Pennsylvania School-Based
ACCESS Program
Overview for PASBO Members
October 8, 2015
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Agenda
 Program Overview
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Background
Roles and Responsibilities
Participation Requirements
Program Components
Statewide Financial Performance
Business Process & Timeline
Direct Service Claiming
Random Moment Time Study (RMTS)
Medicaid Administrative Claiming (MAC)
Cost Settlement
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PROGRAM OVERVIEW
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Background
• School-Based ACCESS Program (SBAP) provides Medicaid
reimbursement for certain medically necessary health-related
services documented in Individual Education Plans (IEPs) for
students who are MA-eligible.
• 2015-2016 school year marks the 24th year anniversary of the
Pennsylvania SBAP.
• Over 500 Local Education Agencies (LEAs) currently participate in
SBAP: school districts, intermediate units, charter schools and early
intervention programs.
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Background cont.
• Centers for Medicare & Medicaid Services (CMS) conducted a
Financial Management Review of Pennsylvania’s SBAP in 2012
• CMS required significant programmatic changes:
– Cost-based Payment Methodology including Random Moment Time
Study (RMTS) and cost reconciliation
– Discontinuance of billing for IEP meetings and collateral services
– Discontinuance of Approved Private Schools/Chartered Schools for
Deaf and Blind as SBAP providers
• DHS continues to evaluate SBAP to ensure the program is in
compliance
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Roles and Responsibilities
Federal
Medicaid
Oversight
Centers for
Medicare &
Medicaid
Services (CMS)
-Sets Federal
requirements that
must be
implemented on
a state level
Operational &
Project Oversight
Public Consulting
Group (PCG)
-Manages webbased systems
used to accurately
collect required
data
-Assists LEAs with
program
requirements
-Submits LEAs’
claims to Medicaid
State Oversight
PA Department of
Human Services
(DHS) &
PA Department of
Education (PDE)
-Determines
requirements for
Pennsylvania
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Day-to-Day
Operations &
Oversight
Local Education
Agencies (LEAs)
-Manages all
program
requirements at
local level
-Maintains
Compliance
-Documents
Services,
Participates in
RMTS, Provides
Cost Report
Participation Requirements
In order to participate in the SBAP program, LEAs are required
to:
 Enroll in the Pennsylvania MA program as a provider of
SBAP services, following the guidelines and agreements to
participate; and
 Submit direct service claims to Medicaid; and
 Participate in the Random Moment Time Study (RMTS) &
submit quarterly costs (Medicaid Administrative Claim); and
 Complete an annual Cost Report.
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Program Components
School Based ACCESS Program components that drive
reimbursement include:
Direct Service
Claiming: Interim
FAI Payments
Cost Settlement:
Annual
Reconciliation of
Direct Service
Claiming
Random
Moment Time
Study (RMTS)
Quarterly Medicaid
Administrative
Claiming (MAC):
MAC Checks
Total LEA
Reimbursement
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Statewide Financial Performance
140,000,000
$115.8
$133.3M
120,000,000
100,000,000
Total Allowable
Costs for Direct
Claiming
80,000,000
60,000,000
Total Medicaid
Administrative
Claiming (MAC)
40,000,000
20,000,000
0
FY 2012-2013
FY 2013-2014
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PROCESS & TIMELINE
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Program Components & Business Processes
Direct
Service
Claiming
•MA Eligibility
•Direct Service
and Transportation
Logs
•Compliance data
•180-day window
•LEA Specific
Rates
Monthly
Medicaid
Administrative
Claiming
(MAC)
• Submit and Certify
Quarterly Costs
Quarterly
RMTS
• Direct Service
Staff Pool
• Administrative
Service Staff Pool
• School Calendar:
• Start/End Times
• Creating shifts
• Responding to
Moments
Quarterly
SBAP Process Timeline
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Cost
Settlement
• Capture costs
• Direct Medical
Percentage
• IEP Ratio
• Transportation
Ratios
• Unrestricted
Indirect Cost Rate
• Direct Service
Staff Pool Lists
Annually
SBAP Timeline – FY 2015-2016
July 2015
• July - Sept: Quarter 4 Begins
(Inactive Quarter – No RMTS
moments)
• Certify Costs for April-June:
Quarter 3 (MAC Checks)
October 2015
• Oct – Dec: Quarter 1 Begins
• 2014-2015 Annual Cost
Settlement Trainings for LEAs
• Certify Costs for July – Sept:
Quarter 4 (MAC Checks)
• Annual Fall Trainings
August 2015
Open Oct – Dec: Quarter 1 RMTS
Staff Pools and School Calendar
September 2015
• Certify Oct – Dec: Quarter 1 RMTS
Staff Pools and School Calendar
November 2015
• Annual Fall Trainings
• Open Jan – March: Quarter 2
RMTS Staff Pools and School
Calendar
December 2015
• Deadline for LEAs to Certify 20142015 Cost Reports
• Certify Jan – March: Quarter 2
RMTS Staff Pools and School
Calendar
January 2016
• Jan – March: Quarter 2 Begins
• Certify Costs for Oct – Dec:
Quarter 1 (MAC Checks)
February 2016
Open April – June: Quarter 3 RMTS
Staff Pools and School Calendar
March 2016
• Certify April – June: Quarter 3
RMTS Staff Pools and School
Calendar
April 2016
• April – June: Quarter 3 Begins
• Certify Costs for Jan – March:
Quarter 2 (MAC Checks)
May 2016
Release Reconciliation for LEAs to
submit 2014-2015 Cost Settlement
CPE Forms
June 2016
• Deadline for LEAs to submit 20142015 Cost Settlement CPE Forms
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DIRECT SERVICE BILLING –
Monthly
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Direct Services
Services are provided or purchased by LEAs
enrolled in the Medical Assistance (MA)
Program to MA-eligible beneficiaries under 21
years of age for whom the service is medically
necessary and documented in the IEP.
Services must be face-to-face to be
compensable
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Direct Services cont.
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Assistive Devices
Audiology Services
Hearing-Impaired Services
Nursing Services
Nurse Practitioner Services
Occupational Therapy
Services
• Orientation, Mobility and
Vision Services
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Personal Care Services
Physical Therapy Services
Physician Services
Psychiatric Services
Psychological Services
Social Work Services
Special Transportation
Services
• Speech and Language
Services
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Tracking Reimbursement
As claims are processed by Medicaid/PROMISe, LEAs
can track approved and denied claims via PCG’s
Reports:
Claims
Processing
 Monthly Management Reports
o Distributed monthly via PCG’s EasyTrac System
o Shows claims submitted/paid/pending on monthly basis
o Shows year to date, and year to year performance
4-6 weeks
o Shows Exceptions (missing compliance data)
 FAI Summary Report
o Shows Payments, Withdrawals, Vendor Fees
o Does not currently show LEA current balance
o Does not reflect funds held by an IU
o Does not reflect MAC claims payments (paper checks
are sent directly to LEA)
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Important Reminders
 DHS Requirement for all Providers – 180 days from date of service to bill
Medicaid
 Capture all services delivered to all eligible students as soon as possible. What
is your LEA internal policy?
 LEA is responsible to review any third party providers/vendors entering
claims “on behalf of” LEA.
 The LEA should regularly review service log status: what logs have been
captured; imported into PCG’s EasyTrac System; status of exception data?
Provide any missing compliance data quickly.
 LEA receives interim payments in FAI account for Paid Claims
 Services are billed to DHS using each LEA’s gross billing rate. If those claims
are approved, they are multiplied by the current FMAP rate to determine the net
interim payment that is then deposited into the LEA’s FAI account.
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RANDOM MOMENT TIME STUDY
(RMTS) – Quarterly
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RMTS
What is the purpose of RMTS?
The Random Moment Time Study (RMTS) methodology is
used to select, capture and code moments in time for
determining on a statewide basis how frequently
participants are involved in a Medicaid billable activity.
RMTS results are used to:
• Develop the Direct Medical Percentage used in the Cost Settlement
Process
• Develop each participating LEA’s quarterly MAC reimbursement
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RMTS cont.
 Prior to the beginning of each quarter, the RMTS SBAP
Coordinator for each participating LEAs must:
o Submit a school calendar for the upcoming quarter (for quarters 1 – 3)
o Submit (or update) a staff pool list (for quarters 1 – 3)
o 4th Quarter is a “non-active” quarter
 Each quarter 3,000 moments are randomly selected (statewide)
o Direct Service cost pool
o Administrative Support cost pool
 All staff receiving a “moment” must respond (5 days)
o Participating LEAs’ goal is 100% response rate
o Statewide response rate needs to be 85% or greater
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Quarterly Staff Pools
 Each LEA’s quarterly Staff Pool List (or, roster) is comprised
of two cost pools:
o Direct Service cost pool must include:
All qualified service providers (e.g. PT, OT, SPL, etc.) who are
providing health-related services to your students where these
services are billed (or could be billed) to Medicaid for cost
reimbursement
o Administrative Support cost pool can include:
“Rule of thumb” is that any staff who (is NOT a direct service provider)
who spends 50% or more of their time (on a typical day) working in
or supporting your Special Education program
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MEDICAID ADMINISTRATIVE
CLAIMING (MAC) – Quarterly
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MAC
 MAC Claims – Submitted & Paid Quarterly
o LEA to enter actual, allowable costs on a quarterly basis
o 30 days to submit quarterly costs (cash basis)
o Once actual costs have been captured and reviewed, and a
MAC claim amount calculated, each participating school
receives a Certification of Public Expenditure (CPE) letter
that must be signed & returned within 10 days. Any letter
received after that deadline would delay payment until the
following quarter
o Participating schools who are entitled to receive a MAC claim
payment will receive a paper check (Note: MAC payment dollars
are never deposited in the school’s FAI account)
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COST SETTLEMENT – Annually
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Cost Settlement Process
What is Cost Settlement?
Cost settlement is the annual reconciliation of
reimbursement of each LEA’s interim payments for direct
service claiming as compared to each LEA’s total Medicaid
allowable costs.
Since SBAP utilizes a cost-based reimbursement
methodology, LEAs cannot receive more than their
Total Medicaid Allowable Costs.
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Cost Settlement Calculation – How it Works
1. District provides their cost data
2. Cost Settlement methodology produces these outcomes:
o NET Medicaid Allowable Costs
o NET Medicaid Interim Payments
3. Cost Settlement result
o When an LEA’s net Medicaid allowable costs exceed its net interim
payments, the LEA will receive a payment for the difference
o When an LEA’s net interim payments exceed its net Medicaid allowable
costs, the LEA must repay the difference
NOTE: Cost Settlement does not include quarterly MAC payments that the
LEA has received during the school year.
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Cost Settlement Paybacks
Common reasons for “pay back” result:
o
The salary and benefit costs for all direct service providers (employees
and contractors) have NOT been included on your quarterly Staff Pool
Lists, therefore, all eligible costs could not be included in your cost
settlement process
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Even when the salary and benefit costs for all service providers have
been captured in the LEA’s Cost Report, in order for them to be included
in your cost settlement process, the LEA must have received
reimbursement for each health-related category they bill to Medicaid.
Otherwise, those costs are EXCLUDED from your Medicaid cost
settlement calculation.
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Cost Settlement Tool and Trainings
• Cost Settlement Estimation Tool
 Allows LEAs to use its costs, its interim payments and previous year’s
statewide ratios, to estimate cost settlement outcome
 Provides estimates only – does not provide final cost settlement
calculations for LEAs
• Cost Settlement Annual Training Webinars
 Dates of 2014-2015 cost settlement webinars:
Day
Tuesday
Wednesday
Monday
Tuesday
Friday
Thursday
Wednesday
Wednesday
Date
10/13/2015
10/21/2015
10/26/2015
11/3/2015
11/6/2015
11/19/2015
12/2/2015
12/16/2015
Time
2:00 pm
10:00 am
1:00 pm
3:00 pm
10:00 am
1:00 pm
3:00 pm
10:00 am
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Contact Information
Becky Ludwick
School-Based ACCESS Program Director
Department of Human Services
Phone: (717) 787-5512
Email: rebludwick@pa.gov
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Additional Resources
SBAP 101
http://www.publicconsultinggroup.com/
client/paaccess/SBAP101.html
SBAP Trainings/Webinars
http://www.publicconsultinggroup.com/
client/paaccess/calendar.html
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Questions?
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