IdahoSchool-Based Services

State by State Commonality = Federal Regulations and Guidance

1988; Congress amended the Social Security Act to allow Local Education Agencies (LEA) to access Medicaid federal funds for some “health related services”

Services that are reimbursed by Medicaid must be listed in the Medicaid statute (section 1905(a) of the Social Security Act) and must be included in the state plan

Schools can receive Medicaid payment for medical services provided to children under Individuals with Disabilities Education Act (IDEA) through a child’s Individualized Education Plan (IEP).

Federal guidance: Health related services included in an Individual Education Plan (IEP) can be reimbursable if all state and federal statutory and regulatory requirements are met, the services are identified in the state plan, and the services are medically necessary

To receive federal matching dollars for medical services the state must have a federally approved state plan

There is no benefit category in the Medicaid statute or state plan titled “school health services”; services, regardless of location, must be identified in the state plan State plan includes:

Eligibility groups and standards Services provided Service requirements Payment rates Amount Duration Scope

*Resources for this information can be found in the *CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997) Link can be found at www.sbs.dhw.idaho.gov

Once You Know One Medicaid Program……….You Know One Medicaid Program

The school-based committee spent several years collaborating to identify Medicaid

reimbursed services in the school that meet the needs of the children on IEP’s in Idaho. The following is a condensed list of collaborative activities regarding school-based services (SBS) and rules:

How We Got Here

Date Target Group Activity August, 2010 School-based Medicaid Committee Discussed the impact to school-based services due to children’s system redesign  School districts/Special Education Directors Webinar posted on how children’s system redesign impacts to schoolsJanuary, 2011 School-based Medicaid Committee Identified SBS workgroup members to work on changes to services/IDAPAFebruary, 2011 School-based Medicaid Workgroup Began workgroup to develop proposal for Centers for Medicare and Medicaid Services

(CMS). The workgroup met 6 full days  School-based Medicaid Committee

SBS workgroup presented the draft proposal, Received feedback from the committee  School-based Medicaid Committee

Committee approved SBS proposal/Submitted SBS proposal to CMS  School-based Medicaid Committee Discuss CMS feedback and service options to the committeeMarch, 2012 School-based Medicaid Committee Shared research from other states  School-based Medicaid Committee Discuss new service options and timelines based on CMS feedbackApril, 2012 School-based Medicaid Workgroup Developed behavioral intervention/consultation services  School-based Medicaid Committee Workgroup presented recommendations for intervention/consultation to the committeeJune, 2012 Families, providers, and community Negotiated Rulemaking Meeting: School-based replacement services

Idaho Association of Special Education Administrators (IASEA) Presentation of the proposed school-based service rules at the annual IASEA conference

January, 2013 Legislature/Public Idaho Administrative Code proposed changes presented by Medicaid: State Department Of Education spoke in support of proposed rules

Idaho Medicaid encourages public and charter schools

to become Medicaid providers so that they can receive Medicaid reimbursement for health related services they are providing to children who are eligible

  Idaho Medicaid also wants to assure that schools who

are receiving reimbursement for health related services are in compliance with federal and state regulations

WHY…………..?

Federal and State Rule Compliance

US Department of Health and Human Services’ concern of school-

based services billings On March 9, 2011, Inspector General testified before a US Senate subcommittee that series of audits over past decade identified improper federal Medicaid payments for school-based health services.

FFY 2013 Work Plan - will review Medicaid payments for school-based services in selected states to determine whether costs claimed for services are reasonable and properly allocated.

Idaho’s CMS Regional Auditor identified school-based services as a priority

Special Study: School-based Services Overview: Medicaid Program Integrity March 5, 2013

Federal Concerns over School-based

Services

Maine (4/2013)

Recommended Repayment of $667,569 Claims were not in accordance with Federal & State

Requirements Lack of adequate documentation to support services

provided Unqualified providers

New Hampshire (10/2012) Recommended Repayment of $2,700,000

Transportation services

* Resources for OIG Reports can be found at: www.oig.hhs.gov

Office of Inspector General Audit Reports

Colorado (4/2012)

Recommend Repayment of $871,246 Claims were not reasonable, allowable and/or

adequately supported.

New Hampshire (1/2012) Recommended Repayment of $494,738

Providing Health services that were not reimbursable Overbilling for services Lack of adequate documentation to support services

provided

* Resources for OIG Reports can be found at: www.oig.hhs.gov

Office of Inspector General Audit Reports

New Jersey (4/2010)

Recommended Repayment of $8,079,312 Lack of documentation to support services provided Lack of referral or prescription for services Unqualified Providers Services provided not documented in IEP

Arizona (3/2010) Recommended Repayment of $21,288,312

Overbilling Lack of documentation Unqualified Providers Unallowable Transportation Lack of referral for services Eligibility not met* Resources for OIG Reports can be found at: www.oig.hhs.gov

Office of Inspector General Audit Reports

Services Provided Idaho Kansas Oregon Colorado Washington Montana Iowa Utah Nevada Wyoming Alaska Texas Kentucky Maryland

OT X X X X X X X X X X X X X

PT X X X X X X X X X X X X X

SLP X X X X X X X X X X X X X

Audiology X X X X X X X X X X

Personal Care X X X X X X X

Nursing X X X X X X X X X X X X

Transportation X X X X X X X X

Interpretive Services X X

Medical Equipment X X X

Behavioral Therapy/Intervention

X X X

Behavioral Health Services

X X X X X X X X X X X X

Psychological/ Counseling

X X X X X X X X X X X X

Targeted Case Management

X X X X

Physician Services X X

Orientation and Mobility Services

X X

Other Services: X X X X X

EPSDT X X X X X X X X X X X X X X

Medicaid Reimbursable Services Provided in Schools

by State

Approximate annual cost of School Based

Services Approximate number

of studentsApproximate annual

cost per student

Iowa $36,000,000 4,500 $8,000

Rhode Island $22,000,000 9,500 $2,315

Idaho $26,400,000 13,231 $1,993

Kansas $24,500,000 12,500 $1,960

Oregon $5,800,000 7,000 $828

New York $44,000,000 75,000 $587

Arizona $22,500,000 39,000 $577

California $124,000,000 225,000 $551

New Jersey $21,500,000 43,000 $500

Colorado $5,600,000 11,310 $494

Indiana $2,900,000 8,000 $363

Washington $5,500,000 18,031 $303

Nevada $1,050,000 3,998 $263

Montana $2,600,000 13,500 $193

Virginia $8,200,000 120,000 $68

SBS Medicaid State Comparison 2010-2011

Virginia

Montana

Nevada

Washington

Indiana

Colorado

New Jersey

California

Arizona

New York

Oregon

Kansas

Idaho

Rhode Island

Iowa

$0

$500

$1,0

00

$1,5

00

$2,0

00

$2,5

00

$3,0

00

$3,5

00

$4,0

00

$4,5

00

$5,0

00

$5,5

00

$6,0

00

$6,5

00

$7,0

00

$7,5

00

$8,0

00

$8,5

00

Annual Average Cost Per Student

2010-2011

By Comparison, Idaho ranked 3rd out of 15 states for the highest annual average cost per student

Approximate annual cost of School Based

Services

Approximate number of students

Approximate annual cost per

student

Idaho $23,303,109 13,676 $1,704

Colorado $8,105,642 12,328 $658

Washington $8,119,192 17,765 $457

2011-2012 State Comparison

FEDERAL CITATION

SERVICE DESCRIPTION

42 CFR 440.50

physicians’ services and medical and surgical services of a dentist

“services furnished by a physician (or a doctor of dental medicine or surgery for a dentist) within the scope of practice of medicine or osteopathy as defined by state law and by or under the personal supervision of an individual licensed under state law to practice medicine or osteopathy”

42 CFR 440.60

medical or other remedial care provided by licensed practitioners

“any medical or remedial care or services provided by licensed practitioners within the scope of practice under state law.” This category is used by states to cover such services as psychologist services and nursing services other than those nursing services specifically identified in the Medicaid statute and regulations (such as private duty nursing, home health nurses or nurse practitioners).

42 CFR 440.90

clinic services “preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished by a facility that is not a part of a hospital but is organized and operated to provide medical care to outpatients.” The services must be furnished under the supervision of a physician or dentist, in a facility which meets the state’s definition of a clinic.”

42 CFR 440.100

dental services “diagnostic, preventive or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession.”

42 CFR 440.110

physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders.

“Physical and occupational therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under the state’s law and must be provided by or under the direction of a qualified licensed physical therapist or occupational therapist. Services for individuals with speech, hearing or language disorders means diagnostic, screening, preventive or corrective services provided by or under the direction of a speech pathologist or audiologist, for which the patient is referred by a physician or other licensed practitioner of the healing arts. It includes any necessary supplies or equipment.”

42 CFR 440.130(a)

diagnostic services “any medical procedures or supplies recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under state law, to enable him or her to identify the existence, nature or extent of illness, injury or other health deviation in a recipient.”

42 CFR 440.130(c)

preventive services “provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability, and other health conditions or their progression; to prolong life and promote physical and mental health and efficiency.”

Federal Regulations for Services

*This chart is not necessarily all-inclusive, and while it indicates the general Federal Medicaid regulatory requirements, schools should check with their state Medicaid agency to determine any additional or specific state requirements. *Resources for this information can be found in the CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)

FEDERAL CITATION

SERVICE DESCRIPTION

42 CFR 440.130(d)

rehabilitative services

“any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his or her best possible functional level.” This optional benefit category is used to cover both mental health and substance abuse services and may include assessments, individual, group and family counseling, therapies, psychosocial rehabilitation services, living skills training, drug abuse treatment, medication monitoring and crisis intervention.”

42 CFR 440.170(a)

transportation services

(Please see the Transportation section of the guide for more specific information on transportation and school-based services).

42 CFR 440.166 nurse practitioner services

“furnished by a registered professional nurse who meets the state’s advanced educational and clinical requirements, if any, beyond the 2 to 4 years of basic nursing education required.”

42 CFR 440.166 Private duty nursing services

“for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or skilled nursing facility.” These services are provided by a registered nurse or licensed practical nurse under the direction of a physician, usually in the beneficiary’s home. However, the nurse is permitted to be taken into the community (such as when the child attends school) with the beneficiary if his or her normal life activities take the beneficiary out of the home and the services have been prescribed by the physician for primary use in the home.”

Section 1905(a)(24) of the Act (soon to be published ate 42 CFR 440.167)

personal care services

“These services are authorized for an individual by a physician in accordance with a plan of treatment or otherwise authorized by the state in accordance with a service plan approved by the state, and may be provided in a home or other location (however, not in a Medicaid-funded inpatient facility) by an individual qualified to provide such services, who is not a member of the individual’s family.”

Section 1905(a)(4) (c) of the Act and 42 CFR 441.20

family planning services

“supplies for children who are of childbearing age, including minors who can be considered to be sexually active and desire such services and supplies. These include services to aid those who voluntarily choose not to risk an individual pregnancy or who wish to control family size. Federal Medicaid law limits coverage of abortion. In general, family planning services are matched at a higher FFP rate of 90%.”

Federal Regulations for Services

*This chart is not necessarily all-inclusive, and while it indicates the general Federal Medicaid regulatory requirements, schools should check with their state Medicaid agency to determine any additional or specific state requirements. *Resources for this information can be found in the CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997)

Managed/ Oversight ALL services are managed

by Licensing RulesPhysician

Recommendation

Idaho Desk Reviews (optional in 2014); MPI Audits; Medicaid technical assistance; Statewide trainings every 2 years;

No Yes

Washington

Managed Care: Minimum of 10 school-based Medicaid program reviews annually. Schools must submit the following annually: All health care professionals, copies of new health

care professionals licenses

Yes No

Texas Managed Care: Commission-administered time study; schools submit expenditure reports quarterly; schools submit

annual cost reports

Yes Yes (for OT, PT, SLP)

Kentucky Managed Care: Schools must apply to be providers annually; all schools receive an annual review; Site surveys;

all schools must conduct a peer review (10% of students) annually

Yes Must have Physician

involvement

Utah Periodic time/cost studies No Yes 

Nevada Fiscal agent provides trainings, medical review, audit and handling disputed payments

 Yes Yes 

Oregon The department has 2 school based policy staff that provide annual trainings and extensive reviews:

Yes No

Alaska Managed Care: Facility site reviews and develops corrective action plans

No No

Montana Managed Care: Fiscal and clinical compliance audits Yes Yes (for unlicensed professionals

and nursing)

California Managed Care: Trainings and audits Yes  Yes(for OT, PT, SLP and Nursing)

Colorado The Department has 2 school based policy staff that provide annual audits of all school districts

Yes  No 

Kansas Monitor through the fiscal agent surveillance review (Physician’s orders and supporting documentation)

Yes Yes

Medicaid Reimbursed School Based Services

Federal Guidance: Providers must follow federal and state

regulations to receive federal matching dollars. School-based Medicaid services has been identified as

high priority by CMS Compliance is necessary to avoid outcomes as

identified in OIG audit reports Extensive amount of collaboration took place prior to the

final rules effective date of July 1, 2013. State Comparison: Apples to Oranges: Each state has

their own federally approved state plan that identifies the standards and requirements for the services that are reimbursable in their schools.

Financial Comparison: Idaho Medicaid continues to demonstrate a high level of annual cost per student as compared to other states.

In Summary….

Frede’ Trenkle-MacAllister Alternative Care Coordinator, BDDS, Medicaid (208) 287-1169 TrenkleF@dhw.idaho.gov

Shannon Dunstan Early Childhood and Interagency Coordinator Idaho State Department of Education (208) 332 – 6908 (office) sdunstan@sde.idaho.gov

We are here for you!

CMS – Medicaid and School Health: A Technical Assistance Guide (August 1997) www.oig.hhs.gov

Kansas: Kansas Health Policy Authority

http://www.kdheks.gov/hcf/program_improvements/downloads/School-Based-Services-032210.pdf http://www.ksde.org/Portals/0/SES/funding/medicaid/medicaid-SchoolBasedFactSheet.pdf

NAME survey/education and Research Committee https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/LEA_01132014_14010.pdf

Montana: Montana Department of Public Health and Human Services:

http://medicaidprovider.hhs.mt.gov/pdf/manuals/schools052013.pdf NAME survey/education and Research Committee

Oregon: Linda Williams, Division of Medical Assistance Programs, Policy Analyst NAME survey/education and Research Committee

Colorado: Shannon Huska, Colorado Department of Health Care Policy and Financing, School Health Services Program Administrator The Department of Health Care Policy and Financing, Colorado, Annual Report

http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1251579136390

Washington: Jim Harvey, Washington State Health Care Authority, School-Based Health Care Services Program Specialist Washington State health care authority:

http://www.hca.wa.gov/medicaid/billing/documents/guides/schoolbasedhealthcareservices_bi_03102013-12312013.pdf

Resources/References

Indiana:

NAME survey/education and Research Committee

Virginia: NAME survey/education and Research Committee

New Jersey: NAME survey/education and Research Committee

Iowa: NAME survey/education and Research Committee :   http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/localedu.pdf

Rhode Island: NAME survey/education and Research Committee http://www.ritap.org/sites/default/files/Medicaid/guidebook.pdf

Arizona: NAME survey/education and Research Committee

California: NAME survey/education and Research Committee http://www.dhcs.ca.gov/provgovpart/pages/lea.aspx http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp

New York: NAME survey/education and Research Committee

Resources/References