Medicaid in Education
Settings – What Every SLP
Needs to Know
Janet Deppe, CCC-SLP
Director, State Advocacy
jdeppe@asha.org
Overview; Topics we’ll cover
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History of Medicaid
Funding Flow ChartsFederal/State/Local Medicaid Programs
Federal Requirements
Early and Periodic Screening and
Diagnosis and Treatment Services
(EPSDT)
Overview Topics (cont)
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Administrative Claiming
Medicaid and IDEA
State Medicaid Plans
Documentation and OIG Audits
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Preventing billing errors
Accessing Medicaid $$
Overview Topics (cont)
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Medicaid Funding Success Stories
Resources
History of Medicaid
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Federal-state matching entitlement
program for low income families
57 million Americans, 28 million children
and 8.6 individuals with disabilites
served (Herz 2005)
$287 billion in Medicaid benefits (2004)
$168 billion (federal) and $119 billion
(state)
History of Medicaid (cont)
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Program originated in Title XIX of the
Social Security Act of 1965
Early Periodic Screening Detection and
Intervention (EPSDT) added in 1967
1988 Catastrophic Medicaid Act allowed
for billing in schools
Funding of Medicaid
Programs
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Medicaid funding is mandatory – IDEA
funding is discretionary
Administered according to State
Medicaid Plan
Two programs: medical assistance
(ma), administration (admin)
50-83% matching rate for ma, 50%
(admin)
Flow of Medicaid Funds to Your School District
Congress appropriates funds annually based on the federal fiscal year beginning
on October 1st. Funds go to the U.S. Department of Health and Human Services
Dollars are received at U.S. Dept. of Health and Human
Services and are administered by the
Centers for Medicare and Medicaid (CMS)
Funds are put in the state’s account at the Federal level and the state draws down the
funds as needed.
• Funds are allocated to each state to match state expenditures for the cost of medical assistance
(i.e., Medicaid is a federal-state matching system.)
• Medicaid’s federal matching rates, or Federal Medical Assistance percentages (FMAPs), are
determined by a formula tied to state per capita income. According to the Kaiser Commission on
Medicaid and the Uninsured, on average the federal matching rate is 57% of the costs of Medicaid
benefits (Medicaid Resource Book, July 2002)
Dollars Received At State Level
• State may or may not require LEAs or school districts to bill for Medicaid services.
• If schools do participate, a system for billing is established:
• States are not required to return all money generated by the schools back to the schools.
It depends on state laws and regulations. (For example, a state may retain a percentage for
administrative costs; a private vendor may retain a percentage.)
Flow of Medicaid Funds to Your School
Dollars Received At the Local Level
• Medicaid revenue, if received by the school district (see above) is placed into the school budget
and allocated as per state and/or local policy. Some states have specific requirements for how a
local district must use funds.
• Examples of how local school districts use Medicaid revenue: special education; general fund;
health services; equipment/supplies; professional development; hiring staff; return funds to
program that generated the revenue; purchase of technology for staff; creation of new special
education programs.
• Some states place restrictions on how local school districts may use Medicaid revenue. Examples:
may only be used for educational purposes and shall not be made available to local communities
for purposes other than education; may not be used to supplant funds currently being spent on
health and social services; must be used within the special education program; may not be
transferred to the district’s general fund.
Teachers and Related Services Providers
Funding reaches teachers and related service providers based on
how local school district allocates the Medicaid revenue
(see above)
Students
Students benefit based on how district allocates Medicaid revenue .
Federal Medicaid
Requirements
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Individual must be enrolled in Medicaid
Service must be covered in state plan
Schools:
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child referred by physician
SLP/A must have CCC or equivalent
SLP/A must maintain appropriate documentation
including dates of service, name of recipient,
person providing service, duration, medical
justification and group vs. individual treatment
EPSDT
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Requires states to provide screening
for vision, dental, and hearing services
Provide assessment of communication
skills or language development
focusing on expression,
comprehension, and articulation
EPSDT ( cont)
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Based on results states must provide
services necessary to treat or
ameliorate deficits, illnesses or
conditions
Administrative Claiming
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Besides payment for services (medical
assistance), school districts can receive
Medicaid reimbursement for:
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Identification and enrollment of eligible
students
Direct support to the provision of health
care services
Individual members have little access to
administrative claiming funds
Medicaid and IDEA funding
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Is this double dipping?
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No, Federal IDEA funds partially cover
therapy services
Medicaid must be primary to IDEA funds
for health-related services
Medicaid vs. IDEA funding – See:
http://www.asha.org/practice/reimburseme
nt/medicaid/IDEAMedicaid.htm
State Medicaid Plans
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States are required to outline plan
Centers for Medicare and Medicaid
(CMS) reviews plan for conformity to
Federal regulations
Must offer services that are medically
necessary
State Medicaid Plan
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Each state has the authority to
establish:
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Eligiblity standards
Determine type, amount and frequency of
services
Set rates and administer the program
State Medicaid Plan
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What does your state plan include:
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Collateral services
Transportation costs
In addition to direct health related services
Medicaid fee schedule state-by-state
KS Provider Home Page
https://www.kmap-stateks.us/Public/provider.asp
Kansas Medical Assistance Program
https://www.kmap-state-ks.us/
Documentation and the Office of
Inspector General (OIG) audits
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20 state Medicaid school-based programs
were audited between 2001-2010. See
findings at:
http://www.asha.org/practice/reimbursement
/medicaid/oig_reports.htm
Areas of concern to SLP/A
 Provider qualifications
 Documentation
 Each of the audits recommended refund of
federal payments
Recent Audit Results (2010)
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AZ and NJ audit results were released in
early 2010
Arizona billed the federal government
$32,212 for school-based Medicaid
services (1/04-6/06)
Based on OIG findings, it was
recommended that $21.3 million be
refunded due to the following reasons;
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Services not provided or overbilled
Recent Audit Results (2010)
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Based on OIG findings, it was
recommended that AZ refund $21.3
million. The following reasons were
cited:
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Services not provided or overbilled
Documentation requirements not met
SLP provider requirements not met
Lack of Prescription/referral
Student eligibility requirements not met
Recent Audit Results (2010)
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NJ findings were similar: The OIG
sampled claims from 7/03 through
10/06. Of the 100 school-based claims
49 compiled with federal and state
requriements and 51 did not. 19 claims
had more than one deficiency. The OIG
recommended that NJ refund
$8,079,312 to the federal government
Recent Audit Results (2010)
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Deficiencies were found in 4 areas:
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Claims had services not provided
Claims lacked a referral or prescription
Claims did not meet federal provider
qualifications
Claims were made for services not
documented in the child’s plan
Commonly Cited Billing Errors
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Lack of appropriate referral
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Lack of Qualified Providers
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Can be a physician or a qualified
practitioner of the healing arts including
SLPs
Use of BA level practitioners without
supervision
Lack of or incomplete documentation
Prevention of Billing Errors
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Ensure that a referral from an approved
provider is obtained (An IEP alone is not an
acceptable substitute for a referral)
Ensure that child meets Medicaid eligibility
Demonstrate that a qualified provider
(maintain license or CCC) is used or
document that the provider is under the
supervision of a qualified SLP
Prevention of Billing Errors
(con’t)
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Ensure that time study forms represent
actual activities performed
Provide adequate documentation
including: Name of recipient, medical
justification, dates of service, person
providing service (include credentials,
ie., CCC), duration, and group vs.
individual therapy
Where does the Medicaid
money go?
Several states deposit in general fund
 Others to Special Education budget
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$$$ to districts does not guarantee access by SLP
program
Some to SLP budget
To Advocate for $$ to SLP or Special
Education budget you need to know:
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% to the district from the state
% to Spec Ed
% ( if any) to the SLP program
Accessing Medicaid funding
Assess your needs (what will
the monies be used for)
 Know the decision makers
 Be proactive: Know what you
want and how to get it
 Gain support of administrators
and the unions
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Accessing Medicaid Funds
(cont)
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Advocate for funds for materials and
supplies, or back to providers as a
bonus or for additional time worked
Know % of students who are Medicaid
eligible (on income and/or disability)
Know how much money district SLPs
generate for the district
Medicaid funding success
stories
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All SLP Medicaid funds go to SLP budget
Pittsburgh Public Schools
Salary increase based on additional work
completing Medicaid documentation;
Minneapolis Public Schools
View successes at:
http://www.asha.org/about/legislationadvocacy/schoolfundadv/default
Resources:
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Center for Medicare and Medicaid
directory of state plans:
www.cms.hhs.gov/medicaid/consumer.
asp
ASHA’s Medicaid reimbursement
resources:
http://www.asha.org/members/issues/r
eimbursement/reimbur-default
Resources
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ASHA Summary of OIG reports:
http://www.asha.org/practice/reimbursement
/medicaid/SchoolBasedServicesSLP.htm
Medicaid funding success stories:
http://www.asha.org/about/legislationadvocacy/state/advocacy-schools.htm
School Finance Committee Medicaid
Resources:
http://www.asha.org/advocacy/schoolfundad
v/default.htm
Questions ????