school-based medicaid cost settlement system 1. medicaid administrative claiming (mac) all direct...
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SCHOOL-BASED MEDICAID COST SETTLEMENT SYSTEM
Medicaid Administrative Claiming (MAC)
All Direct and Administrative staff
Fee For Service(PT, OT, Speech,
Nurse, Psychologist – Care Coordination, Pers. Care 1:1 aide, Specialized Trans.)
50% District
2012 Approach to School-Based Medicaid Programs
Random Moment
Time Study
Cost Settled
RESA admin staff as vendors
Reimbursement from Billing
Quarterly Cost Report
Annual Cost Report
Random Moment
Time Study
Medicaid Eligibility Ratio MERMedicaid Eligibility Ratio
Final costs after reduction
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West Virginia Job Categories – Administrative Costs(50% Federal match) Not cost settled
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Allowable staff in the Admin Pool:
1 . Administrator Principal Special Education Director Program Specialist Special Education Secretary
And ALL staff in any of the other “pools” may also give responses to the time study that are administrative.
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Materials and supplies that relate to Medicaid administrative costs (postage, etc.) - Training related to Medicaid covered services.
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Who support staff in the Admin pool
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Only quarterly ADMIN contractors (RESA Medicaid Specialists)
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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
Quarterly MAC – Admin Claiming
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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
Quarterly MAC – Admin Claiming
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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) $
Quarterly MAC – Admin Claiming
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ANNUAL COST REPORTING COST SETTLEMENT
Medicaid Administrative Claiming (MAC)
All Direct and Administrative staff
Fee For Service(PT, OT, Speech,
Nurse, Psychologist – Care Coordination, Pers. Care 1:1 aide, Specialized Trans.)
50% District
Random Moment
Time Study
Cost Settled
RESA admin staff as vendors
Reimbursement from Billing
Quarterly Cost Report
Annual Cost Report
Random Moment
Time Study
Medicaid Eligibility Ratio MERMedicaid - Special Education Ratio
Final costs after reduction
West Virginia Job Categories
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Job categories and job titles include – 3 different cost “pools”:1 Direct Services . 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 or Case Management
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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
Annual Cost Report - Direct Services
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2013
CountyJuly Direct
ServicesJuly Cost-
Based
August Direct
Services
August Other
September Direct
Services
September Other
October Direct
Services
October Other
November Direct
Services
November Other
December Direct
Services
December Other
January Direct
Services
January Other
February Direct
Services
February Other
March Direct
ServicesMarch Other
April Direct Services
April OtherTotal Direct
ServicesTotal Other
Total Reimburse-
ment
Barbour $237.71 $80,994.21 $21.79 $3,065.86 $6,448.72 $517.82 $7,447.33 $2,512.87 $15,841.49 $2,654.99 $20,368.66 $7,097.43 $78,997.03 19491.33 206714.58 226205.91
2012
CountyJuly Direct
ServicesJuly Cost-
Based
August Direct
Services
August Other
September Direct
Services
September Other
October Direct
Services
October Other
November Direct
Services
November Other
December Direct
Services
December Other
January Direct
Services
January Other
February Direct
Services
February Other
March Direct
ServicesMarch Other
April Direct Services
April OtherMay
Direct Services
May OtherJune
Direct Services
June Other
Total Direct Services
Total OtherTotal
Reimburse-ment
Barbour 3238.07 87952.34 1322.96 15381.32 58.58 10531.75 1157.86 5333.44 57597.43 3730.53 51067.56 608.26 328.37 41912.78 2110.08 43473.03 1026.33 38313.51 3636.89 22551.37 346229.72 368781.09
Handout
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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 StudentsTotal Costs of Care Coordination $12,600
District’s Medicaid Reimbursement for Care Coordination $100,000
Cost Settlement Difference between Costs and Reimbursement $87,400
Care Coordination
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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 StudentsTotal 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
Personal Care 1:1 Aides
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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.
Personal Care Aide Services
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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
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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 StudentsTotal Costs $
District’s Medicaid Reimbursement for Personal Care Aides $
Cost Settlement Difference between Costs and Reimbursement $
Annual Cost Report
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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
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Inappropriate Responses to RMTSExample 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
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Inappropriate Responses to RMTSIssues 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