Idaho SchoolBased Services Once You Know One Medicaid

Idaho School-Based Services

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

How We Got Here 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: 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 schools January, 2011 School-based Medicaid Committee February, 2011 School-based Medicaid Workgroup Identified SBS workgroup members to work on changes to services/IDAPA Began workgroup to develop proposal for Centers for Medicare and Medicaid Services (CMS). The workgroup met 6 full days School-based Medicaid Committee Discuss CMS feedback and service options to the committee March, 2012 School-based Medicaid Committee Shared research from other states School-based Medicaid Committee Discuss new service options and timelines based on CMS feedback April, 2012 School-based Medicaid Workgroup Developed behavioral intervention/consultation services School-based Medicaid Committee Workgroup presented recommendations for intervention/consultation to the committee June, 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 Legislature/Public Idaho Administrative Code proposed changes presented by Medicaid: State Department Of Education spoke in support of proposed rules January, 2013 SBS workgroup presented the draft proposal, Received feedback from the committee Committee approved SBS proposal/Submitted SBS proposal to CMS

Federal and State Rule Compliance 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 Concerns over School-based Services US Department of Health and Human Services’ concern of schoolbased 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 schoolbased 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

Office of Inspector General Audit Reports 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

Medicaid Reimbursable Services Provided in Schools by State Services Provided Idaho Kansas Oregon Colorado Washington Montana Iowa Utah Nevada Wyoming Alaska Texas Kentucky Maryland OT X X X X PT X X X X SLP X X X X Audiology X X X X Personal Care X X X Nursing X X X Transportation X X X Interpretive Services X X Medical Equipment X X X Behavioral Therapy/Intervention X X Behavioral Health Services X X X Psychological/ Counseling X X X Targeted Case Management X X X X Physician Services X Orientation and Mobility Services X X Other Services: X X X X X EPSDT X X X X

SBS Medicaid State Comparison 2010 -2011 Approximate annual cost of School Based Services Approximate number of students Approximate annual cost per student 4, 500 $8, 000 Iowa $36, 000 Rhode Island $22, 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 75, 000 $587 Arizona $22, 500, 000 39, 000 $577 California $124, 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

Annual Average Cost Per Student 2010 -2011 Iowa Rhode Island By Comparison, Idaho ranked 3 rd out of 15 states for the highest annual average cost per student Idaho Kansas Oregon New York Arizona California New Jersey Colorado Indiana Washington Nevada Montana Virginia $0 $500 $1, 000 $1, 500 $2, 000 $2, 500 $3, 000 $3, 500 $4, 000 $4, 500 $5, 000 $5, 500 $6, 000 $6, 500 $7, 000 $7, 500 $8, 000 $8, 500

2011 -2012 State Comparison 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

FEDERAL CITATION Federal Regulations for Services 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. ” *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 Regulations for Services FEDERAL CITATION SERVICE 42 CFR 440. 130(d) DESCRIPTION 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%. ” *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)

Medicaid Reimbursed School Based Services Managed/ Oversight ALL services are managed by Licensing Rules Physician Recommendation Desk Reviews (optional in 2014); MPI Audits; Medicaid technical assistance; Statewide trainings every 2 years; No Yes 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 Managed Care: Commission-administered time study; schools submit expenditure reports quarterly; schools submit annual cost reports Yes 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 Periodic time/cost studies No Yes Nevada Fiscal agent provides trainings, medical review, audit and handling disputed payments 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 California Managed Care: Trainings and audits Colorado The Department has 2 school based policy staff that provide annual audits of all school districts Yes No Monitor through the fiscal agent surveillance review (Physician’s orders and supporting documentation) Yes Idaho Washington Texas Kentucky Utah Yes (for OT, PT, SLP) Yes (for unlicensed professionals and nursing ) Kansas Yes (for OT, PT, SLP and Nursing)

In Summary…. 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.

We are here for you! Frede’ Trenkle-Mac. Allister Alternative Care Coordinator, BDDS, Medicaid (208) 287 -1169 Trenkle. F@dhw. idaho. gov Shannon Dunstan Early Childhood and Interagency Coordinator Idaho State Department of Education (208) 332 – 6908 (office) sdunstan@sde. idaho. gov

Resources/References 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-School. Based. Fact. Sheet. pdf NAME survey/education and Research Committee https: //www. kmap-state-ks. us/Documents/Content/Provider%20 Manuals/LEA_01132014_14010. pdf Montana: Montana Department of Public Health and Human Services: http: //medicaidprovider. hhs. mt. gov/pdf/manuals/schools 052013. pdf NAME survey/education and Research Committee Oregon: Colorado: Linda Williams, Division of Medical Assistance Programs, Policy Analyst NAME survey/education and Research Committee 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/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: Virginia: NAME survey/education and Research Committee Iowa: NAME survey/education and Research Committee : http: //www. dhs. state. ia. us/policyanalysis/Policy. Manual. Pages/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 New Jersey: 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