Direct Billing Administrative Claiming Cost Reporting School- Based Medicaid.

Introduction to School-Based MedicaidMedicaid 101

Objectives Participants will be able to:• Understand the premises of Medicaid and how it plays

into Education.• Name the three sides making up the School-Based

Medicaid triangle.• Understand the importance of each side of the

triangle.

School-Based Medicaid Services

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Administrative C

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Cost Reporting

School-Based

Medicaid

Why is this program important?• At least 155 reasons

• Districts and state schools• 151 participating in SBAC and Direct Services• 4 participating in SBAC only

• Add 97,472 more reasons • Children and students, eligible for special education in KY

• (December 1 count 2013)

• But, add $16,301,333 MORE reasons• Amount of federal Medicaid reimbursement to Kentucky for 2013

• Direct Claims - $5,631,734• Cost Settlement - $5,284,334• Administrative Claiming - $5,385,265

Common Ground Medicaid and Special Education

• Both Medicaid and Special Education are similar in that they both:• Serve individuals• Have treatment plans• Receive federal funding• Have service coordination plans• Do outreach• Document and collect data• Are monitored• Set high standards for providers• Are complex programs• Expect all providers of services are expected to know the Medicaid and Special

Education rules/requirements.

Individual Educational Plan - IEP

• The student’s IEP governs the special educational and related services provided to the student in the educational setting. The need for “related ” services is determined based upon the child’s special education needs. Therefore, the ARC develops an IEP consistent with requirements of the IDEA and state regulations as defined in 707 KAR Chapter 1.

• The IEP and accompanying documents (i.e., evaluation reports, ARC Conference Summaries, tests, physician reports, and other documents supporting the necessity for inclusion of a service in the IEP) document the medical necessity of the service. The IEP becomes the practitioner’s Plan of Care for the provision of Medicaid-covered services.

Current Contractors/Vendors

• Direct Billing • Kentucky School Board Association (KSBA)• Public Consulting Group, Inc. (PCG)• Sivic Solutions Group, Inc. (SSG)

• Administrative Claiming• Sivic Solutions Group, Inc. (SSG)

• Cost Report/Cost Settlement• Fairbanks, LLC

School-Based Health Services(Direct Billing or Fee-For-Services)

School-Based Medicaid

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School-Based Health Services (Direct Billing) Background

• In 1975, Congress amended the Education for the Handicapped Act with Public Law 94-142 to provide protections for parents and children and assist states and local education agencies with the excess cost of educating children with disabilities.• In 1988, Congress amended the Social Security Act to allow

states and local education agencies to access Medicaid federal funds to assist in their efforts to educate children with disabilities (the Medicare Catastrophic Healthcare Act, Public Law 100-360). • In 1994, the Kentucky General Assembly enacted legislation (KRS

605.115) allowing local education agencies to access Medicaid medical assistance payments funding if they agree to provide the matching state funds for the Medicaid covered services

School-Based Health Services ( Direct Billing)

• The Medicaid School-Based Health Services (SBHS) program is a unique Medicaid program designed for local education agencies (LEAs). • The goal of this program is to provide local school districts with another

fiscal resource to offset the costs of providing school-based health related services to students with disabilities in an educational setting under the Individuals with Disabilities Education Act (IDEA).

• The services provided are necessary for the student to benefit from special education.

• There is agreement between the Department for Medicaid Services and the Department of Education that certain services in a student’s Individual Education Program (IEP) are also medically necessary and therefore qualify for Medicaid reimbursement.

• Basic Explanation – Direct billing allows claims to be billed for the services as directed by the IEP.

School-Based Health Services (Direct Billing) Medical Necessity

Per Medicaid Regulation 907 KAR 1:715. School-based Health Services• Addresses a Physical or Mental Disability• The Admissions and Release Committee (ARC) states the service in the

Individualized Education Plan (IEP)• Services are provided in accordance with the IEP• Services are necessary for the student to benefit from special education

Note: Department for Medicaid Services (DMS) considers a service listed in an IEP as meeting medical necessity standards. DMS understands that the Center for Medicaid/Medicare Services (CMS) would review an IEP for medical necessity if auditing an LEA.

School-Based Health Services (Direct Billing) Program Requirements

• The DMS requires that services provided to Medicaid eligible recipients be medically necessary mental or physical health services.

• The Kentucky Department of Education (KDE) requires that related health services provided to students eligible for such services under the IDEA must be necessary for the child to benefit from special education.

• To meet the requirements for each program, the SBHS Medicaid program regulations have been written in a such a way that medical necessity is established by the admissions and release committee (ARC) stating the service in the IEP.

School-Based Health Services (Direct Billing) Covered Services

• Nursing Services• Audiology Services• Speech Therapy• Occupational Therapy• Physical Therapy

• Behavioral Health (Mental Health)• Incidental Interpreters• Assistive Technology• Transportation• Orientation & Mobility

School-Based Health Services (Direct Billing) Components to Medicaid Billing• Therapy• Individual Therapy

• Face-to-face, one-on-one encounter between the student and practitioner• Individual therapy must be specified in the IEP

• Group Therapy• Rehabilitation services which offer activities in a therapeutic environment that

focus on the development and restoration of the skills of daily living• Group must be comprised of 6 or less students• Limited to the following areas: Speech, Occupational, Physical, and Mental

Health Therapies• Group therapy must be specified in the IEP

School-Based Health Services (Direct Billing) Components to Medicaid Billing cont.

• Evaluations• Assessments, tests, and related activities performed under provision of state

and federal requirements for IDEA• Include formal assessments requested by the ARC used to determine a

student’s eligibility (or continuing eligibility) for IDEA services• Include informal assessments to determine student’s progress or regression• Conditions for Medicaid reimbursement• Student is determined eligible for IDEA services• IEP is developed• Student is placed in the least restrictive environment• At least 1 Medicaid covered service is listed on the IEP• The required services must be stated in the evaluation documentation.


• Assistive Technology• Requires evaluation • Documentation requirements

IEPVendor InvoiceProduct Description

• Programming or reconfiguring an assistive device for an individual student• Property of the child• Reimbursable only when provided with another service, such as Speech,

Occupational, or Physical Therapy


• Transportation• The child’s residence to and from the school building where the child receives the

reimbursable related service.• The child’s residence to and from the office of a medical provider or clinic where the child

receives the reimbursable related service. • The child’s home if the child is a home-bound student and receives general education

services at home• Provided on the same day as a Medicaid service• Board-owned specially adapted vehicle• Specially adapted vehicles may have riders who are not eligible for Medicaid or who are not

eligible for school-based transportation on a given day. The presence of other children does not negate Federal Financial Participation (FFP) for the child covered for School-Based Transportation. However, only claims that are pro-rated for the portion of the ride allocated to the Medicaid beneficiary receiving the specialized transportation, are reimbursable by Medicaid.

School-Based Health Services (Direct Billing) Required Licenses/Certifications

Advanced Registered Nurse Practitioner (ARNP)

Current license from the Kentucky (KY) Board of Nursing per 201 KAR 20:057

Registered NurseCurrent license from the KY Board of Nursing per 201 KAR Chapter 20

Licensed Practical NurseCurrent license from the KY Board of Nursing under appropriate supervision and delegation per 201 KAR Chapter 20

Health Aide

Under the supervision of and with training by a KY licensed ARNP or RN and being monitored by the supervising nurse in provision of the delegated and supervised nursing services per 201 KAR 20:400

AudiologistCurrent license from KY Board of Speech Language Pathology and Audiology per 201 KAR 17:012

Speech-Language Pathologist

Current Certificate of Clinical Competence from American Speech Hearing Association (ASHA) ONLY ASHA IS ACCEPTABLE LICENSURE.

Occupational TherapistCurrent license from KY Occupational Therapy Board (KAR 201 Chapter 28)

Occupational Therapy Assistant

Current license from the KY Occupational Therapy Board and under the supervision of a licensed Occupational Therapist (KAR 201 Chapter 28)

Occupational Therapist Aide

Under the direct supervision of the KY licensed Occupational Therapist (KRS 319A. 010 (5))

Physical TherapistCurrent license from the KY Board of Physical Therapy or a temporary permit issued by the KY Board of Physical Therapy (KAR 201 Chapter 22)

Physical Therapist Assistant

Current license from the KY Board of Physical Therapy and under supervision of a licensed Physical Therapist (KAR 201 Chapter 22)

Physical Therapy AideUnder the direct on-site supervision of the KY licensed Physical Therapist or Physical Therapy Assistant (201 KAR 22:053, Section 5.)

Licensed PsychologistCurrent license from the KY Board of Examiners of Psychology in accordance with KRS Chapter 319

Licensed Psychological Practitioner

Current license from the KY Board of Examiners of Psychology (KRS Chapter 319)

Certified Psychologist with autonomous functioning

(AF)

Current license to practice by the KY Board of Examiners of Psychology (KRS Chapter 319)

Certified PsychologistCurrent license and under the supervision of a KY Licensed Psychologist (KRS Chapter 319)

Licensed Psychological Associate

Current license and under the supervision of a KY Licensed Psychologist (KRS Chapter 319)

Certified Psychologist with autonomous functioning

(AF)

Current license to practice by the KY Board of Examiners of Psychology (KRS Chapter 319)

Certified PsychologistCurrent license and under the supervision of a KY Licensed Psychologist (KRS Chapter 319)

Licensed Psychological Associate

Current license and under the supervision of a KY Licensed Psychologist (KRS Chapter 319)

Licensed Professional Clinical Counselor

Current license from the KY Board of Licensed Professional Counselors (KRS Chapter 335)

Board Certified Behavior Analyst

Current license from the Kentucky Board of Behavior Analyst (KRS Chapter 319C)

Board Certified Assistant Behavior Analyst

Current license from the Kentucky Board of Behavior Analyst (KRS Chapter 319C)

Licensed Professional Clinical Counselor

Associate

Current license from the KY Board of Licensed Professional Counselors and under the supervision of an approved clinical supervisor as authorized by the KY Board of Licensed Professional Counselors (KRS Chapter 335)

Social Worker

1. Current license as a social worker by the KY Board of Social Work

2. Current license as a certified social worker by the KY Board of Social Work (KAR 201 Chapter 23)

Licensed Clinical Social Worker

Current license by the KY Board of Social Work (KAR 201 Chapter 23)

Incidental InterpreterEffective July 1, 2003, interpreters must be licensed by the KY Board of Interpreters for the Deaf and Hard of Hearing as required by KRS 309.300 to 309.319

Orientation & Mobility Specialist

1. Current certification by the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP) or

2. Current certification by the National Blindness Professional Certification Board (NBPCB)

Respiratory TherapistCertification by the KY Board of Respiratory Care as required by KRS 314A

School-Based Health Services (Direct Billing) Steps to Approval

1. Complete the SBHS application, secure superintendent’s signature

2. Mail completed application and copies of current licensure to KDE

3. KDE reviews all documentation, sends notification to DMS that district has met all requirements

4. DMS updates the district’s Medicaid Provider number and notified KDE

5. KDE notifies the District and billing agent if applicable.

School-Based Health Services (Direct Billing) Service Log Documentation

• Must be sufficient to identify the patient clearly, justify the diagnosis and treatment and document the results accurately. Must be adequate enough to demonstrate that the service was provided and that the service followed the approved plan of treatment (IEP/IFSP).• Includes the dates of service• Service provider• Where the service was provided• Length of time• Medical documentation related to the diagnosis or medical condition of the

recipient.

School-Based Administrative Claiming(Random Moment Time Study)


Administrative Claim

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School-Based Administrative Claiming(RMTS Program)

• 2003 General Assembly, through the enactment of House Bill 269, authorized the Department of Education (KDE) to implement a strategy for maximizing federal reimbursement under the Medicaid Program for Medicaid eligible administrative functions performed by elementary and secondary schools• KDE and the Department for Medicaid Services (DMS), created the

Medicaid School Based Administrative Claiming (SBAC) Program in an effort to recoup costs associated with administrative activities• Medicaid School Based Health Services (SBHS) program is also available

to assist districts, the Kentucky School for the Blind and the Kentucky School for the Deaf in seeking reimbursement for covered health services listed in the individual education programs (IEP) of children who are eligible under both the Individuals with Disabilities Education Act (IDEA) and Medicaid


Purpose of RMTS Program• Captures the percentage of time staff spend on

administrative tasks related to medical services• Medicaid Outreach• Facilitating Medicaid Eligibility Determination• Transportation Related to Medicaid 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


What is my role in the RMTS?The district’s SBAC Coordinator plays a very important part in the accurate and effective administration of the RMTS process. Responsibilities of the Coordinator include:

• Submit Calendars and Work Schedules using Excel templates • Maintain Participant Data

• Identifying the employees and contractors in the district who should participate in the RMS time study;

• Certify Participant Data • Provide on-going monitoring and follow-up on Response Rates • Review and approve costs for all RMTS participants • Certify quarterly SBAC claim • Submit quarterly Claim to KDE


Staff Pool List• Two Cost Pools make up the Staff Pool List (SPL)• Administrative Personnel - Individuals that perform administrative

functions related to medical services• Consider what the person is doing, not just their title

• Direct Service Personnel – Individuals who perform and provide medical services• General rule: If they are billing, they must be included on the staff pool list


Who Should be on the SBAC Staff Pool List

Administrative Personnel

• Administrators

• Bilingual Assistants

• Diagnostician

• Licensed Speech Language Therapy Assistants

• Program Specialist

• Pupil Support Technicians/Services Administrators

• School Counselors

• School Psychologists/Psychologist Interns

• School Social Workers

• Special Education Teachers

• State Licensed Speech Language Therapist (Non-ASHA)

• Support Technicians - Special Education

Direct Service Personnel

• ASHA Certified Speech Language Therapist

• Board Certified Assistant Behavior Analyst

• Certified Occupational Therapy Assistant (COTA)• Interpreter/Interpreter Assistant• Licensed Audiologist• Health Aide• Licensed Clinical Social Worker• Licensed Occupational Therapist• Licensed Physical Therapist• Licensed Physical Therapist Assistants• Licensed Professional Clinical Counselors• Licensed Psychologist/Certified Psychologist• Orientation and Mobility Specialist• Licensed Practical Nurse (LPN)• Registered Nurse (RN)/Advanced Registered Nurse

Practitioner


5 Important Reminders

• Only participants who are on the certified staff pool list prior to the beginning of the quarter will be listed on the quarterly financials• 100% federally funded employees should not be listed on the staff

pool list, and federal funds should not be claimed• If you plan on billing fee-for-service for a staff member, he/she must

be listed in the staff pool list• “On-behalf of” insurance State payments are claimable• Communication between the Special Education department and

Finance department is critical

Cost Reporting/Cost Settlement


Cost Reporting

Cost Reporting/Cost SettlementOverview

Direct Billing Services or Fee-for-Service (FFS)

• Kentucky transitioned to a cost-based approach for the FFS program and Specialized Transportation beginning with the 2008-2009 cost report period • FFS Cost Reports must be completed annually, and are

used to compare FFS “interim” payments received throughout the year to actual costs collected on the Cost Report • Cost Reports are interrelated with the FFS and the

Administrative Claiming RMTS processes currently in place

Cost Reporting/Cost SettlementRelationship of RMTS to Cost Report

• The CMS approved plan requires that providers submit an annual FFS Cost Report, which will trigger cost reconciliation and a cost settlement.

• The plan also requires that providers must participate in the RMTS time study for SBAC in order to bill for FFS.

• In order to remain eligible for FFS reimbursement, a district must participate in RMTS. Participation includes but is not limited to: • Ensuring RMTS Program Contact has been trained • Ensuring the RMTS Participant List is updated each quarter • Meet the 85% RMTS participation rate requirement

• The results of the time study are the basis for the calculation of the direct medical services percentage that is used during the cost reporting process to allocate costs to the Medicaid program.

Cost Reporting/Cost SettlementInterim Claim Rate Setting & Payment Process

• LEAs submit claims for direct services and transportation services (many LEAs use a third party billing agent such as KSBA, PCG or SSG)

• Interim rates are set by DMS for each of these eligible services • Claims that are submitted to DMS are paid by DMS

Payments are considered interim because it is not until Cost

Settlement that a final payment/collection is made

Cost Reporting/Cost SettlementWhy does the Participant List matter?

• Only those individuals that are listed on the Participant List (PL) will be eligible to have costs reported• Decisions today on the PL, matter tomorrow on the Cost Report • For example, the first quarter’s PL for FY15, which is October-

December 2014, will be due in September 2014

Cost Reporting/Cost SettlementExample of Cost Report Process

During any Fiscal Year (i.e. FY15 = 7/1/14-6/30/15) • LEA submits direct services to DMS for reimbursement • DMS pays the LEA for these services and they are termed

“Interim Payments/Data”

In March of the following year • Cost Report vendor opens website for online financial

reporting for FY12 Cost Report. All reporting is completed within the month and is based on the “Interim” Data as mentioned above

Cost Reporting/Cost SettlementExample of Cost Report Process (cont.)

Beginning in July of the following year • Online Cost Report is re-opened by Fairbanks and “Final” Data is loaded. (This

is due to the fact that if a direct service was delivered on 6/30/2014 (part of FY15), it could successfully be billed to DMS up to 6/29/2015. Thus, data cannot be finalized until 7/1/2015.)

• Only those LEAs that have changes from the Interim to the Final Data will need to re-certify their Cost Report. Fairbanks will load the Final Data and contact the LEA with instructions on how to re-certify.

Beginning in the Fall of the following year • Fairbanks & DMS follow the cost calculation outlined in the approved State

Plan Amendment to determine the cost total the LEA is entitled to under Cost Settlement. Interim payments are captured from DMS. If interim payments are lower, the LEA receives money in Settlement. If interim payments are higher, the LEA must pay back DMS.

School-Based Medicaid Programs

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Time Line• Mid June – September 15 --- Submit SBHS Application to KDE• July --- revise Cost Report data• September --- Certify Staff Pool List in SSG system.• September --- Cost Settlement sent to districts.• October 1 --- New quarter RMTS begins• November --- Financial Report due to SSG• Mid December --- Certify Staff Pool List in SSG system. • January 1 --- New Quarter RMTS begins• February --- Financial Report due to SSG• March --- Cost Report data due to Fairbanks• Mid March --- Certify Staff Pool List in SSG System• April 1 --- New Quarter RMTS begins

Acronyms• SBHS – School-Based Health Services• SBAC – School-Based Administrative Claiming• FFS – Fee-for-Service• KSBA – Kentucky School Board Association• RMTS – Random Moment Time Study• PCG – Public Consulting Group, Inc.• SSG – Sivic Solutions Group, Inc.

Becky StoddardDivision of Budgets and Financial ManagementKentucky Department of EducationCapital Plaza Tower, 16th Floor500 Mero StreetFrankfort, KY 40601502-564-1979 extension [email protected]

Stephanie Mack O’ConnorDivision of Budgets & Financial ManagementKentucky Department of EducationCapital Plaza Tower, 16th Floor500 Mero StreetFrankfort, KY 40601502-564-1979 extension [email protected]

Lucy SentersKentucky Department for Medicaid Services6th Floor West275 East main Street 40621Frankfort, KY [email protected]

Fairbanks Contact InformationClient Information CenterEmail: [email protected]: 866-303-7501

Fairbanks ContactsName: Cathy Loverde

Andrew JosephPhone: 312-450-6379

312-450-6381

Email: [email protected]

[email protected]

Sivic Solutions Group Inc. (SSG)Help Desk Email: [email protected]

Phone: 877-916-3222

mailto:[email protected]







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Direct Billing Administrative Claiming Cost Reporting School- Based Medicaid.

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