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Overview of School-based Medicaid in Idaho Schools.pptx

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Overview of School-based Medicaid in Idaho Schools.pptx Powered By Docstoc
					What will be presented: Overview of School Based 
Medicaid

Who needs this information: Special Education Directors, 
Teachers, Related Service Providers, School Nurses, Medicaid 
Billing Staff

Training Documents:
   • Behavioral Intervention Professional 
   • Behavioral Intervention Paraprofessional
   • Behavioral Intervention Consultation
School Based Medicaid
      Overview
History of IDEA and Medicaid
            Education of All Handicapped
            Children Act of 1975 - Now
            known as the Individual with
            Disabilities Education Act
            (IDEA)
            Ensure children with disabilities 
            receive a free, appropriate public 
            education in the least restrictive 
            environment based on individual 
            needs and individualized 
            education programs.
    History of IDEA and Medicaid
The Medicare Catastrophic
Coverage Act of 1988 (MCCA)
and the Omnibus Budget
Reconciliation Act of 1989
(OBRA ’89)
Allow Medicaid to pay for health 
related services, including 
screening activities and related 
services based on a child’s 
Individualized Education Plan 
(IEP) if the child is Medicaid 
eligible and if the service is 
covered in the state Medicaid 
plan.
Division of 
Medicaid



                School 
                Based 
               Medicaid
  Local 
Educational 
 Agency
Role of Health and Welfare
Role of Local Education
        Agency
   (School Districts)
Education and Medicaid
Medicaid School Based Services
                                Provided by:
                                   – School districts
                                   – Charter schools
                                   – Infant toddler programs


Services provided must be considered 
medically necessary for the student to 
participate in an educational program.
                   http://www.healthandwelfare.idaho.gov/Medical/Medicaid/SchoolBasedServices/tabid/
                   1587/Default.aspx
Must Be Medically Necessary
•   It is a reasonable calculated service to prevent, diagnose, 
    or treat conditions in the participant that endanger life, 
    cause pain, or cause functional significant deformity or 
    malfunction; and
 
•   There is no other equally effective course of treatment 
    available or suitable for the participant requesting the 
    service which is more conservative or substantially less 
    costly.

•   Medicaid services must be of a quality that meets 
    professionally-recognized standards of health care and 
    must be substantiated by records including evidence of 
    such medical necessity and quality.  Those records must 
    be made available to the Department upon request.




                                                                     IDAPA 16.03.09.11.1
   Services not covered by School-
           Based Services
• Vocational Services
• Educational Services
• Recreational Services




                              IDAPA 16.03.09
Beginning in July 1, 2013


     NO
Developmental 
  Therapy
Who Qualifies for Developmental 
     Disabilities Services
                  Life Areas include:
                • Student’s who have an IQ 
                  of 70 or below on a 
                  • self care,
                  Standardized IQ test; and
                  • receptive and expressive 
                     language,
                • Student has an 
                  • learning,
                  educational disability; and
                  • mobility,
                  • self-direction,
                • Limitations  in 3 of 7 life 
                  • capacity for independent 
                  areas
                     living, or
                  • economic self-sufficiency;


                                  IDAPA 16.03.10
How Did We Get Here?
                 Legislative Process
  PUBLIC HEARING SCHEDULE: Public hearings concerning this rulemaking 
  will be held as follows:

Date: September 19, 2012                Date: September 19, 2012
Time: 6:00 p.m. (MDT Time)              Time: 6:00 p.m. (PDT Time)
Place: 1720 Westgate Dr. Suite A        Place: 2195 Ironwood Court
Boise, Idaho 83704                      Coeur d’Alene, Idaho 83814

Date: September 19, 2012                If you are unable to attend a public 
Time: 6:00 p.m. (MDT Time)              hearing in any of the physical locations 
Place: 421 Memorial Drive               listed above, you can join the Boise 
Pocatello, Idaho 83201                  public
                                        hearing from anywhere in the state via 
                                        teleconference.
                                        Teleconference number: 1-1-888-706-
                                        6468
                                        Participant Code: 526505
School-based Medicaid Services:
Beginning in July 1, 2013, schools can bill Medicaid 
for the following services provided to Medicaid-
eligible students who meet specific criteria:
   SB Medicaid Services that may be 
        used on a daily basis:
• Behavior 
  Intervention/Consultation 
  (BI/BC)
• Psychosocial 
  Rehabilitation (PSR)
• Personal Care Services 
  (PCS)
Behavior Intervention

        – Consistent, assertive and 
          continuous intervention 
        – Instruct in replacement 
          behaviors
        – Intervene and prevent 
          maladaptive behaviors
        – Instruct in tools and 
          strategies

                        IDAPA 16.03.09.852
      Behavior Consultation
   
– Consult with LEA 
  service providers
– Perform advanced 
  assessment (FBA)
– Write BIP
– Coordinate 
  implementation of BIP
– Ongoing training




                          IDAPA 16.03.09.852
Student Eligibility for BI/BC
            • Meet criteria for a developmental 
              disability per Idaho Code and 
              IDAPA, 
            • Must exhibit maladaptive behaviors 
              that include but are not limited to 
              frequent disruptive behaviors, 
              aggression, self-injury, criminal or 
              dangerous behavior, and 
            • These maladaptive behaviors 
              impede the student’s learning or tha
              of others.  

                 IDAPA 16.03.10 section 501 , Idaho Code 
                 66-402(5), and IDAPA 16.03.09.851
       Provider Qualifications
           Professional
• Credentialed 
  Special Ed 
  Teacher
• Special Ed 
  Consultant
• IBI Professional


                          IDAPA 16.03.09.12.04
             Provider Qualifications 
              Para-professional
• Must be at least eighteen (18) years of age;
• Demonstrate the knowledge and skills needed and meet SDE 
  standards for Paraprofessionals,
• Must meet the paraprofessional requirements under the 
  Elementary and Secondary Education Act of 1965, as 
  amended, Title 1, Part A, Section 1119. 
• Must be under the supervision of a behavior intervention 
  professional or behavior consultant.




                                           IDAPA 16.03.09.12.04
            Provider Qualifications
            Behavior Consultant
• Master’s or Doctoral degree with 1500 hours relevant 
  coursework; and
• Exceptional Child Certificate, or
• EC/EC Sped Blended Certificate, or
• Special Education Consulting Teacher, or
• Pupil Personnel Certificate (excluding RN or audiologist), or
• Occupational Therapist, or
• Therapeutic Consultation Professional as defined in rule.




                                              IDAPA 16.03.09.12.04
   Psychosocial Rehabilitation

– Individual and group skill 
  training intervention
– Goal is to restore individual to 
  optimal independent 
  functioning
– Aid in the development of more 
  socially appropriate behaviors 
  and prevent a student from 
  requiring a more restrictive 
  living situation



                  http://www.211.idaho.gov/elibrary/PsychosocialRehab.html
        Student Eligibility for 
     Psychosocial Rehabilitation

Students must            Students must 
meet eligibility 
found in IDAPA 
16.03.10 
                    OR   meet Idaho State 
                         Department of 
                         Education eligibility 
Section 112              criteria for 
                         Emotional 
                         Disturbance

                         IDAPA 16.03.10 Section 112 
         Provider Qualifications
      Psychosocial Rehabilitation
•   Licensed physician, licensed •      Psychologist extender
    practitioner of the healing         registered with the Bureau of
    arts, or licensed psychiatrist;     Occupational Licenses;
•   Licensed master’s level         •   Licensed professional or
    psychiatric nurse;                  registered nurse (RN);
•   Licensed psychologist;          •   Psychosocial rehabilitation
•   Licensed clinical professional      specialist as defined in IDAPA
    counselor or professional           16.03.10, “Medicaid Enhanced
    counselor;                          Plan
•   Licensed marriage and family •      Licensed occupational
    therapist or associate              therapist;
    marriage and family therapist; •    Certified school psychologist;
•   Licensed masters social             or
    worker, licensed clinical       •   Certified school social
    social worker, or licensed          worker.
    social worker;
Personal Care Services (PCS)

– Provision of medically 
  oriented tasks having to do 
  with the student’s physical or 
  functional requirements
– Does not address academic 
  needs, but daily living needs 
  such as: grooming, toileting, 
  eating, mobility, dressing, use 
  of adaptive devices, 
  transferring and medication 
  assistance
       Student Eligibility PCS
                   • Student must be on an IEP
                   • Student’s needs must be 
                     assessed utilizing the PCS 
                     School-based Children’s 
                     Assessment

• Assessment must find that the student 
  requires PCS due to a medical condition that 
  impairs physical or functional abilities
             Provider Qualifications
                      PCS 
• Registered Nurse or 
  Licensed Professional 
  Nurse (RN), 
• Licensed Practical Nurse 
  (LPN), 
•  Personal Assistant. A 
  person who meets the 
  standards of Section 39-
  5603, Idaho Code, and 
  receives training to ensure 
  the quality of services. 



                                  IDAPA 23.01.01
 Medicaid Documentation
Specific documentation is required for all 
Medicaid Billable Services.

Be sure that staff are familiar with the 
document requirements for each of the 
billable services.
      Medicaid Billing
• Use Correct Billing Codes
• Bill Correct Units 
• Have Documentation to back up what is 
  billed
• Keep records for 6 years
             Don’t forget…
• Districts must be enrolled as a Medicaid 
  provider to be reimbursed for school 
  based Medicaid services.
• Each service must be specifically identified
  on the IEP.
• Services cannot be educational.
• Services must be medically necessary for 
  the student to access their educational 
  program.


                                       IDAPA 16.03.09
           www.idahotc.com

•Training Calendar
•Online Registration
•Webinars
•Learning Communities
Department of Health and Welfare Website
MedicAide
         Contact Information:

                     Shannon Dunstan
        Early Childhood & Interagency Coordinator
           Idaho State Department of Education 
Division of Student Achievement and School Improvement
               Division of Special Education
                      (208) 332-6908
                 sdunstan@sde.idaho.gov

				
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