School-Based Medicaid Cost Settlement System - PowerPoint PPT Presentation

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School-Based Medicaid Cost Settlement System

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  1. School-Based Medicaid Cost Settlement System

  2. 2012 Approach to School-Based Medicaid Programs Annual Cost Report Quarterly Cost Report Fee For Service (PT, OT, Speech, Nurse, Psychologist – Care Coordination, Pers. Care 1:1 aide, Specialized Trans.) Medicaid Administrative Claiming (MAC) All Direct and Administrative staff Random Moment Time Study Random Moment Time Study RESA admin staff as vendors Medicaid Eligibility Ratio Medicaid Eligibility Ratio MER Reimbursement from Billing Final costs after reduction 50% District Cost Settled

  3. West Virginia Job Categories – AdministrativeCosts(50% Federal match) Not cost settled • Allowable staff in the Admin Pool: And ALL staff in any of the other “pools” may also give responses to the time study that are administrative.

  4. Materials and supplies that relate to Medicaid administrative costs (postage, etc.) - Training related to Medicaid covered services.

  5. Who support staff in the Admin pool

  6. Only quarterly ADMIN contractors (RESA Medicaid Specialists)

  7. Quarterly MAC – Admin Claiming County’s Costs of Providing Services- plus indirect costs $1,000,000 Less the results of the RMTS pilot (all staff who 5% are included in the RMTS Administrative and other rosters) Total $50,000 MER Medicaid Eligible to Total Enrollment Ratio (per county) 46% Total $23,000 Add in ADMIN vendors/contracted costs (RESA Med. Specialist) $10,000 Total $33,000 Federal match (50% always) $16,500

  8. Quarterly MAC – Admin Claiming County’s Costs of Providing Services- plus indirect costs $1,000,000 Less the results of the RMTS Oct – Dec 2012 (all staff who 13.23% are included in the RMTS Administrative and other rosters) Total Costs $132,300 MER Medicaid to Total Enrollment Ratio (per county) 46% Total $60,858 Add in ADMIN vendors/contracted costs (RESA Med. Specialist) $10,000 Total $70,858 Federal match (50% always) $35,429

  9. Quarterly MAC – Admin Claiming County’s Costs of Providing Services- plus indirect costs $ Less the results of the RMTS pilot (all staff who 13.23% are included in the RMTS Administrative and other rosters) Total Costs $ MER Medicaid to Total Enrollment Ratio (per county) 46% Total $ Add in ADMIN vendors/contracted costs (RESA Med. Specialist) $ Total $ Federal match (50% always) $

  10. Annual Cost Reporting Cost Settlement

  11. Annual Cost Report Quarterly Cost Report Fee For Service (PT, OT, Speech, Nurse, Psychologist – Care Coordination, Pers. Care 1:1 aide, Specialized Trans.) Medicaid Administrative Claiming (MAC) All Direct and Administrative staff Random Moment Time Study Random Moment Time Study RESA admin staff as vendors Medicaid - Special Education Ratio Medicaid Eligibility Ratio MER Reimbursement from Billing Final costs after reduction 50% District Cost Settled

  12. West Virginia Job Categories • Job categories and job titles include – 3 different cost “pools”:

  13. Annual Cost Report - Direct Services County’s Costs of Providing Services- plus indirect costs $1,000,000 Less the results of the RMTS Oct-Dec 2012 (staff who 49.20% are included in the direct service pool) Total Costs $492,000 Add in vendors/contracted costs (speech, OT, PT, psychologist) $300,000 Total $792,000 Medicaid Eligible to Direct Services Ratio County’s percentage 46% (handout) Total $364,320 Reimbursement $300,000 Cost Settlement $64,320

  14. Handout

  15. Care Coordination County’s Costs of Providing Special Education Teachers $1,000,000 Less the results of the RMTS - 2.52% Total Costs of Care Coordination $25,200 Vendors/contracted costs $0 Total Costs with Contracted $25,200 District’s IEP ratio reduction Medicaid eligible 50% All Special Ed Students Total Costs of Care Coordination $12,600 District’s Medicaid Reimbursement for Care Coordination $100,000 Cost Settlement Difference between Costs and Reimbursement $87,400

  16. Personal Care 1:1 Aides County’s Costs of Providing Personal Care Services $39,000 Less the results of the RMTS - 14% Total Costs of Personal Care Aide $5,460 Add in vendor/contracted costs $0 Districts IEP ratio reduction Medicaid eligible(Handout) 100% All Special Ed Students Total Costs $5,460 District’s Medicaid Reimbursement for Personal Care Aide $28,000 (Ave. 20 days/month for 10 months) Based on current rate Cost Settlement Difference between Costs and Reimbursement ($22,540) for one personal care 1:1 aide

  17. Personal Care Aide Services DESCRIPTION: Services related to a child’s physical and behavioral health requirements, including assistance with eating, dressing, personal hygiene, activities of daily living, bladder and bowel requirements, use of adaptive equipment, ambulation and exercise, behavior modification, and/or other remedial services necessary to promote a child’s ability to participate in, and benefit from, the educational setting.

  18. Personal Care Aide Services • Not working – paid leave (Snow day or sick leave) • Moment is before workday began (2-hour delay) • Monitoring behavior • Assisting with eating, bathroom needs, safety, medication, mobility, communication

  19. Annual Cost Report County’s Costs of Providing Personal Care Services $ Less the results of the RMTS (14% for personal care aides, 2% for care coordination, 49% for direct services) % Total Costs of Personal Care Aide $ Add in vendor/contracted costs $ Districts IEP ratio reduction Medicaid eligible % All Personal Care Aide Students Total Costs $ District’s Medicaid Reimbursement for Personal Care Aides $ Cost Settlement Difference between Costs and Reimbursement $

  20. PCG’s Time Study Team – “less than appropriate responses were submitted.” • A number of inappropriate responses were received by staff participating in the RMTS. • Two areas of concern: • Incomplete responses • Rudeness/Frustration

  21. Inappropriate Responses to RMTS • Example 2: • Who was with you? • A group of people charged with carrying out the work of an establishment • 2. What were you doing? • Inputting the last “moment in time” documentation instead of using my scheduled paperwork time to prepare for the two IEPs that I have next week. • Why were you doing this activity? • You keep sending me these “moments.” I am itinerant and MCS will not provide me with a computer, IPad, or other internet access to use during treatment blocks of time. Scheduled office time is the only time I can complete these “moments.” • 4. Is this activity regarding a Special Education student? • NA

  22. Inappropriate Responses to RMTS • Issues that arise from inappropriate responses: • Creates additional administrative burden. • Moment can be incorrectly coded if information is omitted or misleading. • When clarification is not received, moment is likely to be coded as non-reimbursable. • Reduction in reimbursement • Medicaid reimbursement is tied to the RMTS results • Penalty if 85% response rate isn’t achieved