medicaid in education settings – what every slp needs to know janet deppe, ccc-slp director, state...
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Medicaid in Education Settings – What Every SLP Needs to Know
Janet Deppe, CCC-SLPDirector, State Advocacy
Overview; Topics we’ll cover
History of Medicaid Funding Flow Charts-
Federal/State/Local Medicaid Programs
Federal Requirements Early and Periodic Screening and
Diagnosis and Treatment Services (EPSDT)
Overview Topics (cont)
Administrative Claiming Medicaid and IDEA State Medicaid Plans Documentation and OIG Audits
Preventing billing errors Accessing Medicaid $$
Overview Topics (cont)
Medicaid Funding Success Stories Resources
History of Medicaid Federal-state matching entitlement
program for low income families 57 million Americans, 28 million
children and 8.6 individuals with disabilites served (Herz 2005)
$287 billion in Medicaid benefits (2004) $168 billion (federal) and $119 billion (state)
History of Medicaid (cont)
Program originated in Title XIX of the Social Security Act of 1965
Early Periodic Screening Detection and Intervention (EPSDT) added in 1967
1988 Catastrophic Medicaid Act allowed for billing in schools
Funding of Medicaid Programs Medicaid funding is mandatory –
IDEA funding is discretionary Administered according to State
Medicaid Plan Two programs: medical assistance
(ma), administration (admin) 50-83% matching rate for ma, 50%
(admin)
Flow of Medicaid Funds to Your School District
Congress appropriates funds annually based on the federal fiscal year beginning on October 1st. Funds go to the U.S. Department of Health and Human Services
Dollars are received at U.S. Dept. of Health and Human Services and are administered by the
Centers for Medicare and Medicaid (CMS)
Funds are put in the state’s account at the Federal level and the state draws down the funds as needed.
• Funds are allocated to each state to match state expenditures for the cost of medical assistance (i.e., Medicaid is a federal-state matching system.)
• Medicaid’s federal matching rates, or Federal Medical Assistance percentages (FMAPs), aredetermined by a formula tied to state per capita income. According to the Kaiser Commission on
Medicaid and the Uninsured, on average the federal matching rate is 57% of the costs of Medicaidbenefits (Medicaid Resource Book, July 2002)
Dollars Received At State Level• State may or may not require LEAs or school districts to bill for Medicaid services.• If schools do participate, a system for billing is established: • States are not required to return all money generated by the schools back to the schools. It depends on state laws and regulations. (For example, a state may retain a percentage foradministrative costs; a private vendor may retain a percentage.)
Flow of Medicaid Funds to Your School
Dollars Received At the Local Level
• Medicaid revenue, if received by the school district (see above) is placed into the school budgetand allocated as per state and/or local policy. Some states have specific requirements for how alocal district must use funds.• Examples of how local school districts use Medicaid revenue: special education; general fund;health services; equipment/supplies; professional development; hiring staff; return funds toprogram that generated the revenue; purchase of technology for staff; creation of new specialeducation programs.• Some states place restrictions on how local school districts may use Medicaid revenue. Examples:may only be used for educational purposes and shall not be made available to local communitiesfor purposes other than education; may not be used to supplant funds currently being spent onhealth and social services; must be used within the special education program; may not betransferred to the district’s general fund.
Teachers and Related Services ProvidersFunding reaches teachers and related service providers based on
how local school district allocates the Medicaid revenue(see above)
Students
Students benefit based on how district allocates Medicaid revenue.
Federal Medicaid Requirements Individual must be enrolled in Medicaid Service must be covered in state plan Schools:
child referred by physician SLP/A must have CCC or equivalent SLP/A must maintain appropriate
documentation including dates of service, name of recipient, person providing service, duration, medical justification and group vs. individual treatment
EPSDT
Requires states to provide screening for vision, dental, and hearing services
Provide assessment of communication skills or language development focusing on expression, comprehension, and articulation
EPSDT ( cont)
Based on results states must provide services necessary to treat or ameliorate deficits, illnesses or conditions
Administrative Claiming
Besides payment for services (medical assistance), school districts can receive Medicaid reimbursement for: Identification and enrollment of eligible
students Direct support to the provision of health
care services Individual members have little access to
administrative claiming funds
Medicaid and IDEA funding
Is this double dipping? No, Federal IDEA funds partially cover
therapy services Medicaid must be primary to IDEA
funds for health-related services Medicaid vs. IDEA funding – See:
http://www.asha.org/practice/reimbursement/medicaid/IDEAMedicaid.htm
State Medicaid Plans
States are required to outline plan Centers for Medicare and Medicaid
(CMS) reviews plan for conformity to Federal regulations
Must offer services that are medically necessary
State Medicaid Plan
Each state has the authority to establish: Eligiblity standards Determine type, amount and
frequency of services Set rates and administer the program
State Medicaid Plan
What does your state plan include: Collateral services Transportation costs In addition to direct health related services Medicaid fee schedule state-by-state KS Provider Home Page
https://www.kmap-state-ks.us/Public/provider.asp
Kansas Medical Assistance Program https://www.kmap-state-ks.us/
Documentation and the Office of Inspector General (OIG) audits
20 state Medicaid school-based programs were audited between 2001-2010. See findings at: http://www.asha.org/practice/reimbursement/medicaid/oig_reports.htm
Areas of concern to SLP/A Provider qualifications Documentation Each of the audits recommended refund of
federal payments
Recent Audit Results (2010) AZ and NJ audit results were released in early 2010 Arizona billed the federal government $32,212 for
school-based Medicaid services (1/04-6/06) Based on OIG findings, it was recommended that
$21.3 million be refunded due to the following reasons; Services not provided or overbilled Documentation requirements not met SLP provider requirements not met Lack of Prescription/referral Student eligibility requirements not met
Recent Audit Results (2010)
Based on OIG findings, it was recommended that AZ refund $21.3 million. The following reasons were cited: Services not provided or overbilled Documentation requirements not met SLP provider requirements not met Lack of Prescription/referral Student eligibility requirements not met
Recent Audit Results (2010)
NJ findings were similar: The OIG sampled claims from 7/03 through 10/06. Of the 100 school-based claims 49 compiled with federal and state requriements and 51 did not. 19 claims had more than one deficiency. The OIG recommended that NJ refund $8,079,312 to the federal government
Recent Audit Results (2010)
Deficiencies were found in 4 areas: Claims had services not provided Claims lacked a referral or
prescription Claims did not meet federal provider
qualifications Claims were made for services not
documented in the child’s plan
Commonly Cited Billing Errors
Lack of appropriate referral Can be a physician or a qualified
practitioner of the healing arts including SLPs
Lack of Qualified Providers Use of BA level practitioners without
supervision Lack of or incomplete documentation
Prevention of Billing Errors Ensure that a referral from an approved
provider is obtained (An IEP alone is not an acceptable substitute for a referral)
Ensure that child meets Medicaid eligibility
Demonstrate that a qualified provider (maintain license or CCC) is used or document that the provider is under the supervision of a qualified SLP
Prevention of Billing Errors (con’t)
Ensure that time study forms represent actual activities performed
Provide adequate documentation including: Name of recipient, medical justification, dates of service, person providing service (include credentials, ie., CCC), duration, and group vs. individual therapy
Where does the Medicaid money go? Several states deposit in general fund Others to Special Education budget
$$$ to districts does not guarantee access by SLP program
Some to SLP budget To Advocate for $$ to SLP or Special
Education budget you need to know: % to the district from the state % to Spec Ed % ( if any) to the SLP program
Accessing Medicaid funding
Assess your needs (what will the monies be used for)
Know the decision makers Be proactive: Know what you
want and how to get it Gain support of
administrators and the unions
Accessing Medicaid Funds (cont)
Advocate for funds for materials and supplies, or back to providers as a bonus or for additional time worked
Know % of students who are Medicaid eligible (on income and/or disability)
Know how much money district SLPs generate for the district
Medicaid funding success stories All SLP Medicaid funds go to SLP budget
Pittsburgh Public Schools Salary increase based on additional
work completing Medicaid documentation; Minneapolis Public Schools
View successes at: http://www.asha.org/about/legislation-advocacy/schoolfundadv/default
Resources:
Center for Medicare and Medicaid directory of state plans: www.cms.hhs.gov/medicaid/consumer.asp
ASHA’s Medicaid reimbursement resources: http://www.asha.org/members/issues/reimbursement/reimbur-default
Resources ASHA Summary of OIG reports:
http://www.asha.org/practice/reimbursement/medicaid/SchoolBasedServicesSLP.htm
Medicaid funding success stories: http://www.asha.org/about/legislation-advocacy/state/advocacy-schools.htm
School Finance Committee Medicaid Resources: http://www.asha.org/advocacy/schoolfundadv/default.htm
Questions ????