1. Overview of School-Based Medicaid
New Directors Training
Idaho Centre on the Grove
September 17, 2015

2. Developed and Presented By: Idaho Division of Medicaid
Frede' Trenkle
Alternative Care
Coordinator
School Based Service,
Idaho Division of Medicaid

3. Developed and Presented By:
SUPPORTING SCHOOLS AND STUDENTS TO ACHIEVE
SHERRI YBARRA, SUPERINTENDENT OF PUBLIC INSTRUCTION
Developed and Presented By:
Shannon Dunstan
Early Childhood and Interagency Coordinator
Idaho State Department of Education

4. History of IDEA and Medicaid
The Medicare Catastrophic Coverage Act of (MCCA) and the Omnibus Budget Reconciliation Act of 1989 (OBRA ’89)
Allowed 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.

5. Role of Health and Welfare
Oversight of all Medicaid programs rests with the Idaho Department of Health and Welfare.
The Division of Medicaid has different units that help administer School Based Medicaid services.
Policy Unit manages existing and drafts new IDAPA rule which is then presented to interested parties for comment and ultimately up the Idaho Legislature to approve. The policy unit also conducts reviews and technical assistance to assure program compliance.
Integrity Unit monitors compliance with IDAPA rule and can perform audits of all Medicaid billings which may result in recoupment of funds if the Medicaid provider (school district) does not provide the documentation of services according to rule.

6. Role of Local Education Agency (School Districts)
Schools have an obligation to provide IDEA services whether they are billing Medicaid or not.
IEP is always written based on the needs of the student. After the IEP is written the school will then determine if the child is eligible for a Medicaid service.
If a LEA desires to bill Medicaid for health related services, the district must apply to become a Medicaid provider.
Each LEA is then responsible for ensuring that all individuals who will be administering Medicaid billable services follow all applicable rules of the School-based Medicaid program.

7. Education and Medicaid
The Medicaid program provides support for children who are eligible for special education services and have specific healthcare needs that affect their educational performance as identified in their IEP.
*Medicaid cannot reimburse for services identified on a 504; all Medicaid reimbursable services in the school must be identified on an IEP.
Medicaid benefits are allowed in the schools, but cannot be used to provide educational, recreational, or vocational activities.

8. Background Checks Idaho Code 33-130
Criminal history checks for must be completed for:
School district employees
Applicants for certificates OR
Individuals having contact with students
(If a school contracts with community providers they need to assure that those contractors have a background check from the State Department of Education)
The school district is responsible for checking the Medicaid exclusionary lists (State and Federal) to assure they are not hiring a person to provide a Medicaid service who is excluded to bill Medicaid

9. Medicaid Reimbursable Services
Evaluations
Medical Equipment and Supplies
Transportation Services
Interpretive Services
Psychotherapy
Psychosocial Rehabilitation
Physical Therapy
Occupational Therapy
Speech/Audiological Therapy
Personal Care Services
Nursing Services
Behavioral Intervention
Behavioral Consultation
(Each service has different individual requirements for student eligibility, program and staff requirements; refer to IDAPA )
Medicaid will reimburse school districts and charter schools for the following services: (Read the slide)

10. Medicaid is a Medical Model
Medicaid will reimburse for services that are medically necessary and identified in the State Plan.
If service eligibility criteria is based on a diagnosis Medicaid would look for a “medical diagnosis”.
An “educational determination” does not automatically qualify a child for a service.

11. Educational Determination Vs. Medical Diagnosis
An educational determination for services is based on a finding by an IEP team that the 3-prong test has been met, establishing a need for special education.
A medical diagnosis is based on the criteria in the DSM- V. The DSM-V is the standard reference that healthcare providers use to diagnose mental and behavioral conditions and is published by the American Psychiatric Association.
When discussing student eligibility for the different services, it is important to understand that Medicaid must follow the medical model, therefore, it is important to understand the difference between an “educational determination” versus a “medical diagnosis”. Read the slide

12. Medical Diagnosis VS. Educational Determination
DSM - V
Guided by
Individual Disabilities Education Act (IDEA)
Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
Symptoms are adversely impacting
Academic Functioning
(Ages 3 and above)
Adaptive Functioning
Performed by
Team Membership defined in IDEA
Professional
Diagnostic training
Age
3 – 21
Children and Adults
Process and Method
Specific evaluation process and procedures are required and methods are identified.
Not Specified:
Process and procedures determined by
referral concerns.
Developmental or Cognitive testing for rule out of developmental delay
Included
•Observation
•Testing
•Interview
Evaluation of
Child in all areas of suspected disability.
Child, Family Concerns, Stressors
This slide gives additional information on the differences between Medical diagnosis versus educational determination. Please take a moment to review this slide.

13. Requirements for all Medicaid Reimbursable Services

14. Recommendation Requirements
All services (including evaluations) must be recommended by a physician or other practitioner of the healing arts.
( : Practitioner of the Healing Arts. A physician’s assistant, nurse practitioner, or clinical nurse specialist who is licensed and approved by the state of Idaho to make such recommendations or referrals for Medicaid services. )
These recommendations must be signed and dated by the physician or other practitioner of the healing arts.
These recommendations must be obtained prior to the provision of services
These recommendation are effective for a period of 365 days.
OT/PT/SLP have additional physician order requirements.
IDAPA
All services including evaluations must be recommended by a physician or other practitioner of the healing arts. A practitioner of the healing arts is defined in IDAPA. These professionals are a physician’s assistant, nurse practitioner, or clinical nurse, all who are licensed in the State of Idaho. These recommendations must be signed and dated by the physician and they must be obtained prior to the provision of services. These recommendations are effective for a period of 365 days. For OT/PT/SLP there are additional physician order requirements.

15. Physician Order OT/PT/SLP
Physician order must include, at a minimum, the service to be provided, the frequency, and, where applicable, the duration of each therapeutic session.
In the event that services are required for extended periods, these services must be reordered at least every 90 days……except
If the child has a chronic medical condition, documented by the physician, nurse practitioner, or physician assistant, there must be a reorder at least every 6 months.
IDAPA
Read the slide

16. IEP and Other Service Plans
Type, frequency, and duration of the service(s) provided
Title of the provider(s), including the direct care staff delivering services under the supervision of the professional
Measurable goals, when goals are required for the service
Specific place of service
IDAPA
The IEP, Service plan, and/or transitional IFSP must include the following:
Type, frequency, and duration of the services provided
Title of the providers, including the direct care staff delivering services under the supervision of the professional. If the schools require flexibility to the service then they can include different providers in different settings on the IEP. For example: “Behavioral intervention will be provided by a professional and/or a paraprofessional under the supervision of a professional in an individual and/or group setting for 120 minutes weekly.” Only include providers and settings that the IEP has identified as a need for the student. If you know that a paraprofessional will never provide the service then you would not include this in your IEP. Remember that Medicaid will reimburse for services identified on the IEP, so if the school does not include group behavioral intervention services on the IEP, then they cannot bill Medicaid for this service if provided in the group setting.

17. 120 Day Review
A documented review of progress toward each service plan goal completed at least everyone 120 days from the date of the annual plan. (IDAPA )
Current IEP progress reports can demonstrate compliance with this rule as long as the report includes a “review of progress” for each goal.
At least every 120 days, the school must have a documented review of progress for each goal identified on the IEP. The school can utilize the progress report to assure compliance with this requirement. The progress report must have a review of progress that includes a narrative that is parent friendly and explains progress for each goal.

18. Service Detail Report Name of Student
Name and title of the person providing the service
Date, time, and duration of service
Place of service, if provided in a location other than school
Category of service
Brief description of the specific areas addressed
*Must correspond to the IEP goal, if applicable
Student’s response to the service when required for the service
IDAPA
When a school submits a claim for Medicaid reimbursement there must be a service detail report that corresponds to each claim. The service detail reports must include the following:
Name of student
Name and title of the person providing the service. Remember there must be a title, if a paraprofessional is providing the service then their title could be “paraprofessional”
Place of service, if provided in a location other than the school
Category of service. This is the service provided, for example: Professional behavior intervention in a group setting
Brief description of the specific areas. To be in compliance with this regulation the specific areas must correspond directly to the IEP goals. Some schools have included the actual goals on the IEP to assure compliance with this rule.
Student’s response to the service when required for the service. The student’s response must correspond directly to the IEP goal and should include data based on the measurable goal to demonstrate progress.

19. Requirements for all Services
Documentation that supports the claim to Medicaid must be maintained by the school and must be retained for a period of 6 years. ( )
Documentation of Qualifications of Providers. ( )
Documentation that parents were notified of the health-related services and equipment (services, providers, type, location, frequency, and duration of the services) for which they will bill Medicaid. ( )
Documentation that the school district provided the parent or guardian with a current copy of the child’s plan and any pertinent addenda. ( a)
Documentation that the school requested the name of the student’s primary care physician from the parent or guardian. ( b)
The following requirements must be met for all claims to Medicaid:
Documentation that supports the claim to Medicaid must be maintained by the school and must be retained for a period of 6 years. Remember, the school is solely responsible for all claims to Medicaid. Therefore the school must have possession of all documentation that supports those claims. This information can be kept electronically as long as the school is following Medicaid’s electronic recordkeeping and electronic signature policies. These policies can be found at:
Documentation of Qualifications of providers. This information must be current at the time of the claims to Medicaid, and must be maintained for 6 years. Schools will need to assure that they have updated licenses and certifications at all times.
Documentation that parents were notified of the health-related services and equipment (services, providers, type, location, frequency and duration of the services) for which they will bill Medicaid. This information is generally discussed during the IEP meetings, if the school has IEP meeting notes this would satisfy this requirement.
Documentation that the school district provided the parent or guardian with a current copy of the child’s plan and any pertinent addenda. If the parent signs the IEP or if the school mails the IEP to the parent and has documentation of this then the school would be in compliance with this rule.
Documentation that the school requested the name of the student’s primary care physician from the parent or guardian.

20. REMEMBER!!
Schools have an obligation to provide IDEA services whether they are billing Medicaid or not.

21. Resources to Know and Use
Medicaid School-Based Services website:
Idaho Training Clearinghouse website: (Topics, School-Based Medicaid)
Molina: (Provider handbooks, Information Releases, Fee schedule links, ICD-10 information, etc.)
Children’s Developmental Disability Services website: (Habilitation Intervention criteria)

22. QUESTIONS???

23. Frede' Trenkle, Alternative Care Coordinator; School Based Service,
Idaho Division of Medicaid
(208)

24. SUPPORTING SCHOOLS AND STUDENTS TO ACHIEVE
SHERRI YBARRA, SUPERINTENDENT OF PUBLIC INSTRUCTION
Shannon Dunstan
Early Childhood & Interagency Coordinator
Idaho State Department of Education
Division of Special Education
(208)
Charlie Silva
Special Education Director
Idaho State Department of Education
Division of Special Education
(208)