Medicaid Reimbursement Medicaid Reimbursement for School-Based Health for School-Based Health

Care ServicesCare Services

OverviewOverview

Purpose of the programPurpose of the program Reasons for the program changesReasons for the program changes Program updates and what they mean to the school Program updates and what they mean to the school

districtsdistricts ReimbursementReimbursement Rates Rates Covered services Covered services Provider qualificationsProvider qualifications DocumentationDocumentation

Purpose of the ProgramPurpose of the Program

The purpose of the program is to pay school The purpose of the program is to pay school districts for some of the healthcare related districts for some of the healthcare related

services included in an IEP.services included in an IEP.

Reasons for the program changesReasons for the program changes

2003 OIG Audit2003 OIG Audit Non-covered/unauthorized servicesNon-covered/unauthorized services Unqualified providersUnqualified providers Unsupported servicesUnsupported services

CMS Corrective Action PlanCMS Corrective Action Plan Ensure costs are allowable & adequately supportedEnsure costs are allowable & adequately supported Amend the State Medicaid Plan Amend the State Medicaid Plan

ReimbursementReimbursement

ReimbursementReimbursement

Effective for dates of services on or after Effective for dates of services on or after September 1, 2007September 1, 2007 School districts bill DSHS/Medical AssistanceSchool districts bill DSHS/Medical Assistance Medical Assistance pays the school districts Medical Assistance pays the school districts

directlydirectly School districts receive all available state and School districts receive all available state and

federal dollarsfederal dollars School districts pay their billing contractor directlySchool districts pay their billing contractor directly

Requirements for Medicaid Requirements for Medicaid ReimbursementReimbursement

Medicaid enrolled clientMedicaid enrolled client

Enrolled in special educationEnrolled in special education

Services must be in the IEPServices must be in the IEP

Provided by qualified staffProvided by qualified staff

RatesRates

Prior to September 1, 2007Prior to September 1, 2007 Cost-basedCost-based

September 1,2007 and afterSeptember 1,2007 and after Community-basedCommunity-based

How does this impact school district How does this impact school district billing?billing?

An increase in the number of codes the school An increase in the number of codes the school districts will use to bill Medical Assistancedistricts will use to bill Medical Assistance

By definition some codes pay a flat rateBy definition some codes pay a flat rate Some codes pay by units of timeSome codes pay by units of time

A unit of time is 15 minutesA unit of time is 15 minutes No more rounding upNo more rounding up

Important Points About New RatesImportant Points About New Rates

New rates are all inclusiveNew rates are all inclusive

School districts will no longer bill for School districts will no longer bill for collateral servicescollateral services

Simplify billingSimplify billing

Covered Services Covered Services

Medical Assistance pays only for services that Medical Assistance pays only for services that are medically necessary, andare medically necessary, and Address the physical and/or mental Address the physical and/or mental

disabilities of a child, anddisabilities of a child, and Are prescribed by a physician or Are prescribed by a physician or

recommended by another qualified recommended by another qualified healthcare provider, andhealthcare provider, and

Included in the IEPIncluded in the IEP

Covered Services include:Covered Services include:

Physical therapyPhysical therapy Occupational therapyOccupational therapy Speech-language servicesSpeech-language services AudiologyAudiology Nursing servicesNursing services Psychological evaluation and testingPsychological evaluation and testing Counseling services and …Counseling services and …

Please RememberPlease Remember

Evaluations and assessments for Evaluations and assessments for covered services are reimbursable only covered services are reimbursable only when the plan of care, or treatment when the plan of care, or treatment plan, is incorporated into the IEPplan, is incorporated into the IEP

Provider QualificationsProvider Qualifications

Code of Federal RegulationsCode of Federal Regulations Therapist qualificationsTherapist qualifications

Revised Code of WashingtonRevised Code of Washington Professional licensure Professional licensure

Washington Administrative CodeWashington Administrative Code Professional practice standardsProfessional practice standards

Provider Qualifications, continuedProvider Qualifications, continued

Providers must meet both federal and state Providers must meet both federal and state education and work experience requirements education and work experience requirements and where applicable, must be licensed by and where applicable, must be licensed by their professional licensing boardtheir professional licensing board

Providers requiring a professional Providers requiring a professional licenselicense

Physical therapistsPhysical therapists

Occupational therapistsOccupational therapists

Registered nurses (RN)Registered nurses (RN)

Licensed practical nurses (LPN)Licensed practical nurses (LPN)

Providers Exempt from the State Providers Exempt from the State Licensure RequirementsLicensure Requirements

Speech-language pathologistsSpeech-language pathologists

AudiologistsAudiologists

CounselorsCounselors

PsychologistsPsychologists

To be exempt providers must:To be exempt providers must:

Meet the education and work experience Meet the education and work experience requirements necessary for licensurerequirements necessary for licensure

Be ESA certified, and Be ESA certified, and

Limit their practice to the school settingLimit their practice to the school setting

Medical Assistance Policy ExceptionMedical Assistance Policy Exception

School psychologists who:School psychologists who:

Have a masters degree in school psychologyHave a masters degree in school psychology

Are ESA certified, andAre ESA certified, and

Limit their practice to the school settingLimit their practice to the school setting

““Under the direction of”Under the direction of”

Providers have the clinical and fiduciary Providers have the clinical and fiduciary responsibility for all services provided under responsibility for all services provided under their direction or supervisiontheir direction or supervision

The nature, frequency and scope of The nature, frequency and scope of supervision is determined by the supervising supervision is determined by the supervising therapist according to their professional therapist according to their professional practice standardspractice standards

Important InformationImportant Information

Effective September 1, 2007, Medicaid will no Effective September 1, 2007, Medicaid will no longer reimburse school districts for healthcare longer reimburse school districts for healthcare related services provided by para-related services provided by para-professionals, aides or instructional assistants.professionals, aides or instructional assistants.

Nurse Delegation ExceptionNurse Delegation Exception

Non-credentialed school employees may Non-credentialed school employees may provide certain limited health care tasks when provide certain limited health care tasks when delegated by a registered nurse and supervised delegated by a registered nurse and supervised according to professional practice standardsaccording to professional practice standards

Documentation RequirementsDocumentation RequirementsWAC 388-502-0200WAC 388-502-0200

The provider must:The provider must: Establish the medical necessity for servicesEstablish the medical necessity for services Develop a treatment plan including amount, Develop a treatment plan including amount,

scope & duration of servicesscope & duration of services Report on daily progressReport on daily progress Adjust the treatment plan as indicatedAdjust the treatment plan as indicated Report outcomesReport outcomes

OTHEROTHER

The role of the Medicaid reimbursement The role of the Medicaid reimbursement coordinatorcoordinator

Medicaid reimbursement policies and Medicaid reimbursement policies and proceduresprocedures

The billing codesThe billing codes Current Procedural Terminology (CPT) 2007Current Procedural Terminology (CPT) 2007

Professional AdditionProfessional Addition(800) 621-8335(800) 621-8335

Coverage list and new fee scheduleCoverage list and new fee schedule

Important InformationImportant Information

Please hold all Medicaid billings until Please hold all Medicaid billings until November 1, 2007, so the department November 1, 2007, so the department assures all systems are in place to assures all systems are in place to accurately process your billsaccurately process your bills

Contact InformationContact Information

Christine BessChristine Bess

Program ManagerProgram Manager

School-Based Health Care Services School-Based Health Care Services

bessce@dshs.wa.govbessce@dshs.wa.gov

(360) 725-1668(360) 725-1668