History

1. 1 Virginia Department of Medical Assistance Services (DMAS) and Virginia Department of Education (DOE) Medicaid and Schools Annual Training October 2011

2. 2 History Medicare Catastrophic Coverage Act of 1988 Medicaid funds could be used to pay for health-related services provided under Individuals with Disabilities Education Act (IDEA). Provided by a participating Medicaid provider Medically necessary Included in the state's Medicaid plan Provided to an individual enrolled in Medicaid Screened for any other third party payment that may be available for reimbursement.

3. 3 History 1991 � The Department of Medical Assistance Services (DMAS) began covering some health related services in schools due to requirement from the Governor�s Child Health Task Force The 2002 Virginia General Assembly directed DMAS to maximize federal reimbursement for services, by working with numerous organizations including Local Education Agencies (LEAs).

4. 4 Currently in Virginia� 2011 - Health related services have expanded over the years in Virginia for which LEAs may receive reimbursement School Divisions can submit claims to DMAS for reimbursement for these health related services for children enrolled in Medicaid, FAMIS or FAMIS Plus. FAMIS is Virginia�s Child Health Insurance Program (CHIP) FAMIS Plus is Medicaid for children

5. 5 Virginia: Medicaid and Schools These services must be provided by school division employees, contracted employees, or contracted agencies. Effective 2011-12 School year Contractors will no longer be included in the time study and none of their costs will be included in the administrative claim. All of their costs instead will be included in the medical services cost report and these costs will not be discounted by the Direct Services Time Study percent.

6. 6 Virginia: Medicaid and Schools Approved Services Physical Therapy Occupational Therapy Speech-Language Therapy Audiology Psychiatric, Psychology and Mental Health Nursing Personal Care Medical Evaluations Specialized Transportation

7. 7 Virginia: Medicaid and Schools Approved Services The following services/administrative duties are for both general education and special education students Early Periodic Screening, Diagnosis and Treatment (EPSDT) well child visits, sick visits and immunizations Administrative Claiming

8. 8 Federal and State Match Rates LEAs receive federal Medicaid and CHIP reimbursement that must be matched by state and/or local dollars. Federal Match rate for Administrative Claiming is 50% DMAS keeps half of federal share Federal Match Rate for Medicaid is 50%

9. 9 Federal and State Match Rates cont. Federal Match Rate for Medicaid Expansion and FAMIS is 65% Exception is American Recovery and Reinvestment Act enhanced rates for Medicaid from January 2009 � June 2011

10. 10 Business Associates Agreement To ensure privacy and security of protected health information (PHI) Individually identifiable information, including demographics, which relates to a person's health, health care, or payment for health care as specified in 45 CFR � 160.103 of the Final HIPAA Privacy Rule. LEAs shall not use PHI otherwise than as expressly permitted by the Agreement, or as required by law.

11. 11 Modification to BAA for Outreach School divisions have option of using FAMIS and FAMIS Plus Eligibility Reports (also known as the Medicaid Eligibility Report) for outreach purposes. Modification to the BAA must be completed Contact Ashley Barton for contract mod. Outreach to families to education about FAMIS and FAMIS Plus eligibility and services is a claimable administrative activity!

14. dmasva.dmas.virginia.gov

16. 16 Direct Services Requirements Medicaid Signed Provider Agreement with DMAS Current license on file with DOE for each service practitioner Services must be specified in the IEP Special Education Obtain parental permission for billing public insurance

17. 17 Direct Services Requirements (cont.) Direct service providers must meet provider requirements Billable services are limited to those covered by DMAS Direct service providers must complete DMAS required documentation Billing must occur!

18. 18 Provider Qualifications Provide DOE copy of provider qualifications if: Provider is new to the school division, or Provider has change in qualifications Notify DOE when a provider has left the school division. Claims will pend and deny reason �0148 - Rendering Provider Not Certified to Perform Procedure� if this process is not followed

19. 19 Provider Qualifications DOE will perform random audits on provider qualifications. Only send to DOE if requested Do not submit paperwork to DOE for: Personal Care Assistant Transportation Clarification that Local education agency based providers with conditional or provisional licenses are not qualified for DMAS reimbursement of direct services.

20. 20 Assessments Currently, assessments are a covered service only if included in IEP Time study respondents do not know if assessment will result in IEP Statewide school statistics on assessments

21. 21 Personal Care Assistant ServicesFor Behavioral Issues Services to assist the child with disabilities in self-sufficiency and communications Challenging behaviors Emotional instability Cognitive impairments Social skill deficits Need for supervision

22. 22 Personal Care Assistant ServicesFor Behavioral Issues Specific services must be in IEP and a behavioral plan developed and supervised by qualified provider: Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate, qualifications of the person delegated to and the supervisory requirements.Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate, qualifications of the person delegated to and the supervisory requirements.

23. 23 Quality Management Reviews (QMRs) DMAS must provide for continuing review and evaluation of the care and services paid through Medicaid, including the review of services by Medicaid providers. LEAs will receive letter from DMAS with the list of Medicaid recipients, randomly selected who received services during a specific review period.

24. 24 Quality Management Reviews (QMRs) QMRs will be processed as a desk review based upon the documentation and information requested in the letter. Information may be submitted by the US Postal Service, United Parcel Services, Federal Express, facsimile, or hand delivery.

25. 25 Quality Management Reviews (QMRs) The information submitted is legible, accurate, and complete. Staff will complete review and provide the LEA with outcome letter and actions taken as necessary. DMAS QMR does not eliminate provider from Utilization Reviews or Federal Audits.

26. What do school division staff need to know to connect families to services their children are eligible outside school?

27. 27 Medicaid covers federally mandatedservices, which include, but are not limited to: Inpatient and outpatient hospital services, Emergency hospital services, Physician and nurse midwife services, Federally qualified health centers and rural health clinic services, Laboratories and x-ray services, Transportation services, Family planning services and supplies, Nursing facility services, Home health services (nurse, aide), and Early and Periodic Screening, Diagnosis, and Treatment program for children (�EPSDT�).

28. 28 Medicaid also covers optional services,including, but not limited to: Certified pediatric nurse and family nurse practitioner services, Routine dental care for persons under age 21, Prescription drugs, Rehabilitation services such as physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services, Home health services (PT, OT, SLP), Hospice, Some mental health services, Some substance abuse services; and Intermediate care facilities for persons with developmental and intellectual disabilities and related conditions.

29. 29 Home and community-based Medicaid �waiver� programs HIV/AIDS Waiver, Alzheimer�s Waiver, Day Support for Persons with Intellectual Disabilities Waiver, Elderly or Disabled with Consumer-Direction Waiver, Intellectual Disabilities Waiver, Technology Assisted Waiver, and Individual and Family Developmental Disabilities Support Waiver.

30. What if there is a medical need a child has which is not covered by the Medicaid mandated, optional or waiver services (outside school setting)?

31. 31 What is EPSDT?   Medicaid�s Early Periodic Screening Diagnosis and Treatment Program is the benefit plan for children under the age of 21 Preventive care, traditional diagnostic and treatment services are the backbone of the program There is no special application process for EPSDT. Children are automatically eligible for EPSDT when enrolled in the Medicaid or FAMIS Fee-for-Service benefit plans

32. 32 Scope of Services Individualized health care, diagnostic services, and �treatment� as listed in the Federal Medicaid statute, must be provided when medically necessary to correct and ameliorate (improve) physical and mental conditions discovered during screening services whether or not included in the Medicaid state plan The program does not cover services that are experimental or investigational

33. 33 Specialized Services In Home Behavioral Therapy Residential Behavioral Treatment Substance Abuse Residential Treatment Personal Care Private Duty Nursing Nutritional� Assistive Technology Hearing Aids

34. 34 What is Not Covered? Services must be deemed as medically necessary Certain services are not covered by EPSDT due to Federal Limitations Respite Care Environmental Modifications Vocational Services Educational Services 2 year old requiring assistance with toileting would not meet criteria for medical necessity for example 2 year old requiring assistance with toileting would not meet criteria for medical necessity for example

35. 35 Where to Send Service Requests Requests for services may be faxed to: (804) 612-0043 Requests for services may be mailed to: DMAS Maternal and Child Health Division 600 E. Broad St., Ste 1300 Richmond VA, 23219

36. 36 Service Requests DMAS processes all typical requests within 10-15 business days MCO�s use their own PA processes To find MCO contact numbers use this link: http://www.dmas.virginia.gov/downloads/mcrguides/Chapter_8.pdf

37. 37 EPSDT Contacts Brian Campbell, EPSDT Services Supervisor Training and policy (804) 786-0342 brian.campbell@dmas.virginia.gov Anne Young Private Duty Nursing (804) 371-2635 anne.young@dmas.virginia.gov Shirlene Harris Behavioral Services (804) 225-3124 shirlene.harris@dmas.virginia.gov Tabitha Taylor Personal Care, Nutritional Services, AT, Hearing Aids, etc (804) 225-3231 Tabitha.Taylor@dmas.virginia.gov Jeff Beard Substance Abuse Treatment (804)371-7981 Jeff.Beard@dmas.virginia.gov

38. Reimbursement Bill Lessard, Director Provider Reimbursement Division Virginia Department of Medical Assistance Services

39. 39 Virginia School�s Medicaid Revenue from Admin Services

40. 40 Virginia School�s Medicaid Revenue from Medical Services

41. 41 Reimbursement Highlights Treatment of contractors in time study State budget requirement Proposed expansion of services under state contract Improving claims submission

42. 42 Contractors If contractors furnish reimbursable medical services, no longer included in time study or administrative claim beginning with FY12 Contractor costs in the cost report will not be multiplied by medical services time study percentage (100% of cost will be included)

43. 43 State Budget Requirement Five percent of the federal share kept by the state beginning in FY12 Will be deducted from the FY12 settlement in late FY13 To cover DMAS costs in assisting school divisions in submitting cost reports

44. 44 Expand State Contract Current contract with UMASS includes administration of statewide time study and preparation of administrative claims for schools DMAS will add additional services for FY13 and bid the whole contract Would be effective July 1, 2012

45. 45 Additional State Contracted Services Prepare annual medical service cost reports Assist school divisions in eligibility matching Monitor claims submission

46. 46 Benefits of Expanding Contracted Services Improve quality and consistency of cost reporting in a manner similar to administrative claiming Assist school division staff up front who may be new, unfamiliar with Medicaid and unfamiliar with financial reporting Less dependent on resources and proficiency at each school division

47. 47 Requirement to Submit Claims While the final cost settlement is not claims based, schools are required to submit claims for all Medicaid students receiving Medicaid covered services furnished by Medicaid qualified practitioners

48. 48 Monitoring Claims Submission Compliance School divisions required to calculate a percentage of Medicaid services billed School divisions either must track this up front (preferable) or audit a representative sample of Medicaid students with an IEP

49. 49 Transition FY09 cost reports � Use new method if requested by DMAS FY10 cost reports � Option to use new method when submitting cost report or if requested by DMAS FY11 cost reports � Use new method when submitting cost reports

50. 50 Submitting Claims Should be a Priority DMAS wants to reimburse school divisions all they are entitled to receive while minimizing audit risk DMAS will include claims monitoring in expanded contract But school divisions are still responsible for submitting claims School divisions with a low percentages of services billed may want to consider a billing contractor

51. 51 More Information Today Breakout sessions Random Moment Time Study Transportation Cost-based Reimbursement

52. 52 Medicaid Reimbursement Information for School Divisions On the DMAS web site http://www.dmas.virginia.gov/pr-sbs.htm

53. 53 Update to RMTS effective 10/3/11 For clarification of testing, UMASS may ask you to provide addition information such as: If the child is currently not special ed eligible, are you conducting the evaluation/assessment for: purposes of providing intervention�in the regular education class? purposes of 504 reasonable accommodations? or purposes of Special Education eligibility determination (under IDEA)?

54. 54 Psych evaluation in SPED %s Remember to track the number of psychological evaluations/reevaluations completed and the number of students who ended up being eligible for special education This number is required to be submitted to Department of Education, Amy Edwards for cost settlement purposes.

55. 55 School Services Contact Information DMAS Chandra Shrestha, 804-371-2446, chandra.shrestha@dmas.virginia.gov Ashley Barton, 804-371-7824, ashley.barton@dmas.virginia.gov UMASS (RMTS, Admin Claiming, Cost Information) Sue Fischer, 800-535-6741, susan.fischer@umassmed.edu

56. 56 School Services Contact Information DOE Amy Edwards, 804-692-0150, amy.edwards@doe.virginia.gov Clifton Gunderson (Cost Settlement) Anne Morrow, 804-270-2200, anne.morrow@cliftoncpa.com