OME ! ! September 16, 2014 2:00-5:00 PM The Conference & - - PDF document

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WELCOM

OME!

!

September 16, 2014 2:00-5:00 PM The Conference & Event Center Niagara Falls, NY

INTR

TRODUCTI TION TO TO SCHOOL-BASED ED

MEDI

DICAID

(T (THE

HE ACADEM DEMY)

2:00-2:10 Overview, History and Purpose 2:10-2:50 Medicaid 2:50-3:30 Special Education 3:30-4:00 Break 4:00-4:30 Integrating Medicaid and Special Education 4:30-5:00 Discussion and Q & A

TODAY’S SCHED

EDULE

AT THE END OF

OF THIS ACAD ADEMY,

, YOU WILL BE

BE ABLE TO TO: 1. Describe at least three of the primary features of the Medicaid Program that are pertinent to all states in the country. 2. Explain at least three of the primary features of the federal IDEA law as it applies to Special Education programs in the country’s public schools. 3. Discuss three considerations for developing a school-based billing program. 4. Learn some fun facts about Niagara Falls.

OBJECTI

CTIVES VES

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The Niagara Falls are visited by around 30 million people every year. It is illegal to go over Niagara Falls. Although several people have tried anyway, very few have survived to tell about it. Annie Edson Taylor was the first person to go over the Falls in a barrel and survive.

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The Niagara Falls State Park is the oldest state park in the United States (1885).

In 2012 Nik Wallenda became the first person to cross the Niagara Falls by tightrope in 116 years. He was required to receive permission from both the Canadian and US Governments and to present his passport upon entry into Canada.

Medicaid 9/5/2014 1

Melinda Hollinshead, Ph.D.

Arizona Health Care Cost Containment System (AHCCCS)

Niagara Falls, NY

September 16, 2014

Participants will be able to:

1) Describe at least three of the primary features of the Medicaid School Based Services (SBS) Program that are pertinent to all states in the country. 2) Explain at least three of the primary features of the federal IDEA law as it applies to Special Education programs in the country’s public schools. 3) Discuss three considerations for developing a school-based billing program.

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Participants will Understand:

 The Governing Tenets of Medicaid  The Medical Model  Section 1905(a) Services  Reimbursement

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Medicaid 9/5/2014 2

• In 1965, Congress enacted Title XVIII

II (Medic icare) and Title e XIX (Med edic icaid id) of the Social Security ACT

• Medicaid designed as an Entitlement Program,

where individuals under specified income levels, as well as defined “categoricals”, were deemed to be entitled to coverage.

• Medicaid remains the largest source of medical

and/or health related funding for the indigent population.

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• As established under Title XIX, Medicaid was

intended as a cooperative program funded by both federal and state governments, with the proportion of federal to state funds, known as Feder eral l Financia ial l Partic icipation ion (FFP), determined by formula based on changes in State Per Capita

• Income. (Section 1905(b).
• Originally meant as an entitlement for the aged,

blind, and disabled individuals, and families that qualified for Aid to Famil ilies ies with Dependen ent Children en(A (AFD FDC) C), now known as Tempor

• rary

y Assis istance for Needy Families ilies (TANF).

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• In 1972, federal law created Supplement

ntal Secur urity y Income (SSI SI) as a cash benefit for the aged, blind and disabled poor. Recipients became automatically covered as a “categorical group up” in most states.

• The federal government has significantly

expanded Medicaid eligible populations by mandating that benefits be provided to additional groups.

• Originally Medicaid was primarily cost-based for

institutional providers and fee-for-service (FFS) for individual providers.

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Medicaid 9/5/2014 3

• Other significant Legislative actions

have included:

• 1965 – The Early and Periodic Screening,

Diagnosis, and Treatment Act (EPSDT)

• 1975 – The Education for All Handicapped

Children Act (now Individuals with Disabilities in Education Act (IDEA))

• 1988 – Amend Title XIX to add Section

1903(c) (c) of the Act

• 2004 – Individuals with Disabilities

Education Act.

• 2010 – Affordable Care Act (ACA)

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• In the 1990s many states started to examine

alternative approaches and funding mechanisms to relieve state budget restrictions and to expand scopes of Medicaid coverage.

• This led to many Revenue Maximization, Upper

Payment Limit, Disproportionate Share, and other funding initiatives.

• In 1997 the State Children’s Health Insurance

Program (CHIP) was enacted as Title XXI of the Social Security Act.

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• The intent of CHIP was to cover children in families

with incomes below 200% FPL or 50% more than the state eligibility threshold.

• Each state had the option to use their CHIP funds

to cover children in regular Medicaid, or to create a new and separate program.

• The next great expansion of the Medicaid program

is as a result of the 2010 enactment of the Patient Protection n and Affordable Care Act, known as the ACA or Health h Care Reform.

• Implementation of ACA began on January 1, 2014.

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Medicaid 9/5/2014 4

• Designed as a joint venture and a

partnership between state and federal government.

• Has moved toward a state administered

federal program.

• Has its own culture and logic.
• Designed as an acute care, episode driven

model – i.e., the Medical Model.

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• Medicaid is primarily regulated at the federal

level and administered at the state level.

• The framework for Title XIX is established, in

general terms, through laws, regulations, policies and guidelines.

• This framework sets parameters for eligibility

standards, coverage and scope of benefits, delivery models, etc.

• Within these parameters, each state selects the

scope of its own Medicaid program.

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• All elements of the selected state program

must be demonstrated to meet all limitations and guidelines that are establis ished ed by Federal l law, regulation

• n, and

polic icy y – and practic ice. e.

• State programs are administered in

accordance with an Approved State Plan, a comprehensive written description of the unique state design.

• Approved State Plan serves as a contract

between the state and CMS.

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Medicaid 9/5/2014 5

• The Centers for Medicare and Medicaid Services

(CMS) has been delegated by the Secretary of Department of Health and Human Services (DHHS) S) to oversee approval and implementation of state plans, as well as any amendments or changes.

• CMS operates through 10 Regional Offices, with

each state within a Region assigned a CMS State Representative.

• State plans contain detailed descriptions of: the

state agency organization structure, service detail, assurances related to compliance with federal rules and regulations, and eligibility groups.

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• Payor of Last Reso

sort: All other legally liable

private coverage and government program sources must meet their obligation to pay claims for medical services. Medicaid will generally deny claims determined to be the responsibility of other payors, or do a “pay and chase” with Third Party y Liability y (TPL) systems.

• Free Care Exclu

clusio sion: n: Medicaid funds

generally may not be used to pay for services that are offered free to everyone.

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Medicaid 9/5/2014 6

• Statewide: The benefits of the State Plan

must be uniform throughout all geographic areas of the state.

• Comp

mpar arab ability: Services must be “equal in

amount, scope, and duration” for all beneficiaries, but can be greater for certain groups (e.g., EPSDT recipients)

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• States are required by law and regulation to

take all reasonable measures to ascertain the legal liability of third parties to pay for care and services made available under the State Plan.

• TPL is a required function of the Single State

Agency under the Medicaid State Plan.

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• Once the state has made a determination

that a liable third party exists for a claim, then the state is required to either “cost avoid” or “pay and chase.”

• Cost

st avoid idanc nce – the service provider is required to bill and collect from liable third parties before submitting a claim to Medicaid.

• Pay and Chase

se – Medicaid pays the claims then attempts to recover payment from liable third parties.

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Medicaid 9/5/2014 7

• In 1988, the U.S. Supreme Court issued a

decision in the case of Bowen vs. Massachusetts, 487 U.S. 879.

• In this decision, the Court ruled that school

districts may receive Medicaid reimbursement for health services provided to Medicaid eligible special education students.

• Subsequent to the decision, Congress

amended Title e XIX of the Act through the Medic icare e Catastrop

• phic

ic Cover erage Act of 1988 88.

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(c) Nothing in this title shall be construed as

prohibiting or restricting, or authorizing the Secretary to prohibit or restrict, payment under subsection (a) for medical assistance for covered services furnished to a child with a disability because such services are included in the child’s individualized education program established pursuant to part B of the Individuals with Disabilities Education Act or furnished to an infant or toddler with a disability because such services are included in the child’s individualized family service plan adopted pursuant to part C of such Act.

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• The federal government participates in (reimburses

states for) a portion of their Title XIX expenditures, which is called FFP FFP.

• CMS mandates that expenditures be classified as

either Admini nistration or Direct Servi vices.

• Admini

nistrative ve expenditures are reimbursed at 50% Match Rate by the feds.

• Direct Services are reimbursed at the Federal

Medical Assistance Percentages (FMAP) rate, which is a formula derived from the state’s per capita income relative to all states, and varies between 50% and 83%.

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Medicaid 9/5/2014 8

• The Individuals with Disabilities Education

Act (IDEA) of 2004 mandates that children with disabilities have access to a “free and appropriate public education,” including special education and “related services.”

• Under IDEA, the purpose is to assist a child in

special education with the supports necessary to meet the child’s needs.

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• To be Medicaid eligible, services must be included

among those listed in Section n 1905(a) of the Act.

• Services must be included in the regular State Plan,

which is available to all Medicaid recipients, or

• r be

made available under EPSD SDT in the State Plan, which makes services available to children under 21.

• Since there is no category of benefits titled “School

Health Services,” the SBS services must be described in terms of the specific item in Section n 1905(a).

• Allowable services must be prescribed in the IEP.

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Covered services include:

• 1905(a

(a)( )(4)(B (B): “early and periodic screening, diagnostic, and treatment services (as defined in subsection (r)) for individuals who are eligible under the plan and are under the age

• f 21;”

Where Section 1905(r) lists: (1) Screening Services (2) Vision Services (3) Dental Services (4) Hearing Services

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Medicaid 9/5/2014 9

• 1905(a)(5) “Such other necessary health care,

diagnostic services, treatment, and other measures described in section 1905(a) to correct

• r ameliorate defects and physical and mental

illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.”

• 1905(a)(6): “medical care, or any other type of

remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law.”

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 Physical therapy  Occupational Therapy  Speech, Hearing and Language Services  Audiology  Personal Care Services  Nursing  Transportation  Case Management  Rehabilitative Services

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• Providers of services submit claims to the

Medicaid Agency for services rendered on behalf of Medicaid eligible recipients.

• In the School Based Services arena, the

Educational Agency is generally the provide der to Medicaid, and submits a reimbursement claim to Medicaid.

• Claims submitted are usually of the format

Units of Service x Rate Per Unit.

• Some units are time based and some a event

based

• i.e., reimbursed by Medicaid on a Fee basis

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Medicaid 9/5/2014 10

• How the rate per unit is calculated

determines the type of reimbursement system:

• Medicaid Program Fee for Service (FFS

FFS) based on a Fee Schedule.

• Community Rate
• Cost Based Reimbursement
• There are also two separate components to

the Total Costs of School Based Services:

• Direct Medical Services
• Administrative Claiming

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• Through the School Year (State Fiscal Year (SFY))

services are billed to and reimbursed from Medicaid using an Interim Rate applied to the Units of Service.

• At the end of the SFY, costs are determined based on

data provided through an annual cost reporting and calculation process, and the actual costs are then applied to the total interim payments paid to the school district to determine Total Allowable Annua nual Costs.

• If Total Annual Costs are greater than Interim

payments made, then there is a settlement made to the provider. If Total Costs are less than Interim payments made, the difference is recaptured by the Medicaid Agency.

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• The only approved method for allocating costs to

allowable health services is a Random Moment Time Study (RMTS).

• Under the governing formulation, there are also

threshold response rates required to maintain the “validity” of the sampling method.

• In gener

neral, only those individuals who are included in the RMT MTS may have their cost included in the annual cost report.

• Allowable costs must then be further allocated

based on those services recommended in an IEP.

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Medicaid 9/5/2014 11

• Defining, determining, and calculating

actual total cost

• Need for cross departmental coordination

and cooperation

• Audit Issues and Requirements

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• RMTS issues:
• Response rates
• Quality of responses
• Capturing appropriate personnel
• Commitment of resources

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Melinda Hollinshead, Ph.D. Medicaid School Based Claiming Division of Fee For Service Management AHCCCS 701 E. Jefferson St., 8200 Phoenix, Arizona 85034 602-417-4746 Melinda.Hollinshead@azahcccs.gov

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9/5/2014 1

Part 2: Special Education

September 16, 2014 Elaine Lerner, New Jersey Department of Education

1

Objectives for Today

Participants will be able to:

1) Describe at least three of the primary features of the Medicaid School Based Program that are pertinent to all states in the county. 2) Explain at least three of the primary features of the Federal IDEA law as it applies to Special Education programs in the country’s public schools. 3) Discuss three considerations for developing a school-based billing program.

2

Goals for Part 2, Special Education

Participants will be able to:

Explain Special Education laws at the Federal and State Level. Identify case law which had an effect on Special Education. Compare and contrast programs and services provided through Special Education and Medicaid.

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9/5/2014 2 Navigating the Laws at the State and Federal Level

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Federal and State Laws

Constitutional law- Is the body of law dealing with the distribution and exercise of government power by Congress or state legislature Statutory law- Enacted laws become statute Regulatory Law- Implementation of the constitutional law and statute Case Law- Court decisions have an effect on practices and legislation.

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IDEIA/IDEA

The Individuals with Disabilities Education Improvement Act of 2004 (IDEIA) Title 1- Amendments to the Individuals with Disabilities Education Act (IDEA)

Part A-D of the IDEA (20 U.S.C. 1400 et seq.)

Part A- General Provision Part B- Assistance for Education of All Children with Disabilities

34CFR Parts 300 and 301

Part C-Infants and Toddlers Part D- National Activities to Improve Education of Children with Disabilities

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9/5/2014 3

Federal Special Education Offices

Special Education Regulations are written and enforced by the US Department of Education

Office of Special Education and Rehabilitative Services (OSERS) Office of Special Education Programs Office of Civil Rights (OCR)- 504 Family Compliance Office (Family Education Rights and Privacy Act/FERPA)

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Travel Back to School Law Class

Case law often excluded students with disabilities from attending school

1893 Massachusetts Supreme Court (Watson v. City of Cambridge) 1919 Wisconsin Supreme Court (Beattie v. Board of Education) 1958 Supreme Court of Illinois (Department of Public Welfare v. Haas)

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Travel Back to School Law Class

1969 State of North Carolina- passed a law making it a crime for parents to have their child with a disability attend school after being excluded from public school.

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Travel Back to School Law Class

Case Law and Legislation

1954 Brown v. Board of Education (separate but equal) 1972 PARC v. Commonwealth of PA (Free appropriate public education-FAPE) 1972 Mills v Board of Ed of the District of Columbia 1973 Section 504 of the Rehabilitation Act of 1973 (Prohibits discrimination in agencies receiving federal funds)

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Travel Back to School Law Class

Case Law and Legislation

1974 P.L. 93-380, Education Amendments of 1974 (FAPE, procedural safeguards, least restrictive environment- LRE, federal funds) 1975 Enacted P.L. 94-142, the Education for all Handicapped Children Act of 1975. (EAHCA)  P.L. 94-142, (FAPE, procedural safeguards, LRE, nondiscriminatory evaluation, Individualized Education Program- IEP)

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Travel Back to School Law Class

Case Law and Legislation

1986 P.L. 99-457, Education of the Handicapped Amendments of 1986 (federal incentives to adopt infant/toddler programs) 1990 P.L. 101-476, Individuals with Disabilities Education Act (revised language and added other disability categories)  P.L. 101-336, Americans with Disabilities Act

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9/5/2014 5

Travel Back to School Law Class

Case Law and Legislation

1997 P.L. 105-17, IDEA 1997 (restructured law and added some provisions) 2004 Individuals with Disabilities Education Improvement Act of 2004- IDEIA (added more provisions and requirements to support students with disabilities)  IDEIA added the consent requirement for Medicaid billing.

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Travel Back to School Law Class

FERPA v. HIPAA

1974 Family Educational Rights and Privacy Act (FERPA) Section 444 of General Education Provision Act, 34 CFR Part 99 (required education records and students’ personally identifiable information to remain confidential and private) 1996 Health Insurance Portability and Accountability Act (HIPAA) (overhaul of third party payor system mostly for health care and implementation of insurance policy.

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US Department of Education Scope

There were 13,600 operating local education agencies in 2011–12 Beginning this fall, local education agencies will be responsible for the education of 49.8 million students, about 1.3 million children are expected to attend public prekindergarten in 2014, and enrollment in public kindergarten is expected to reach approximately 3.7 million students In fall 2014 about 4.1 million public school students will begin 9th grade.

http://nces.ed.gov/fastfacts/display.asp?id=372



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9/5/2014 6 US Department of Education Scope

Public secondary enrollment is projected to show a decrease of 4 percent between 2007 and 2012, and then increase again through 2020. Public secondary school enrollment in 2020 is expected to be about 5 percent higher than in

• 2012. Total public elementary and secondary

enrollment is projected to set new records every year from 2011 to 2020.

http://nces.ed.gov/fastfacts/display.asp?id=65



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US Department of Education Scope

 Public elementary and secondary schools spent about $619 billion for the 2014–15 school year. On average, the current expenditure per student is projected at $12,281 for this school year. Expenditures include salaries for school personnel, benefits, student transportation, school books and materials and energy costs.

http://nces.ed.gov/fastfacts/display.asp?id=372



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US Department of Education Scope

 Federal contribution to public elementary and

secondary schools includes funds from the US DOE, and other federal agencies including the Department of Health and Human Services, Head Start and the Department of Agriculture’s School Lunch Program

http://nces.ed.gov/fastfacts/display.asp?id=372



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9/5/2014 7

US Fiscal Supports for Education

 The Non Defense Discretionary (NDD) Spending for FY 13 for Education and Training was 15% or $88 billion K-12 education accounts for 47% of the spending in this category, primarily for students with disabilities and low-income students. Another 22% of spending in this category include early education, employment, services for children and families, seniors, people with disabilities, and

• thers. (Head Start, Workforce Investment Act.)

http://www.cbpp.org/cms/index.cfm?fa=view&id=3973



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Impact of Funding

 “NDD funding is set to decline over the next decade as a share of the economy. The 2011 Budget Control Act (BCA) set limits or “caps” on annual discretionary funding through 2021, imposing separate caps for defense and non-defense

• funding. Under the caps, NDD spending will fall to

its lowest level as a share of gross domestic product (GDP) on record by 2017, with data going back to 1962, and will continue to fall thereafter.” -Center

• n Budget and Policy Priorities.

http://www.cbpp.org/cms/index.cfm?fa=view&id=3973



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District Features

 Special populations: English language

learners, youth in special education, toddlers, alternative learning centers, deaf, homeless, ….. Special characteristics: small and rural, high- poverty, large and urban, first ring suburbs, tribal schools, Charters, cooperatives, joint powers, … Community in general: school board, culture, principals, special education directors, superintendents, “local control”…



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9/5/2014 8

IDEA Law Divided by Parts- B

 Part B-

Regulation of services for children and youth ages 3 to 21 years State Education Agency is lead agency Parents may not incur costs Interagency collaboration desired Individualized Education Program (IEP) 

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IDEA Law Divided by Parts- C

 Part C- Regulation of services for infants and toddlers ages 0 to 3 years Governor designates a lead agency States are permitted to charge parents Interagency collaboration expected Individualized Family Services Plan (IFSP) 

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Navigating Special Education Regulations

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9/5/2014 9

§300.8 Child with a disability

Has been evaluated according to §300.304 through 300.311 as having:

Mental retardation Hearing impairment (including deafness) Speech or language impairment Visual impairment (including blindness) Serious emotional disturbance Orthopedic impairment Autism Traumatic brain injury Other health impairment Specific learning disability Deaf-blindness Multiple disabilities And, needs special education and related services



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§300.9 Consent

 Parents must:

 Be fully informed of all relevant information, for which consent is sought, in his/her native language, or mode of communication  Understand and agree in writing to activity for which consent is sought including list of records that will be release and to whom  Understand consent is voluntary and may be revoked at anytime  Revocation is not retroactive and does not negate an action that occurred after consent was given and before consent was revoked *several sections in IDEA using phrase ‘consent’ not all are related to Medicaid but this one IS (more later)



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§300.15 Evaluation

Procedures used in accordance with §300.304 through 300.311 to determine if a child has a disability and the nature and extent of the special education and related services the child needs.



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9/5/2014 10 §300.17 Free appropriate public education (FAPE)

Special education and related services that:

Are provided at public expense, under public supervision and direction, and without charge Meet the standards of the SEA Include an appropriate preschool, elementary school, or secondary school education in the State involved Are provided in conformity with an individualized education program (IEP) that meets the requirements of §§ 300.320 through 300.324 

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§300.22 Individualized education program (IEP)

A written statement for a child with a disability that is developed, reviewed, and revised in accordance with §300.320 through 300.324



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§300.23 Individualized education program team

A group of individuals described in §300.321 that is responsible for developing, reviewing, or revising an IEP for a child with a disability.



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9/5/2014 11 §300.28 Local educational agency (LEA)

Any state-recognized public board of education or public authority legally constituted for administrative control or direction of, or to perform a service function for public elementary

• r secondary schools in any political subdivision
• f a State, or combination of school

districts/counties recognized by State as an administrative agency for public elementary or secondary schools



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§300.30 Parent

Biological or adoptive parent of a child Foster parent, unless state law prohibits Guardian generally authorized to act as parent or make educational decision for the child (but not the State if child is a ward of the State) Individual acting in place of biological or adoptive parent (grandparent, stepparent, other relative) with whom child lives, or who is legally responsible for child’s welfare Surrogate parent who has been appointed in accordance with §300.519 

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§300.34 Related services

Transportation and such developmental, corrective, and other support services as are required to assist a child with a disability to benefit from special education and includes:

Speech-language pathology and audiology services Interpreting services Psychological services Physical and occupational therapy Recreation including therapeutic recreation Early identification and assessment of disabilities in children



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§300.34 Related services

(continued) Counseling services including rehabilitation counseling Orientation and mobility services Medical services for diagnostic or evaluation purposes School health services School nurse services Social work services Parent counseling and training



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§300.39 Special education

Specially designed instruction, at no cost to the parents, to meet the unique needs of a child with a disability, including:

Instruction in the classroom, the home, in hospitals and institutions, and other settings Instruction in physical education Specially designed instruction means adapting, as appropriate to the needs of the child, the content, methodology, or delivery of instruction. 

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§300.41 State educational agency (SEA)

The State board of education or other agency

• r officer responsible for the State supervision of

public elementary and secondary schools, or an

• fficer or agency designated by the Governor or

by State law.



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9/5/2014 13 §300.42 Supplementary aids and services

Aids, services, and other supports provided in regular education classes, other education- related settings, and in extracurricular and nonacademic settings, to enable children with disabilities to be educated with nondisabled children to the maximum extent appropriate.



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§300.43 Transition services

Coordinated set of activities in a results-oriented process that helps a child with a disability move from school to post-school activities Is based on each child’s needs, strengths, preferences, and interests Includes instruction, related services, community experiences, development of adult living objectives and if appropriate daily living skills May be special education or part of a specially designed instruction, or a related service if needed to assist a child with a disability benefit from special education 

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§300.101 FAPE Requirements

Available to all children ages 3-21 Each state must ensure FAPE available to any individual child, even though child has not failed, been held back and is advancing from grade to grade



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§300.101 FAPE Requirements

Child Find

All children with disabilities residing in the State including those who are homeless, wards of the State, and those attending private schools, regardless of the severity of their disability, and who are in need of special education and related services are identified, located, and evaluated 

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§ 300.137 (c) Services Plan

Services plan for each child served under Sec. 300.130 through 300.144. If a child with a disability is enrolled in a religious or other private school by the child's parents and will receive special education or related services from an LEA.

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§ 300.137 (c) Services Plan

Initiate and conduct meetings to develop, review, and revise a services plan for the child, in accordance with Sec. 300.138(b); and Ensure that a representative of the religious or

• ther private school attends each meeting. If the

representative cannot attend, the LEA shall use

• ther methods to ensure participation by the

religious or other private school, including individual or conference telephone calls.

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9/5/2014 15

§ 300.137 (c) Services Plan

Each parentally-placed private school child with a disability who has been designated to receive services under Sec. 300.132 must have a services plan* that describes the specific special education and related services that the LEA will provide to the child in light of the services that the LEA has determined, through the process described in Secs. 300.134 and 300.137, it will make available to parentally-placed private school children with disabilities.

(*New Jersey Medicaid does not reimburse for related services as listed in a services plan; does yours?)

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Methods of Ensuring Services §300.154(a)

Establishing responsibility for services Requires an interagency agreement or other mechanism to coordinate between the non- educational public agency (Medicaid Agency) Interagency Agreement must include A method to determine the financial responsibility

• f each agency for providing services to ensure FAPE

The financial responsibility of each non- educational agency, “including the State Medicaid agency” must precede the financial responsibility of the LEA or SEA

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Methods of Ensuring Services §300.154(a)

Interagency Agreement must include (cont’d) The conditions, terms, and procedures under which an LEA must be reimbursed by other agencies Procedures for resolving interagency disputes, including procedures an LEA may initiate, to secure reimbursement from other agencies Policies and procedures for agencies to determine and identify the interagency coordination responsibilities to promote the coordination, timely, and appropriate delivery of services

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9/5/2014 16 Methods of Ensuring Services §300.154(b)

Obligation of non-educational public agencies If a non-educational public agency is otherwise

• bligated under law to provide or pay for services

that are also considered special education or related services, that agency must fulfill the obligation directly or indirectly The Medicaid agency may not disqualify an eligible service for Medicaid reimbursement because that service is provided in a school context.

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Methods of Ensuring Services §300.154(b)

Obligation of non-educational public agencies

If the non-educational public agency fails to provide or pay for a service, the LEA or SEA must provide or pay for the service in a timely manner. The LEA or SEA is authorized to claim payment from the non-educational public agency according to the terms of the interagency agreement.

47

Methods of Ensuring Services §300.154(c)

The requirements of establishing responsibility may be met through

Statute or regulation Signed agreements Other appropriate written methods approved by the Secretary

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9/5/2014 17 Methods of Ensuring Services §300.154(d)

Children with disabilities who are covered by public benefits or insurance

May not require parents to enroll in public benefits

• r insurance programs in order for their child to

receive FAPE May not require parents to incur out-of-pocket expenses such as copays, deductibles, spenddowns,

• r parental fees but may pay the costs parents would

be required to pay

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Methods of Ensuring Services §300.154(d)

Children with disabilities who are covered by public benefits or insurance

May not use a child’s benefits if that use would:

Decrease lifetime coverage Result in the family paying for services that would otherwise be covered by the public benefits or insurance program and that are required for the child outside of school Increase premiums or lead to discontinuation of benefits or insurance Risk loss of eligibility for home and community based waivers, because of aggregate health-related expenditures (Will be interesting to see impact of Affordable Care Act to families)

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Methods of Ensuring Services §300.154(d)

Children with disabilities who are covered by public benefits or insurance

Must obtain parental consent consistent with §300.9

 The new regulations have two basic

requirements :

Notification to parents regarding their rights before benefits are accessed and annually thereafter One time written consent which specifies the parents’ understanding and agreement of accessing public benefits.

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9/5/2014 18 Methods of Ensuring Services §300.154(e)

Children with disabilities who are covered by private insurance

May access private insurance only if the parents provide consent consistent with §300.9 each time the school proposes to access the insurance Inform the parents their refusal does not relieve the school of its responsibility to provide all required services at no cost to the parents

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Methods of Ensuring Services §300.154(f)

Use of Part B funds

If the school can’t get parental consent to use public or private benefits, or insurance when the parents would incur a cost for a specific services required under FAPE, the school may use its Part B funds to pay for the service Schools may use Part B funds to pay for copays, deductibles, and spenddowns Proceeds from public benefits or private insurance are not treated as income Spending Medicaid funds is not considered for purposes

• f maintenance of effort

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Parental Consent

IDEA Part B Final Regulations Related to Parental Consent to Access Public Benefits or Insurance (e.g., Medicaid) On February 14, 2013, the Department published in the Federal Register IDEA Part B final regulations that changed the requirements in 34 CFR 300.154(d) related to parental consent to access public benefits or insurance (e.g., Medicaid). Previously, public agencies were required to

• btain parental consent each time access to public benefits
• r insurance was sought. These final regulations, which took

effect on March 18, 2013, will make it easier for school districts to access public benefits while still protecting family rights.

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9/5/2014 19 Parental Consent

The new rules—

ensure that parents of children with disabilities are informed of all

• f their legal protections when public agencies seek to access public

benefits or insurance to pay for services; and address the concerns expressed by State educational agencies and local educational agencies that requiring parental consent each time access to public benefits or insurance is sought, in addition to the parental consent required by the Family Educational Rights and Privacy Act and section 617(c) of the IDEA, imposes unnecessary costs and administrative burdens.

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Special Education Eligibility

56

Child has a disability IDEA Child’s disability adversely affects his/her educational performance Child is not eligible for special education Child is not eligible for special education Child may be eligible for adaptations under 504 Does child need a related service to benefit from specialized instruction (special education) How much & what type

• f related service does

child need to benefit from specialized instruction Child receives specialized instruction (special education)

YES YES YES YES NO NO NO

How are Medicaid and Special Education Different?

Medicaid

• Funding “unlimited”
• Specific covered services
• Can charge co-pays and

spend-down/deductible

• Audits result in payback
• State administration VERY

prescriptive

• Come to Medicaid to apply
• Rights and responsibilities
• Birth to death, but low

income

• Other insurance must pay first
• Payment for service to

provider

Special Education

• Funding appropriated
• Any services/supports

needed

• Must be free
• Focused monitoring results

in corrective action

• All about local control
• Must find all, even homeless
• Rights
• 0-2, 3-21/22/26
• May not use other ins if

there is cost to parent

• Payment for staff salary,

contracts, materials, etc.

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9/5/2014 20 How are Medicaid and Special Education Similar?

Medicaid

 Treatment, service, or care plan  HIPAA  Case management  Best and evidenced based practice  Provider credentials  Documentation  Early Periodic Screening, Diagnosis, and Treatment

Special Education

 Individualized Education Program, Services Plan  FERPA, HIPAA  Service coordination  Best and evidenced based practice  Highly qualified  Paper work, SPP, data  Early intervening, Child Find, Assessment, Special Ed

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How are Medicaid and Special Education Similar?

Medicaid

 Must serve all who are eligible  Must meet eligibility criteria  Appeals process  Payer of last resort (except education)  Home & CB Waivers  Support children and families of children with special needs

Special Education

 Must serve all who are eligible  Must meet eligibility criteria  Due process  Payer of last resort  Least restrictive environment  Support children and families of children with special needs

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Medicaid Special Education hospice chiropractic inpatient lab x-ray history phys-ed math career counseling reading physical therapy

• ccupational therapy

speech-language-audiology nursing special transportation mental/behavioral health personal care assistance assessment

The Overlap…..

Meducaid

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9/5/2014 21 Contact Information

Elaine Lerner, Education Program Development Specialist New Jersey Department of Education Phone: (609)984-7902 Email: elaine.lerner@doe.state.nj.us

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9/5/2014 1

National Alliance for Medicaid in Education * September 16, 2014 * Niagara Falls, NY

Jennifer Haase Muskegon Area ISD - Michigan

1.

Describe at least three of the primary features of the Medicaid Program that are pertinent to all states in the country.

2.

Explain at least three of the primary features of the federal IDEA law as it applies to Special Education programs in the country’s public schools.

3.

Discuss three considerations for developing a school-based billing program.

AT THE END OF THIS ACADEMY, YOU WILL BE ABLE TO:

SCHOOL-BASED SERVICES: OVERVIEW

The Medicaid School-Based Services Program is a joint venture between the State and Federal Government. Participating schools receive partial reimbursement for medically necessary services provided to eligible children. Participation is voluntary and each state must have their own CMS approved plan. Know and understand YOUR state’s Medicaid Plan. Work closely with your State Department of Education and Medicaid Agency.

9/5/2014 2

SCHOOL-BASED SERVICES: OVERVIEW

Michigan has 56 Intermediate School Districts (ISDs) which serve as liaisons between the state and local districts. The Muskegon Area ISD manages the School-Based Services Program for 11 LEAs, 3 PSAs and one center program. Although each state’s program is unique, the federal requirements are constant and we can learn a great deal from each other. My goal is to provide an overview of School-Based Services and share my experience managing a program.

SCHOOL-BASED MEDICAID REIMBURSEMENT

SCHOOL-BASED SERVICES: $$$ FOR SCHOOLS

Medicaid is the largest single source of ANY kind of federal grant to states. Michigan SBS averages close to $110 Million in reimbursement annually. Total reimbursement for districts served by the Muskegon Area ISD averages between $2 - $2.5 million annually. It’s essential to work with your district administrators to ensure they understand the value of participating in School Based Services!

9/5/2014 3

SCHOOL-BASED SERVICES: PROGRAM

Michigan’s reimbursement program includes both Fee for Service and Administrative Outreach.

 FEE FOR SERVICE provides partial reimbursement to schools for

direct medical services provided to special education students until their 21st birthday.

 ADMINISTRATIVE OUTREACH provides partial reimbursement to

schools for administrative costs incurred while helping families access Medicaid services through the referral, planning and coordination of programs and services.

SCHOOL-BASED SERVICES: PROGRAM

A School-Based Services Program places the bulk of responsibility

• n staff from two main categories:

LEA MEDICAID COORDINATOR (ME) and PROVIDERS (OT, PT, SPEECH THERAPIST, TEACHER, ETC.) Other staff will be involved at different times during the year, but on a much more limited basis.

LEA MEDICAID COORDINATOR

Managing a SBS Medicaid Program can be overwhelming, with many things demanding attention. However, the main responsibilities

• f an LEA Medicaid Coordinator typically fall into the following areas:

PERSONNEL FINANCIAL REPORTING PROGRAM COMPLIANCE

9/5/2014 4

LEA MEDICAID COORDINATOR

Personnel

One of the most important aspects of managing a Medicaid SBS Program is Personnel.



Ensuring they have the proper license, certification, and/or approval in order to participate.



Reviewing the funding source for participating providers to verify they meet the program requirements.



Providing training for new staff, as well as refresher sessions and communicating new requirements.

LEA MEDICAID COORDINATOR

I work with LEAs on the submission of both quarterly and annual financial reports:



Provide information on trainings offered by our state Medicaid vendor.



Review financial reports for accuracy and verify they haven’t omitted costs or included ones that are unallowable.



Compile and submit the Annual Financial Report. In addition, I use the Annual Financial Report to project revenue and review reconciliations, as they are received from the state. Financial Reporting

LEA MEDICAID COORDINATOR

Requirements vary by state - know them! Be aware of changes and monitor for compliance.



Student Documentation – IEPs, Parent Consent, Prescriptions, Medicaid Eligibility.



Provider Claim Submission – Consistent and Compliant.



Quality Assurance Plan Program Requirements

9/5/2014 5

LEA MEDICAID COORDINATOR MEDICAID PROVIDER

Medicaid can be confusing and often-times very frustrating for

• Providers. It is essential for them to understand the program

requirements and their roles.

STUDENT DOCUMENTATION CLAIM SUBMISSION

MEDICAID PROVIDER

Each state functions differently and in Michigan, each ISD has different procedures. Therefore, some of the following may be done by someone other than a Provider. However, ALL are requirements of a SBS Program:

 Student must have a current IEP that

specifically lists a reimbursable service.

 Parent must have signed a Medicaid consent

prior to claims being submitted.

 Prescriptions (if required) must be on file.

Student Documentation

9/5/2014 6

MEDICAID PROVIDER

All staff who participate in Medicaid MUST submit compliant claims on a consistent basis. This requires that the provider:



Receive training (initial and ongoing) on how to submit claims and have access to the electronic system, if applicable.



Regularly and consistently record compliant claims.

Claim Submission

MEDICAID SBS - PROGRAM CHALLENGES

Effectively managing a School Based Services Program is not without challenges! Two of the most common ones I face are BUY-IN BY PROVIDERS and PROGRAM COMPLIANCE.

PROVIDER BUY-IN

Providers often view Medicaid as a complicated program that requires a lot of documentation….and they are right! I often hear about TIME CONSTRAINTS and they usually want to know the BENEFITS OF PARTICIPATION for their district. Providers (and other district staff) don’t always see a direct correlation between the time required to participate and the financial benefit to their district.

9/5/2014 7

PROVIDER BUY-IN: TIME CONSTRAINTS

Providers are being pushed to do more with less and Medicaid seems to fall low on their growing list of priorities. A couple easy ways to help them is to:

 Provide FAQ Documents and Tip Sheets that are position specific.  Send Email updates and newsletters, as needed.

If Providers can receive helpful information quickly and in a format that is easy to understand, they are more apt to be an active participant in the School-Based Services Program.

PROVIDER BUY-IN: BENEFITS OF PARTICIPATION

One of the most common questions I am asked by Providers is how much their district receives from the services they submit. They want to know how much money their service on X date generated. I receive similar questions from Business Offices who question the value of spending time preparing quarterly and annual financial reports. How often and what information you share with Providers and other school staff will have a HUGE impact on the success of your SBS Program. It is essential that ALL staff understand the amount of money schools receive through Medicaid reimbursement.

PROGRAM COMPLIANCE

It is imperative that your School-Based Services Program is compliant and audit ready. It’s not if you will be audited, it’s when!

9/5/2014 8

PROGRAM COMPLIANCE

The School-Based Services Program must be monitored regularly to ensure compliance and it is essential that you are AUDIT READY.



Be aware of and communicate program changes to staff. Network with other Medicaid Coordinators and work closely with your State Medicaid Agency and Department of Education.



Use Quality Assurance File reviews to identify issues and notify districts right away. This allows for corrections to be made and minimizes the risk of an audit finding.



MDCH has been conducting SBS Audits throughout Michigan and they post findings online. This is a valuable tool to identify issues and implement changes before we are audited.

SCHOOL-BASED SERVICES

The School-Based Services Medicaid Program is valuable - especially now during the tough financial situation experienced by many public schools. Understand the requirements for your state, communicate with district staff, monitor for compliance and network with other coordinators!

THANK YOU!

9/5/2014 9

CONTACT INFORMATION:

JENNIFER HAASE

Muskegon Area Intermediate School District jhaase@muskegonisd.org 231-767-7224