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

W ELCOM OME ! ! September 16, 2014 2:00-5:00 PM The Conference & Event Center Niagara Falls, NY I NTR TION TO TO S CHOOL -B ASED ED TRODUCTI M EDI DICAID (T (T HE HE A CADEM DEMY ) T ODAY ’ S S CHED EDULE 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 O BJECTI VES CTIVES A T THE END OF OF THIS A CAD 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. 1

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. 2

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. 3

Medicaid 9/5/2014 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. NAME Academy 2014 2 Participants will Understand:  The Governing Tenets of Medicaid  The Medical Model  Section 1905(a) Services  Reimbursement NAME Academy 2014  3 1

Medicaid 9/5/2014  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. NAME Academy 2014 4  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 orary y Assis istance for Needy Families ilies (TANF). NAME Academy 2014 5  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. NAME Academy 2014 6 2

Medicaid 9/5/2014  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) NAME Academy 2014 7  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. NAME Academy 2014 8  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. NAME Academy 2014 9 3

Medicaid 9/5/2014  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. NAME Academy 2014 10  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. NAME Academy 2014 11  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 on, 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 . NAME Academy 2014 12 4

Medicaid 9/5/2014  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. NAME Academy 2014 13 NAME Academy 2014 14 sort: All other legally liable  Payor of Last Reso 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. NAME Academy 2014 15 5

Medicaid 9/5/2014  Statewide: The benefits of the State Plan must be uniform throughout all geographic areas of the state. ability: Services must be “equal in  Comp mpar arab amount, scope, and duration” for all beneficiaries, but can be greater for certain groups (e.g., EPSDT recipients) NAME Academy 2014 16  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. NAME Academy 2014 17  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. NAME Academy 2014 18 6