school-based medicaid cost settlement system august 31, 2012

SCHOOL-BASED MEDICAID COST SETTLEMENT SYSTEM

August 31, 2012

C e n te rs fo r M ed ic a r e & M ed ic a id S e rv ic es

M e d i ca r e M e d i ca i d S C H IP H IP A A P u b lica t io n s L o ca l In fo rm a tio n S ta ts & D a ta R e se a rc h & D em o s L a w s & R eg s P u b lic A ffa irs A b o u t C M S

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M edicaid

M edicaid is a jointly-funded, F edera l-S tate health

insurance program for certain low-income and needy

people. It covers approximately 36 million individuals

including children, the aged, blind, and/or dis abled, and

people who are eligible to receive federally as s isted

income maintenance payments.

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72.62% 72.62%27.38% 27.38%

Medicaid Program - Jointly Funded - Federal/State

Changes annually per state’s capita income.

Each School District – 1st #

Scheduled Rates

Audiology - $36 per service

Physical /Occupational Therapy - $10 per 15 minutes

Speech Therapy - $7 per 15 minutes Individual session

Nurse - $7 per 15 minutes Individual session - specialized procedure

Psychology - $100 per evaluation

Each School District – 2nd #

Cost-Based Rate Salaries/Benefits

Initial/Triennial IEP - $500 per IEP Annual IEP $100 per IEP Personal Care (full) - $90 per day Personal Care (part) - $45 per day Sp. Trans. Vehicle - $20 per day (round trip) Sp. Trans. Aide - $18 per day (round trip) Care Coordination - $78 per month

1990 2000

RESA LEA

WVDHHR - Molina Processing Agency;Bureau ofMedical Services BMS

Remittance AdviceDenial/pending

Electronic claim

Billing Form or WVEIS Entry

Provide the service: Speech, PT, OT, etc. Progress Notes Attendance Records

Fed Payment – Direct Deposit72.62%

Serves as the Clearinghouse

Historical Approach to School Based Medicaid Programs to 2003

WV: Introduction to Medicaid Cost Based School Based Health Services 6

Fee for Service (FFS)

72.62%

Medicaid Administrative

Claiming(MAC)50%

LEA $ RESA $

• “Compartmentalized” programs with minimal integration• Various compliance issues in both programs

One reason the Federal government proposed to eliminate MAC

RESA LEA



Electronic claim


Supporting Documentation: IEP Progress Notes Attendance Records Care Coordination form


Fed -Medical Administrative Claiming (MAC)

50%

Districts provided 50% (except for

RESA 2)

Each School District – 1st #

Scheduled Rate

Audiology $36 per service

Physical /Occupational Therapy $10 per 15 minutes

Speech Therapy $7 per 15 minutes Individual session

Nurse $7 per 15 minutes Individual session

Psychology $100 per evaluation

Each School District – 2nd #

Cost-Based Rate added Indirect costs

Initial/Triennial IEP $700 per IEP Annual IEP $170 per IEP Personal Care (full) $190 per day Personal Care (part) $95 per day Sp. Trans. Vehicle $26 per day (round trip) Sp. Trans. Aide $22 per day (round trip) Care Coordination $98 per month

1990 2003Direct Services

RESA LEA



Electronic claim


Supporting Documentation: IEP Progress Notes Attendance Records Care Coordination form


Fed -Medical Administrative Claiming (MAC)

50%

Districts provided 100% (except for

RESA 2)

$2,164,052.58

$12,063,984.40

$14,649,453.07

$16,672,684.10

$21,596,755.78

$30,803,857.04

$38,516,237.61$39,366,911.72

$38,312,540.83

$42,233,949.75

$48,341,185.25

1 2 3 4 5 6 7 8 9 10 11

Medicaid Reimbursement for FY 00 through FY 10Series1

•In response to CMS questions, West Virginia is implementing a new reimbursement methodology for school based services, effective July 1, 2012.

•Effective for dates of service beginning July 1, 2012, school based providers will be reimbursed using a cost based reimbursement methodology.

•School based providers will be required to participate in a Random Moment Time Study and complete an annual cost report as part of the new methodology.

• School Based providers will still need to submit Fee-for-service claims for services rendered throughout the year.

•In addition to the changes in the direct services, West Virginia will also be implementing a Medicaid Administrative Claiming (MAC) program to capture administrative costs for activities performed in support of the Medicaid program.

Overview of Program Changes

2012 Approach to School-Based Medicaid Programs

Programs now work together Integrated time study for Medicaid

Administrative Claiming (MAC) and Fee For Service reimbursement

District administrative personnel costs will be included in the cost report and will take part in the time-study to determine what part of their costs is eligible for MAC

The direct service costs (therapists, special education teachers, personal care aides) will be included in the cost report and will take part in the time study to determine what part of their costs is eligible for reimbursement AND determine what responses qualify for MAC.


MAC

50% match

Overview of FFS Cost Reporting Process The purpose of the Medicaid Fee-For-Service (FFS) Program is to provide

reimbursement for medically necessary services that are received in schools and provided or arranged by a school system for Medicaid-eligible students with an Individualized Education Program (IEP)

Services are currently reimbursed according to a mix of cost based and fee schedule

Effective for dates of services beginning July 1, 2012, services will be cost reimbursed and an annual Medicaid cost report must be filed by each LEA Medicaid cost will be calculated through a series of calculations including a

Cost Report, a Random Moment Time Study (RMTS) methodology, Cost Reconciliation and Cost Settlement

Medicaid cost will be compared to Medicaid interim payments for direct services and a settlement will be calculated for each LEA When LEA Medicaid costs exceed Medicaid interim payments, a

settlement will be due to the LEA When LEA Medicaid costs are less than Medicaid interim payments, the

LEA will return the overpayment to MedicaidWV: Introduction to Medicaid Cost Based

School Based Health Services 13

West Virginia Job Categories – Direct ServiceFee for Service (72.62% Fed match)


Job categories and job titles include – 3 different cost “pools”:

1 . WV Licensed Audiologist WV Licensed Occupational Therapist WV Licensed Physical Therapist Speech Language Therapist WV Licensed Registered Nurse WV Licensed Psychologist

2.Personal Care Aide – Personal Care 1:1

3.Special Education Teacher - Care Coordination

Cost Settlement Calculation Example –


1.0 Total Costs of Eligible Direct Services Provider Costs (county’s cost)

$1,000,000

2.0 Indirect Cost Rate 115.00%

3.0 Total Costs of Eligible SBHS Provider Costs $1,150,000

4.0 RMTS Direct Medical Percentage Results (Statewide results) 65.00%

5.0 Direct Medical Services Costs $747,500

6.0 Costs of Contracted Vendors $100,000

7.0 Total Costs of SBHS Provider Costs $847,500

8.0 Application of Medicaid Eligibility Rate (IEP Ratio) (county’s) 50.00%

9.0 Medicaid Direct Medical Services Costs (for the county) $423,750

10.0 Medicaid Payments Received (by the county) $473,750

11.0 Medicaid Cost Settlement (at the end of the year – July 2013) $0

Medicaid Administrative Claiming (MAC) in WV


MAC offers reimbursement for the costs of administrative activities, such as outreach, that support the Medicaid program.

Allowable activities are:

Medicaid outreach and related training Facilitating Medicaid eligibility application Health-related referral activities & monitoring of health service

delivery Medical service program planning, policy development, and

interagency coordination Arranging for Medicaid-related transportation and provision of

Medicaid-related translation

School Based Examples of Activities


Providing information to individuals and families regarding the West Virginia Medicaid program and available services

Scheduling and/or coordinating EPSDT screens or other medical and mental health diagnostic services

Gathering any information that may be required in advance of these referrals

Developing internal plans and strategies to improve health service delivery and eliminate gaps

Attending a parent meeting for a child with issues that may need outside health or counseling services

West Virginia Job Categories – Administrative Costs(50% Federal match) Not cost settled


Job categories and job titles include –

1 . Administrator Principal Special Education Director Assistant Principal Special Education Secretary Program Specialist RESA Medicaid Specialist

Non Allowable Staff


• Staff included in the calculation of the Unrestricted Indirect Cost Rate cannot be included on your staff pool list

– These include costs reported in the following function codes:

• Business Support Services• Plant Operations and Maintenance

– The costs in these function codes are not allowable because the Unrestricted Indirect Cost Rate is used in the calculation of the claim

– Staff who are paid entirely from these function codes should be removed from the staff pool list

– Partially paid staff from allowable object codes can be included

1.0 Total Costs of Administrative Costs (county’s cost) $1,000,000



4.0 Costs of Contracted Vendors (RESAs) not subject to RMTS $10,000

5.0 Total Costs of Administrative Costs $110,000



Administrative Claiming - not billing for direct services

Because RESAs will be treated like other vendor for cost reporting purposes, the RESAs will now need to bill counties just like any other vendor effective July 1, 2012: Hours Worked X Billable Rate.In the past, RESAs may have simply billed a county for a certain percentage of an employee’s salary and fringe benefits, based on a pre-determined agreement with the county. Such an agreement does not take into consideration the fact that the employee does not spend all of their time providing services for the county 9ex. General time spent in the office, continuing education, etc.). The RESAs will now need to develop appropriate billable rates to charge to the counties based on the actual hours spent providing Medicaid reimbursable services.

In terms of determining rates for Medicaid billing services, keeping hourly documentation of time spent for each district and billing accordingly would be the preferred method of calculating the rates.

However, we would be happy to discuss the reimbursement method based on the amount of reimbursement received – with a bit more clarity surrounding the process they would be using, we would be better equipped to provide advice. Please let me know if you would like to arrange for a time next week to discuss this further.

Preliminary Results of 1st RMTSFebruary - March

Response rates – 85% required (3000 moments per “pool”)

» 92.13% - Direct Services» 83.20% - Care Coordination» 78.60% - Personal Care» 89.47% - Admin

Preliminary Results of 1st RMTSFebruary - March

Service percentages responses

» 49.16% - Direct Services» 4.24% (4.15%) - Care Coordination» 20.21% (18.48%) - Personal Care

PCG’s Time Study Team – “less than appropriate responses were submitted.”

A number of inappropriate responses were received by staff participating in the RMTS.

Two areas of concern:

• Incomplete responses• Rudeness/Frustration

Inappropriate Responses to RMTSExample 1: (Would not be coded as Medicaid allowable cost. Needs more detail.)

1. Who was with you?• No one

2. What were you doing?• Duty

3. Why were you doing this activity?• Assigned duty

4. Is this activity regarding a Special Education student?• No

Inappropriate Responses to RMTSExample 2: 1. Who was with you?

• A group of people charged with carrying out the work of an establishment

2. What were you doing?• Inputting the last “moment in time” documentation

instead of using my scheduled paperwork time to prepare for the two IEPs that I have next week.

3. Why were you doing this activity?• You keep sending me these “moments.” I am itinerant

and MCS will not provide me with a computer, IPad, or other internet access to use during treatment blocks of time. Scheduled office time is the only time I can complete these “moments.”

4. Is this activity regarding a Special Education student?• NA

Inappropriate Responses to RMTSIssues that arise from inappropriate responses:

Creates additional administrative burden.

Moment can be incorrectly coded if information is omitted or misleading.• When clarification is not received, moment is likely to

be coded as non-reimbursable.

Reduction in reimbursement• Medicaid reimbursement is tied to the RMTS results• Penalty if 85% response rate isn’t achieved



1.0 Total Costs of Eligible Costs Direct Services (county’s cost) $1,000,000









10.0 Medicaid Interim Payments Received (by the county) $400,000




1.0 Total Costs of Eligible Costs Care Coordination (county’s cost) $1,000,000





6.0 Costs of Contracted Vendors $0



9.0 Medicaid Direct Medical Services Costs (for the county) $23,862.50

10.0 Medicaid Interim Payments Received (by the county) $24,000.00

11.0 Medicaid Cost Settlement (at the end of the year – July 2013) $317.50



1.0 Total Costs of Eligible Costs Personal Care Aide (county’s cost) $1,000,000









10.0 Medicaid Interim Payments Received (by the county) $300,000


Quarterly Staff Pool List Updates


Staff can only be added once a quarter, no one can be added for the quarter after the staff pool list has been submitted (Vendors not included in time study)

Once RMTS is implemented, the staff pool list from the previous quarter should be updated every quarter LEAs can add, remove, or change participants’ information at this

time

If questions arise about the update, PCG will contact the LEA to get clarification

After all staff pool lists have been returned and quality checks completed, PCG will generate state-wide Random Moment Time Study (RMTS) sample

Current Quarter Process


• Pull your staff pool list - be sure to list the Job Title, First and Last Names, Email Address and School Name (optional)

• Provide PCG with the LEA staff pool list the first time – Following the first upload, you will be trained by PCG to

use the online Staff Pool List web-based system

Quarterly Cost Reports - County TreasurersCosts of Direct Services – Audiological, Speech, Occupational, Physical, Psychological, Nurses (RNs) Services

Costs of Care Coordination – Special Education Teachers (of students with disabilities)

Cost of Personal Care – 1:1 Aides

Cost of Administrative Personnel

Cost of Specialized Transportation – Not subject to RMTS

Quarterly Payroll InformationFirst Name

Cost Pool Job Title Employee ID

Total Salary

Total Benefits

Compensation Federal Sources (IDEA)

Net Compensation Expenditures

John Direct Service

Speech Language Pathologist

92001111 $25,000 $3,900 $10,000 $18,900

John Care Coordination

Special Education Teacher

92001112 $39,000 $2,300 $42,300

John Personal Care

Aide 92001113 $12,500 $2,859 $15,359 $0

District’s Specialized Transportation Cost Report

Draft form – will be completed electronically.

District’s Cost Report

Draft form – will be completed electronically.

District’s Quarterly Cost Report

Codes – Accuracy ImportantProject Codes: 43310 – IDEA School-age Funding 43320 – IDEA Preschool Funding

Program Function Codes: 21210 Multi-categorical 2 (Other codes) 2 22161 Occupational Therapy 22162 Physical Therapy etc.

Object Codes: 111 Regular professional (salary) 121 Regular service (salary) 2XX Benefits

RMTS Rosters

Rosters of staff in an Excel Template (PCG) - in August 2012

RMTS – October – December 2012

RMTS – January – March 2012

RMTS – April – June 2012

school-based medicaid cost settlement system august 31, 2012

Documents

school based services

school based providers

iep annual iep

school district

iep personal care

school based medicaid

day personal care

minutes speech therapy