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Medicaid Eligible - West Virginia Department of Education

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					Medicaid and Education


      June 13, 2012
www.cms.gov
            State Plan

     Each state
determines its State
  Plan within the
 general guidelines
of the federal CMS.
       Medicaid and Education Timeline


1989                1990             2000

                    IDEA           Medicaid
U.S.                               State Plan
Congress                           Amended
                   WV Code
                   18-2-5b
   Medicaid
                                       Added
reimbursement                      IEPs, Care Coor,
                   Only OT, PT,
  for children                        Sp. Trans.
                     Speech,
   with IEPs                        Personal Aides
                   Nursing, and
                   Psychology
               IDEA
Reduction of Other Benefits.--Nothing
in this part shall be construed to
permit the State to reduce medical or
other assistance available or to alter
eligibility under title V of the Social
Security Act… or title XIX of the Social
Security Act (relating to Medicaid for
infants or toddlers with disabilities)
within the State.
         1990                          2000
   Each School District – 1st #   Each School District – 2nd #

  Therapy Provider #              Cost-Based Provider #
0 00XXXXXXXX                      15XXXXXXXX - New
   NPI # - 2009

  Audiology #                     Initial/Triennial IEP
  OT #                            Annual IEP
                                  Personal Care (full)
  PT #
                                  Personal Care (part)
  SLP #
                                  Sp. Trans. Vehicle
  RN #
                                  Sp. Trans. Aide
  Psychology #                    Care Coordination
Code   Description                    Frequency Federal
                                                match
T1001 Nursing Assessment/Evaluation   2x/year   $99.66
T1000 Nursing Services (Specialized   15 min.   $6.02
      Procedures)
WVEIS #                              Diagnosis Code                              School


County                       Beginning Date           Ending Date                      Procedure              Units
                                                                                           T1001
Ind. Provider #              Beginning Date           Ending Date                      Procedure              Units
                                                                                           T1000


Private Duty Nursing Services: Written physician’s orders with diagnosis and specialized care
    required. Must be identified on IEP (Care plan may be attached).
                                                                                                                 Service
   Code                                           Procedure                                                       Unit
 T1001            Nursing Assessment/Evaluation                                                               1 per year

 T1000            Nursing Services, Individual services (including the planning for the delivery              15 minutes
                  of care in consultation with the parent, physician, school personnel, private                                 15
                  duty nurse and delivery of actual specialized health procedures and evaluation
                  of the student’s response to the treatments summarized below.)                                                minute
Authorized Individual Nursing Services/Treatments:                                                                              =1
 Anaphylactic Reaction                Manual Resuscitator                             Postural Drainage and Percussion          billing
 Catheterization: Clean-Self-         Mechanical Ventilator                           Seizure Management                        unit
 Sterile
 Crede’s Method                       Measurement of Blood Sugar with                 Subcutaneous Insulin Infusion
                                      a Glucometer                                    Pump/Bolus
 Emergency Medication
 Administration
                                      Oral Suctioning                                 Subcutaneous Insulin by Injection         7.5 min.
 Enteral Feeding (tube feeding)       Ostomy Care: Emptying/Changing
                                      of Ostomy Pouch
                                                                                      Tracheostomy Care
                                                                                                                                may
 Epinephrine Auto-Injector
 Inhalation Therapy by Machine
                                      Oxygen Administration
                                      Peak Flow Meter
                                                                                      Vagus Nerve Stimulator
                                                                                      Administering Medications through         round
                                                                                      Gastrostomy/N-G Tube
 Long-Term Medication                 Phrenic Nerve Stimulator                        Epinephrine Twinject                      up
 Administration
                                                                                      Special Dietary Needs Medical
                                                                                      Statement

Date     1    2        3        4     5      6        7        8        9        10        11      12    13      14        15
Proc.
Time

Date     16   17      18     19     20     21    22       23       24       25        26     27     28    29      30       31
Proc.
Time



_____________________________________                                   _________________
      Signature                                                              Date
Menu
                            Billing
                                                   Electronic         WVDHHR -
                            Form or
                            WVEIS
                                                     claim            Molina
                            Entry                                     Processing
       LEA                            RESA        Remittance Advice   Agency;
                                                  Denial/pending
                                                                      Bureau of
                                                                      Medical
                                                                      Services
Supporting Documentation:             Payment –                       BMS
   IEP                                Direct
   Progress Notes                     Deposit
   Attendance Records
   Care Coordination form
       Documentation

• Student Related Documentation
     Included in IEP services – related service
     Notes/log

• Billing Documentation - WVEIS
The federal CMS is requiring
states to adopt a cost settlement
approach for school-based
Medicaid reimbursement
beginning July 1, 2012.
                             Cost Report Process
                    Cost Reports will be submitted through a web
                     based software system
                              More comprehensive cost report training will be provided in the future




WV: Introduction to Medicaid
Cost Based School Based                               21
Health Services
   Cost Settlement Calculation Example
 1.0       Total Costs of Eligible SBHS Provider Costs (County’s costs)      $1,000,000

 2.0       Indirect Cost Rate                                                  115.00%

 3.0       Total Costs of Eligible SBHS Provider Costs                       $1,150,000

 4.0       RMTS Direct Medical Percentage Results (Statewide results)           65.00%

 5.0       Direct Medical Services Costs                                      $747,500

 6.0       Application of Medicaid Eligibility Rate (IEP Ratio) (County’s)      50.00%

 7.0       Medicaid Direct Medical Services Costs (for the quarter)           $373,750

 8.0       Medicaid Interim Payments Received (for the quarter)               $200,000

 9.0       Medicaid Cost Settlement (at the end of the year – July 2013)      $173,750


WV: Introduction to Medicaid
Cost Based School Based                       22
Health Services
            Cost Settlement Calculation 2nd
                  Example – Pay Back
 1.0       Total Costs of Eligible SBHS Provider Costs (county’s cost)       $1,000,000

 2.0       Indirect Cost Rate                                                  115.00%

 3.0       Total Costs of Eligible SBHS Provider Costs                       $1,150,000

 4.0       RMTS Direct Medical Percentage Results (Statewide results)           65.00%

 5.0       Direct Medical Services Costs                                      $747,500

 6.0       Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)      50.00%

 7.0       Medicaid Direct Medical Services Costs (for the county)            $373,750

 8.0       Medicaid Interim Payments Received (by the county)                 $500,000

 9.0       Medicaid Cost Settlement (at the end of the year – July 2013)     -$126,250


WV: Introduction to Medicaid
Cost Based School Based                        23
Health Services
           Cost Settlement Calculation 3rd
                 Example – Neutral
 1.0       Total Costs of Eligible SBHS Provider Costs (county’s cost)       $1,000,000

 2.0       Indirect Cost Rate                                                  115.00%

 3.0       Total Costs of Eligible SBHS Provider Costs                       $1,150,000

 4.0       RMTS Direct Medical Percentage Results (Statewide results)           65.00%

 5.0       Direct Medical Services Costs                                      $747,500

 6.0       Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)      50.00%

 7.0       Medicaid Direct Medical Services Costs (for the county)            $373,750

 8.0       Medicaid Interim Payments Received (by the county)                 $373,750

 9.0       Medicaid Cost Settlement (at the end of the year – July 2013)            $0


WV: Introduction to Medicaid
Cost Based School Based                        24
Health Services
$ County’s
 costs for
billable services            Rate billed for
– excluding IDEA
                            SLP, PT, OT, PSY,
                    Match      RN, AUD
 Results of                 Rate billed for
   RMTS                         Care
  (statewide)
                            Coordination

                            Rate billed for
                            Personal Care
 #Medicaid
                                Aides
  Eligible/
 #Special Ed.
        $
    County’s        Medicaid-covered services
    costs for
     billable       •Audiological Services
    services –
    excluding
                    •Speech therapy services
      IDEA          •Physical therapy services
                    •Occupational therapy services
                    •Psychological evaluation
 Results of         •RN – Specialized Procedures

   RMTS             Care Coordination
(Direct billable)   activities
                    Personal care activities
                    •Communication;
    #Medicaid       •Safety;
     Eligible/      •Mobility;
      Special
    Education
                    •Behavior;
                    •Medical/health
                               RMTS Site Preview




WV: Introduction to Medicaid
Cost Based School Based               27
Health Services
                               RMTS Site Preview




WV: Introduction to Medicaid
Cost Based School Based               28
Health Services
                               RMTS Site Preview




WV: Introduction to Medicaid
Cost Based School Based               29
Health Services
                               RMTS Site Preview




WV: Introduction to Medicaid
Cost Based School Based               30
Health Services
                                For Additional Support

                    LEA contact will e-mail files to
                     wvsbhs@pcgus.com
                           No later than January 2012
                           Staff Roster – LEA contact to CREATE
                           Calendar – LEA contact to CREATE
                    Reminder
                           PCG will code using a centralized standard coder
                           Training will be embedded in the RMTS
                    For additional assistance, please contact the
                     Public Consulting Group’s West Virginia Hotline
                     at
                           E-Mail Address: wvsbhs@pcgus.com

WV: Introduction to Medicaid
Cost Based School Based                      31
Health Services
RMTS Responses (Direct Services)
     Inappropriate Response: I was not providing
     direct services to students.
     Appropriate Response: I was working on
     writing new IEP goals regarding transition for a
     student.


     Inadequate Response: Who was with you?
     Some students and an adult.
     Appropriate Response: Five students and an
     aide.
        PCG’s Advice

When indicating that you were participating in
or preparing for an IEP Meeting,

please indicate the portion of the IEP on which
you were working during your moment

(i.e., health related services goals, transition,
state assessments, etc.).
 $ County’s
  costs for
  billable
  services


  Results of
    RMTS

               Drawing from Basic
               Information Page –
               Special Education
#Medicaid      screen WVEIS
 Eligible/
 #Special
Education
   Important LEA Data Collection Needs
                    IEP Ratio must be maintained and tracked for Medicaid cost
                     allocation purposes
                           Medicaid-allowable costs are determined by
                            multiplying total direct medical services times the
                            IEP ratio. Number of Medicaid Eligible FFS
                                Total
                               Students Receiving Direct Medical Services
          IEP
                                              with an IEP
                          =
         Ratio
                                  Total Number of Students Receiving
                                  Direct Medical Services with an IEP



WV: Introduction to Medicaid
Cost Based School Based                     35
Health Services
                Medicaid Administrative Claiming (MAC)
                                                         Additional $
                                             MAC




WV: Introduction to Medicaid
Cost Based School Based           36
Health Services
Medicaid Administrative Claiming (MAC)

•Medicaid Outreach
•Facilitating Medicaid Eligibility Determination
•Direct Medical Services
•Translation Related to Medicaid Services
•Program Planning, Policy Development and
Interagency Coordination Related to Medicaid
Services
•Medicaid related training
•Referral, Coordination, and Monitoring of
Medicaid Services and Documentation
$ County’s
                    Same
 costs for          participants   Rate billed for
billable services
– excluding IDEA
                                    SLP, PT, OT,
                                   PSY, RN, AUD

 Results of                        Rate billed for
   RMTS                             Care Coor. –
 (statewide) –                      (Treatment
                                     Planning?)

                                   Rate billed for
% #Medicaid                        Personal Care
  Eligible/                            Aides
 #Special Ed.
                                                      COUNTY BUDGET FOR IDEA and State Aid - FY 2012_ _

                                           ENTER ALLOCATIONS                                             $997,309.00          $45,215.00      $103,471.00 $1,145,995.00
 5 Digit
           3 Digit
Program                                                                                              IDEA School Age (3-   IDEA Preschool                       Total Budget for
           Object                                     Description                                                                             State Aid
Function                                                                                                    21)                (3-5)                             This Line Item
            Code
  Code
                     S PECIAL EDUCATION - PERS ONNEL
                     List each position by FTE and type of position, including exceptionality if
                     applicable; and program function code. Fixed charges may be aggregated.               43-2-1             43-2-2           02-2-1


 21210      111      1.0 multi-catagorical teacher           Don’t bill Med.                                  $54,584.00                                              $54,584.00
 21210      121      5 1.0 primary paraprofessionals                                                         $143,916.00                                             $143,916.00
 21210      121      5 1.0 middle paraprofessionals                                                          $124,315.00                                             $124,315.00
 21210      121      3 1.0 high school paraprofessionals                                                      $85,200.00                                              $85,200.00
 21282      121      1.0 pre-school special needs paraprofessionals                                                              $28,255.00                           $28,255.00
 21271      111      .5 1.0 teacher of the gifted                                                                                                  $34,000.00         $34,000.00
 22721      121      1.0 bus aide                                                                             $34,130.00                                              $34,130.00
 22134      111      .10 school nurse                                                                          $5,065.00                                               $5,065.00
 22142      111      3 0.50 school psychologists                                                              $97,845.00                                              $97,845.00
                                                           S ub Total S pecial Education Personnel           $545,055.00         $28,255.00        $34,000.00        $607,310.00
 5 Digit
           3 Digit
Program                                                                                              IDEA School Age (3-   IDEA Preschool                       Total Budget for
           Object                                     Description                                                                             State Aid
Function                                                                                                    21)                (3-5)                             This Line Item
            Code
  Code
                     S PECIAL EDUCATION - S ERVICES
 2xxxx                                                                                                                                                                     $0.00
 22150      151      contracted speech                                                                        $15,000.00                                              $15,000.00
 21273      341      orientation & mobility trainer                                                            $2,000.00                                               $2,000.00
 21223      341      vision specialist                                                                        $10,000.00                                              $10,000.00
 22161
 22162
            341
            341
                     occupational therapy services
                     physical therapy services
                                                                    Don’t bill Med.                           $70,135.60
                                                                                                              $15,000.00
                                                                                                                                  $2,536.71        $16,890.00         $89,562.31
                                                                                                                                                                      $15,000.00
 21219      112      extended school year services                                                             $8,000.00                                               $8,000.00
                                                                                                                                                                           $0.00
                                                                                                                                                                           $0.00
                                                                                                                                                                           $0.00
                                                                 REMAINING IN ALLOCATION                   #REF!              #REF!            #REF!                 #REF!
Online Strategic Plan




     Maintenance Of Effort (MOE)
     State/Local
    In a cost-based system,
Medicaid reimbursement will
 cover the costs of providing
special education and health-
 related services to Medicaid
       eligible students.
http://wvde.state.wv.us/osp/medicaid.html

				
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