMS works closely with each State Medicaid agency. In Connecticut it is the Department of Social Services (DSS). Each State is responsible for the operation of its Medicaid program. The Department of Education works closely with the state Medicaid agency for policy and technical assistance.

• CMS provides the framework for State Medicaid programs and each state establishes and administers its Medicaid program within this framework.

• Medicaid programs vary considerably from state to state, and states regularly revise their own Medicaid programs.

States have a great deal of flexibility in how they design and administer the SBCH Medicaid program. Within the scope of broad federal regulations each state decides:

Who is eligible for services

• •

Who can provide services What services are allowable

CT SBCH Program

• • • • • CT changed from Bundled rate to Fee for Service in 2010. – How has this affected districts revenue?

Interim rates the completion of cost reconciliation and settlement which the district supplies on a yearly basis.

rates began in Oct. 2010 are provisional in nature , pending Direct Billing for services deemed medically necessary and are included in a student’s IEP Some administrative services can be claimed in the cost report with proper documentation. These are not considered claimable as direct billing .

CT DSS is currently negotiating with CMS on changes that may impact the CT SBCH program. Districts will be informed of all directives from DSS to ensure that all rules and regulations are being followed. CT State Plan and matrix outlines all eligible services and qualified providers.

Maximizing Medicaid Reimbursement Opportunities

Maximize Claiming Opportunities

District plan to ensure that all services are being claimed through a well designed plan.

– • • • •

Under billed Services Out of District Billing Evaluations Nursing Services

Medicaid Compliance

Documentation that districts must maintains to ensure compliance.

• Providers licensure – • Signature on file licenses and certification must be maintained by district copy of providers signatures must be documented • IEP documentation - student is identified to receive “medically necessary services” this serves as the student’s prescription • Student Attendance • Provider Attendance • Billing/service records • Monthly progress – what therapeutic activity was given how the student responded to the service in relationship to the goals in the IEP • Parental consent – new guidelines from DSS and the Dept. of Education

Reconciliation and Settlement

Cost Study –

2011 (desk review – June 2013 settlement due) • • •

Administrative Costs –Administrative salaries –

(must provide support to Medicaid program)

Include transportation costs reflective of IEP

(monitors can only be claimed if one on one is indicated in Student’s IEP) •

Documentation requirements from districts includes:

Data collections, district snap shots, employee universe and random time studies.

Recent Changes to SBCH

Parental Consent – in order for a district to participate in the SBCH program beginning March 18, 2013 parental consent and parental notification must be obtained for the district to submit claims for Medicaid reimbursement. Guidelines and regulations will be sent to the school district regarding how parental notification and consent will be obtained to meet the new guidelines. The Department of Education will be working with DSS to ensure that districts will be following all necessary guidelines.

Durable Medical Equipment – For the 2011 and 2012 cost report DME has been removed from calculations. Districts were notified NOT to include this cost from their ED001 reports and not to provide additional documentation at this time.

Transportation - Districts should be able to document that the actual transportation coincides with a “medically necessary service” provided on the same day of transportation.


Can drivers and monitors salaries and fringe benefits be included for

transportation costs? Districts that have provided this information may be asked to submit documentation for a desk review. Monitors must be indicated as providing one on one services in student’s IEP.

Five Keys to Success

1. On-going oversight to ensure all services are being captured in a timely manner.

2. Establishment of a quality Medicaid billing and oversight program. 3. Holding all staff accountable.

4. Being compliance ready.

5. Tracking and integrating changes to the SBCH program.

SBCH Qualified Providers

• • These providers must meet the qualifications in accordance with services as defined by CGS ( Connecticut General Statutes ) and acting within his or her scope of practice under Connecticut State Law. The following providers have been approved in the Connecticut SBCH program to provide “medically necessary services” that are part of a student’s IEP program.

Audiologist, Audiologist Assistant, Hearing Instrument Specialist, Chiropractor, Naturopath, Physician, Podiatrist, Respiratory Therapist, Optometrist, Nurse Practitioner, Registered Nurse, LPN, Psychiatrist, Psychologist, Social Worker, School Counselor, Speech Pathologist, Speech Assistant, Physical Therapist, PT Assistant, Occupational Therapist, COTA ( Certified Occupational Therapist Assistant )

Assistants must be supervised by a qualified licensed provider who will oversee services being provided that are part of the student’s IEP. All services that are provided must be signed off and documented in student’s file.

SBCH Eligible Services

• The following services have been approved by SBCH and are the current Connecticut State plan based on a matrix from Massachusetts.

Services must be documented in the Student’s current IEP plan and are provided by licensed providers who meet all state regulations and are acting within his or her scope of practice under Connecticut State law.

• • • • • • • • • • Audiology Clinical Diagnostic Laboratory Services Mental Health Services (Psychological and Counseling Services) Nursing Services Occupational Therapy Physical Therapy Respiratory Care Services Speech/Language Optometric Services Assessments – the identification and assessment of health related needs for medical services for the purposes of determining educational recommendations

• • • • • • • • •

Medicaid Nomenclature

CMS – Centers for Medicare and Medicaid DSS DAS SBCH – Department of Social Services Department of Administrative Services The Connecticut School Based Child Health program (referred as SBS –school based health services in other States) HP Hewlett Packard is the fiscal agent for the State Districts are required to enroll in the SBCH program and apply for NPI(National Provider Identifier)Number OIG Office of Inspector General – (Audits) HIPPA Health Insurance and Portability and Accountability Act ( maintains the security and privacy of health data) FERPA Family Educational Rights and Privacy Act – allows a school to disclose information from a students educational records.

FMAP - Federal Medical Assistance Percentages In CT – 50% these are the percentage rates to determine the matching funds for each State’s Medicaid programs

Helpful Links

• National Alliance for Medicaid in Education (NAME): • Center of Medicare / Medicaid Services (CMS): • Federal Medical Assistance Percentage (FMAP):

• HIPAA Privacy and Security Rules: • HIPAA versus FERPA Privacy Protections and Student Health Records: • • OIG homepage:

Contact Information

Pam Katz Director, Mid Atlantic Region CompuClaim 304 Main Street #415 Norwalk, CT 06851 [email protected]

203-856-6124 Peter Carson President CompuClaim 221 Third Street Newport, RI 02840 [email protected]

401-849-4702 ext. 120