1. SCHOOL-BASED MEDICAID COST SETTLEMENT SYSTEM August 31, 2012

2. www.cms.gov

3. 72.62% 27.38% Medicaid Program - Jointly Funded - Federal/State Changes annually per state’s capita income.

4. Each School District – 1 st # Scheduled Rates Audiology - $36 per service Physical /Occupational Therapy - $10 per 15 minutes Speech Therapy - $7 per 15 minutes Individual session Nurse - $7 per 15 minutes Individual session - specialized procedure Psychology - $100 per evaluation Each School District – 2 nd # Cost-Based Rate Salaries/Benefits Initial/Triennial IEP - $500 per IEP Annual IEP $100 per IEP Personal Care (full) - $90 per day Personal Care (part) - $45 per day Sp. Trans. Vehicle - $20 per day (round trip) Sp. Trans. Aide - $18 per day (round trip) Care Coordination - $78 per month 19902000

5. RESA LEA WVDHHR - Molina Processing Agency; Bureau of Medical Services BMS Remittance Advice Denial/pending Electronic claim Billing Form or WVEIS Entry Provide the service: Speech, PT, OT, etc. Progress Notes Attendance Records Fed Payment – Direct Deposit 72.62% Serves as the Clearinghouse

6. Historical Approach to School Based Medicaid Programs to 2003 WV: Introduction to Medicaid Cost Based School Based Health Services 6 Fee for Service (FFS) 72.62% Medicaid Administrative Claiming (MAC) 50% LEA $RESA $ “Compartmentalized” programs with minimal integration Various compliance issues in both programs  One reason the Federal government proposed to eliminate MAC

7. RESA LEA WVDHHR - Molina Processing Agency; Bureau of Medical Services BMS Remittance Advice Denial/pending Electronic claim Billing Form or WVEIS Entry Supporting Documentation: IEP Progress Notes Attendance Records Care Coordination form Fed Payment – Direct Deposit 72.62% Fed -Medical Administrative Claiming (MAC) 50% Districts provided 50% (except for RESA 2)

8. Each School District – 1 st # Scheduled Rate Audiology $36 per service Physical /Occupational Therapy $10 per 15 minutes Speech Therapy $7 per 15 minutes Individual session Nurse $7 per 15 minutes Individual session Psychology $100 per evaluation Each School District – 2 nd # Cost-Based Rate added Indirect costs Initial/Triennial IEP $700 per IEP Annual IEP $170 per IEP Personal Care (full) $190 per day Personal Care (part) $95 per day Sp. Trans. Vehicle $26 per day (round trip) Sp. Trans. Aide $22 per day (round trip) Care Coordination $98 per month 19902003 Direct Services

9. RESA LEA WVDHHR - Molina Processing Agency; Bureau of Medical Services BMS Remittance Advice Denial/pending Electronic claim Billing Form or WVEIS Entry Supporting Documentation: IEP Progress Notes Attendance Records Care Coordination form Fed Payment – Direct Deposit 72.62% Fed -Medical Administrative Claiming (MAC) 50% Districts provided 100% (except for RESA 2)

11. In response to CMS questions, West Virginia is implementing a new reimbursement methodology for school based services, effective July 1, 2012. Effective for dates of service beginning July 1, 2012, school based providers will be reimbursed using a cost based reimbursement methodology. School based providers will be required to participate in a Random Moment Time Study and complete an annual cost report as part of the new methodology. School Based providers will still need to submit Fee-for-service claims for services rendered throughout the year. In addition to the changes in the direct services, West Virginia will also be implementing a Medicaid Administrative Claiming (MAC) program to capture administrative costs for activities performed in support of the Medicaid program. Overview of Program Changes

12. 2012 Approach to School-Based Medicaid Programs  Programs now work together  Integrated time study for Medicaid Administrative Claiming (MAC) and Fee For Service reimbursement  District administrative personnel costs will be included in the cost report and will take part in the time-study to determine what part of their costs is eligible for MAC  The direct service costs (therapists, special education teachers, personal care aides) will be included in the cost report and will take part in the time study to determine what part of their costs is eligible for reimbursement AND determine what responses qualify for MAC. WV: Introduction to Medicaid Cost Based School Based Health Services 12 MAC 50% match

13. Overview of FFS Cost Reporting Process  The purpose of the Medicaid Fee-For-Service (FFS) Program is to provide reimbursement for medically necessary services that are received in schools and provided or arranged by a school system for Medicaid-eligible students with an Individualized Education Program (IEP)  Services are currently reimbursed according to a mix of cost based and fee schedule  Effective for dates of services beginning July 1, 2012, services will be cost reimbursed and an annual Medicaid cost report must be filed by each LEA  Medicaid cost will be calculated through a series of calculations including a Cost Report, a Random Moment Time Study (RMTS) methodology, Cost Reconciliation and Cost Settlement  Medicaid cost will be compared to Medicaid interim payments for direct services and a settlement will be calculated for each LEA  When LEA Medicaid costs exceed Medicaid interim payments, a settlement will be due to the LEA  When LEA Medicaid costs are less than Medicaid interim payments, the LEA will return the overpayment to Medicaid WV: Introduction to Medicaid Cost Based School Based Health Services 13

14. West Virginia Job Categories – Direct Service Fee for Service (72.62% Fed match) WV: Introduction to Medicaid Cost Based School Based Health Services 14  Job categories and job titles include – 3 different cost “pools”: 1. WV Licensed Audiologist WV Licensed Occupational Therapist WV Licensed Physical Therapist Speech Language Therapist WV Licensed Registered Nurse WV Licensed Psychologist 2. Personal Care Aide – Personal Care 1:1 3. Special Education Teacher - Care Coordination

15. Cost Settlement Calculation Example – WV: Introduction to Medicaid Cost Based School Based Health Services 15 1.0Total Costs of Eligible Direct Services Provider Costs (county’s cost) $1,000,000 2.0Indirect Cost Rate115.00% 3.0Total Costs of Eligible SBHS Provider Costs$1,150,000 4.0RMTS Direct Medical Percentage Results (Statewide results)65.00% 5.0Direct Medical Services Costs$747,500 6.0Costs of Contracted Vendors$100,000 7.0Total Costs of SBHS Provider Costs$847,500 8.0Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)50.00% 9.0Medicaid Direct Medical Services Costs (for the county)$423,750 10.0Medicaid Payments Received (by the county)$473,750 11.0Medicaid Cost Settlement (at the end of the year – July 2013)$0

16. Medicaid Administrative Claiming (MAC) in WV WV: Introduction to Medicaid Cost Based School Based Health Services 16  MAC offers reimbursement for the costs of administrative activities, such as outreach, that support the Medicaid program.  Allowable activities are :  Medicaid outreach and related training  Facilitating Medicaid eligibility application  Health-related referral activities & monitoring of health service delivery  Medical service program planning, policy development, and interagency coordination  Arranging for Medicaid-related transportation and provision of Medicaid-related translation

17. School Based Examples of Activities WV: Introduction to Medicaid Cost Based School Based Health Services 17  Providing information to individuals and families regarding the West Virginia Medicaid program and available services  Scheduling and/or coordinating EPSDT screens or other medical and mental health diagnostic services  Gathering any information that may be required in advance of these referrals  Developing internal plans and strategies to improve health service delivery and eliminate gaps  Attending a parent meeting for a child with issues that may need outside health or counseling services

18. West Virginia Job Categories – Administrative Costs (50% Federal match) Not cost settled WV: Introduction to Medicaid Cost Based School Based Health Services 18  Job categories and job titles include – 1. Administrator Principal Special Education Director Assistant Principal Special Education Secretary Program Specialist RESA Medicaid Specialist

19. Non Allowable Staff WV: Introduction to Medicaid Cost Based School Based Health Services 19 Staff included in the calculation of the Unrestricted Indirect Cost Rate cannot be included on your staff pool list – These include costs reported in the following function codes: Business Support Services Plant Operations and Maintenance – The costs in these function codes are not allowable because the Unrestricted Indirect Cost Rate is used in the calculation of the claim – Staff who are paid entirely from these function codes should be removed from the staff pool list – Partially paid staff from allowable object codes can be included

20. 1.0Total Costs of Administrative Costs (county’s cost)$1,000,000 2.0RMTS Direct Medical Percentage Results (Statewide results)10.00% 3.0Direct Medical Services Costs$100,000 4.0Costs of Contracted Vendors (RESAs) not subject to RMTS$10,000 5.0Total Costs of Administrative Costs$110,000 6.0Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)50.00% 7.0Medicaid Direct Medical Services Costs (for the county)$55,000 Administrative Claiming - not billing for direct services

21. Because RESAs will be treated like other vendor for cost reporting purposes, the RESAs will now need to bill counties just like any other vendor effective July 1, 2012: Hours Worked X Billable Rate. In the past, RESAs may have simply billed a county for a certain percentage of an employee’s salary and fringe benefits, based on a pre-determined agreement with the county. Such an agreement does not take into consideration the fact that the employee does not spend all of their time providing services for the county 9ex. General time spent in the office, continuing education, etc.). The RESAs will now need to develop appropriate billable rates to charge to the counties based on the actual hours spent providing Medicaid reimbursable services.

22. In terms of determining rates for Medicaid billing services, keeping hourly documentation of time spent for each district and billing accordingly would be the preferred method of calculating the rates. However, we would be happy to discuss the reimbursement method based on the amount of reimbursement received – with a bit more clarity surrounding the process they would be using, we would be better equipped to provide advice. Please let me know if you would like to arrange for a time next week to discuss this further.

23. Preliminary Results of 1 st RMTS February - March Response rates – 85% required (3000 moments per “pool”) » 92.13% - Direct Services » 83.20% - Care Coordination » 78.60% - Personal Care » 89.47% - Admin

24. Preliminary Results of 1 st RMTS February - March Service percentages responses » 49.16% - Direct Services » 4.24% (4.15%) - Care Coordination » 20.21% (18.48%) - Personal Care

25. 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

26. Inappropriate Responses to RMTS Example 1: (Would not be coded as Medicaid allowable cost. Needs more detail.) 1.Who was with you? No one 2. What were you doing? Duty 3.Why were you doing this activity? Assigned duty 4. Is this activity regarding a Special Education student? No

27. Inappropriate Responses to RMTS Example 2: 1.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. 3.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

28. 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

29. Cost Settlement Calculation Example – WV: Introduction to Medicaid Cost Based School Based Health Services 29 1.0Total Costs of Eligible Costs Direct Services (county’s cost)$1,000,000 2.0Indirect Cost Rate115.00% 3.0Total Costs of Eligible SBHS Provider Costs$1,150,000 4.0RMTS Direct Medical Percentage Results (Statewide results)49.16% 5.0Direct Medical Services Costs$565,340 6.0Costs of Contracted Vendors$100,000 7.0Total Costs of SBHS Provider Costs$665,340 8.0Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)50.00% 9.0Medicaid Direct Medical Services Costs (for the county)$332,670 10.0Medicaid Interim Payments Received (by the county)$400,000 11.0Medicaid Cost Settlement (at the end of the year – July 2013)$67330

30. Cost Settlement Calculation Example – WV: Introduction to Medicaid Cost Based School Based Health Services 30 1.0Total Costs of Eligible Costs Care Coordination (county’s cost)$1,000,000 2.0Indirect Cost Rate115.00% 3.0Total Costs of Eligible SBHS Provider Costs$1,150,000 4.0RMTS Direct Medical Percentage Results (Statewide results)4.15% 5.0Direct Medical Services Costs$47,725 6.0Costs of Contracted Vendors$0 7.0Total Costs of SBHS Provider Costs$47,725 8.0Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)50.00% 9.0Medicaid Direct Medical Services Costs (for the county)$23,862.50 10.0Medicaid Interim Payments Received (by the county)$24,000.00 11.0Medicaid Cost Settlement (at the end of the year – July 2013)$317.50

31. Cost Settlement Calculation Example – WV: Introduction to Medicaid Cost Based School Based Health Services 31 1.0Total Costs of Eligible Costs Personal Care Aide (county’s cost)$1,000,000 2.0Indirect Cost Rate115.00% 3.0Total Costs of Eligible SBHS Provider Costs$1,150,000 4.0RMTS Direct Medical Percentage Results (Statewide results)18.48% 5.0Direct Medical Services Costs$212,520 6.0Costs of Contracted Vendors$2,000 7.0Total Costs of SBHS Provider Costs$214,520 8.0Application of Medicaid Eligibility Rate (IEP Ratio) (county’s)50.00% 9.0Medicaid Direct Medical Services Costs (for the county)$106,260 10.0Medicaid Interim Payments Received (by the county)$300,000 11.0Medicaid Cost Settlement (at the end of the year – July 2013)$193740

32. Quarterly Staff Pool List Updates WV: Introduction to Medicaid Cost Based School Based Health Services 32  Staff can only be added once a quarter, no one can be added for the quarter after the staff pool list has been submitted (Vendors not included in time study)  Once RMTS is implemented, the staff pool list from the previous quarter should be updated every quarter  LEAs can add, remove, or change participants’ information at this time  If questions arise about the update, PCG will contact the LEA to get clarification  After all staff pool lists have been returned and quality checks completed, PCG will generate state-wide Random Moment Time Study (RMTS) sample

33. Current Quarter Process WV: Introduction to Medicaid Cost Based School Based Health Services 33 Pull your staff pool list - be sure to list the Job Title, First and Last Names, Email Address and School Name (optional) Provide PCG with the LEA staff pool list the first time – Following the first upload, you will be trained by PCG to use the online Staff Pool List web-based system

34. Quarterly Cost Reports - County Treasurers Costs of Direct Services – Audiological, Speech, Occupational, Physical, Psychological, Nurses (RNs) Services Costs of Care Coordination – Special Education Teachers (of students with disabilities) Cost of Personal Care – 1:1 Aides Cost of Administrative Personnel Cost of Specialized Transportation – Not subject to RMTS

35. Quarterly Payroll Information First Name Cost PoolJob TitleEmployee ID Total Salary Total Benefits Compens ation Federal Sources (IDEA) Net Compens ation Expendit ures JohnDirect Service Speech Language Pathologist 92001111$25,000$3,900$10,000$18,900 JohnCare Coordina tion Special Education Teacher 92001112$39,000$2,300$42,300 JohnPersonal Care Aide92001113$12,500$2,859$15,359$0

36. District’s Specialized Transportation Cost Report Draft form – will be completed electronically.

37. District’s Cost Report Draft form – will be completed electronically.

38. District’s Quarterly Cost Report

39. Codes – Accuracy Important Project Codes: 43310 – IDEA School-age Funding 43320 – IDEA Preschool Funding Program Function Codes: 21210 Multi-categorical 2 (Other codes) 2 22161 Occupational Therapy 22162 Physical Therapy etc. Object Codes: 111 Regular professional (salary) 121 Regular service (salary) 2XX Benefits

40. RMTS Rosters Rosters of staff in an Excel Template (PCG) - in August 2012 RMTS – October – December 2012 RMTS – January – March 2012 RMTS – April – June 2012