Massachusetts School-Based Medicaid: Lessons Learned from Expansion/Free Care Preparations

Transcription

1 Massachusetts School-Based Medicaid: Lessons Learned from Expansion/Free Care Preparations Healthy Students, Promising Futures Meeting Washington, D.C. Wednesday, December 5, 2018 Executive Office of Health and Human Services Presented by: Caitlin N. Feuer, Cross Agency Medicaid Program Manager, Massachusetts Office of Medicaid

2 Agenda 1. 1 Massachusetts Medicaid and School-Based Medicaid Program overview 2. 2 Expansion processes SPA submission and approval Implementation preparations 3. 3 Expansion changes Covered services Direct Service Claiming 4. 4 Takeaways Expansion challenges Suggested questions before submitting your own SPA 2

3 Overview Massachusetts Medicaid and School-Based Medicaid Program 3

4 Massachusetts Medicaid & School-Based Medicaid 1 Massachusetts administers the Children s Health Insurance (CHIP) and Medicaid as one program called MassHealth The School-Based Medicaid Program (SBMP) offers Local Education Agencies (LEAs) an opportunity to receive federal dollars to offset costs for providing certain Medicaid-covered services and administrative activities in a school setting. MassHealth oversees SBMP and monitors compliance with state and federal Medicaid law The University of Massachusetts Medical School (UMMS) administers the program on behalf of and in conjunction with MassHealth since the Program s inception in

5 SBMP History Bundled rate claiming for direct services 2009-present - Random Moment Time Study (RMTS) implemented - Interim direct service claims submission & annual cost report reconciliation - Quarterly Admin claims 2016 State Plan Amendment (SPA) in response to Free Care Reversal submitted ( Expansion ) 2018 Expansion announced with July 1, 2019 effective date Administrative claiming added with 15-minute time study methodology 2015 Applied Behavior Analysis (ABA) services included under preexisting School-Based State Plan authority 2017 Expansion SPA approved 5

6 SBMP Claiming 1 LEA reimbursement is based on actual costs and LEAs can seek reimbursement for: 1. Direct health services through Direct Service Claiming (DSC) 2. Certain administrative expenses associated with the provision of medical services and MassHealth outreach/enrollment assistance through Administrative Activity Claiming (AAC) Local Education Agencies can seek DSC reimbursement for children whose non-emergency services can be claimed under Medicaid or CHIP authority 6

7 1 Cost-Based Reimbursement Structure Simplified Direct Service & Admin Activities Cost Report Calculation Allowable Costs for Covered Services Medicaid Eligibility Rate RMTS Results (Statewide per pool) Gross Medicaid Reimbursable Amount (LEA-specific) Annual Cost Report Calculation (Direct Service Only) Gross Medicaid Reimbursable Amount Interim Payments Cost Report Payment 7

8 Processes 2 SPA submission and approval Implementation preparations 8

9 How did we get to Expansion? 2 Centers for Medicare and Medicaid Services (CMS) letter (SMD# dated December 15, 2014) removed the free care limitation CMS confirmed guidance that medically necessary services, regardless of IEP, may be considered for reimbursement in schoolbased Medicaid programs at 2015 NAME Conference January 2016 joint call held by U.S. Dept. of Health and Human Services (HHS), CMS and U.S. Dept. of Education (DOE) encouraged states to submit State Plan Amendments 9

10 How did we get to Expansion? (cont.) 2 March 2016 Massachusetts assembled a workgroup to explore submitting a SPA and prepare for expansion. The workgroup included: MassHealth program, finance, legal, clinical staff UMMS as program vendor Massachusetts Dept. of Elementary & Secondary Education (DESE) Massachusetts Dept. of Public Health (DPH) School Nursing Director SPA submitted to CMS September 2016 Formal questions received in November 2016 Second round of questions received February 2017 CMS approved SPA July

11 While we were waiting for SPA Approval 2 Tried our best to prepare Developed implementation plan, which included: Training plan Identification of MMIS changes Identification of UMMS system changes Identified specific nursing services, potential billable procedure codes & interim rates Began updating instruction manuals/guides Staff transition CMS indicated we could NOT implement RMTS pool or activity code changes or otherwise begin implementation 11

12 SPA Approval! Now what? 2 Approved with a July 2016 effective date in July 2017 Could not retroactively claim per CMS Could not implement in the fiscal year that was underway (no LEA preparation, IT infrastructure changes required) Asked ourselves what effective date would be reasonable for LEA compliance and participation and then we asked the LEAs 12

13 and then we asked the LEAs 2 In March 2018, MassHealth shared written material and video of narrated PowerPoint about key opportunities and barriers for expansion What expansion will entail Amended contract requirement (previously took 6-8 months) DESE shared guidelines around parental consent requirement per FERPA MassHealth administered the survey and asked whether July 1, 2018 or July 1, 2019 was most feasible and desirable implementation date Overall feedback indicated while LEAs would want a revenue pickup as soon as possible, it was not feasible to implement in four months Shared results of survey with LEAs before formally announcing expansion would be effective July 1,

14 Launching LEA expansion prep: partnership in action 2 In order to maximize participation and compliance, engaging LEAs every chance we get -based outreach Mentioning expansion/contracts during help desk calls Trainings DESE s Commissioner Updates DPH Nurse Training Days Communicated to LEAs that they would directly need to be involved Give them every tool possible to succeed, including meaningful resources and access to information 14

15 Developing SBMP Communications Strategy 2 Reviewed entire body of communications Determined strategy website/accessibility forward Website redesign New online Resource Center Began overhauling all externally facing materials and created new documents Updated Program Guidelines Created Quick Reference Pages/formalized cheat sheets Updated Contact Forms - required LEA contacts 15

16 LEA training 2 Kicked off training for LEAs with all-day trainings during the last week of September Jointly presented by MassHealth, UMMS, DESE, and DPH Worked aggressively to encourage LEAs to directly engage the right people in the process LEA representatives sending billing vendor is not enough Multiple staff per LEA (e.g. RMTS coordinators, Special Education Director AND Nursing/Health Director, billing staff, LEA revenue/accounting staff, etc.) Unprecedented 500 person attendance in-person and via livestream with 90% of LEAs represented at the training Due in large part to multi-agency outreach and UMMS push to ask why aren t you registered? Focus was on reinforcing existing program requirements and explaining how expansion fits within the program Offered takeaway questions to aid in preparation efforts and ongoing compliance 16

17 Continuous LEA training future plans 2 Planned for Spring 2019: Nursing Services-focused training planned for Spring All other direct medical services focused training(s) RMTS focus training Planned for late Summer/early Fall 2019: RMTS training for RMTS coordinators Administrative Activity Claiming training Additional training and resources likely to be added Sent a digital training evaluation to all LEAs to learn what worked, what did not work, and why 10% of LEAs did not attend MassHealth and UMMS will develop additional training and materials based on LEA feedback 17

18 Expansion Changes 3 Covered services Direct Service Claiming 18

19 Expansion Methodology Changes 3 Simplified Direct Service Cost Report Calculation Allowable Costs for Covered Services RMTS Results (Statewide per pool) Medicaid Eligibility Rate (LEA-specific) Gross Medicaid Reimbursable Amount All three direct service inputs above changed as a result of program expansion (admin claiming methodology unchanged) 19

20 Covered Services & Providers 3 The services listed below are the MassHealth Covered Services within the current scope of the School-Based Medicaid Program SBMP Covered Services Through June 30, 2019 Services MUST be Pursuant to an IEP Applied Behavior Analysis Services Audiology Occupational Therapy Personal Care Services Physical Therapy Psychological Counseling Skilled Nursing Services Speech-Language Therapy Vision Services 20

21 Current vs. Expansion 3 SBMP Expansion includes the following changes: 1 IEP requirement lifted, including coverage of initial evaluations Covered services can be pursuant to a Section 504 plan, other health plan, or are otherwise medically necessary 2 Inclusion of additional licensed practitioners DESE-licensed School Psychologist (most anticipated) Optometrist Licensed Dietician / Nutritionist Dental Hygienist 3 Inclusion of new service specialty types Medical Nutritional Services provided by a registered dietician or licensed nutritionist Dental assessments/screenings provided by a dental hygienist or fluoride treatments provided by a nurse 21

22 Covered Services & Providers 3 The services listed below are the MassHealth Covered Services within the scope of the SBMP starting July 1, 2019, regardless of inclusion in an IEP SBMP Covered Services Effective July 1, 2019 Applied Behavior Analysis Services Audiology Dental Assessments / Screenings (Fluoride varnish) Medical Nutritional Services Health / Behavioral Health Screenings and other services under EPSDT Occupational Therapy Personal Care Services Physical Therapy Physician Medical Evaluations Psychological Counseling Skilled Nursing Services Speech-Language Therapy Vision Services 22

23 Methodology Changes: RMTS 3 Random Moment Time Study (RMTS) Pools Current (through June 30, 2019) Three pools: 1) Direct Service 2) Admin Only 3) ABA Therapy Expansion (Starting July 1, 2019) Four pools: 1) Mental/Behavioral Health 2) Therapy Services 3) Medical Services 4) Admin Only Mental/Behavioral Health Therapy Services Medical Services ABA providers Counselors Psychologists Social Workers Speech/Language providers Occupational Therapy providers Physical Therapy providers Audiology/Hearing providers Dental Hygienists Nurses Nutritionists/Dieticians Optometrist Personal Care Service providers Physicians Medicaid Billing Personnel 23

24 Methodology Changes RMTS (cont.) 3 Mental/Behavioral Health Pool - IEP Direct Service % - Non-IEP Direct Service % - Admin % Therapy Services Pool - IEP Direct Service % - Non-IEP Direct Service % - Admin % Medical Services Pool - IEP Direct Service % - Non-IEP Direct Service % - Admin % - Admin % Admin Only Pool Under expansion, direct service RMTS % will be split into IEP and non-iep percentages. The admin calculation remains unchanged. 24

25 Methodology Changes - RMTS 3 RMTS questions and pre-defined answer mapping required substantial revision to accurately isolate the IEP vs. non-iep reimbursable direct service time Used the opportunity to improve, clarify existing wording based on LEA feedback and historical write-in answers Revised RMTS pre-defined answers rolled out this school year (without impact to reimbursement) Offers RMTS participants opportunity to get used to the new organization and wording Offers MassHealth/UMMS opportunity to get feedback about the wording and language so that it can be further improved prior to expansion implementation next year when it impacts reimbursement 25

26 Medicaid Eligibility Rates 3 Three separate Medicaid Eligibility Rate (MERs) will be used: 1. Direct Service Claiming for IEP Services: MER based on population of IEP students for whom the LEA seeks reimbursement 2. Direct Service Claiming for non-iep Services: MER based on district-wide population of students for whom the LEA seek reimbursement 3. Administrative Activity Claiming (unchanged under expansion): school-district wide total student population eligibility percentage 26

27 Current Cost Report calculation reminder 3 Simplified Direct Service & Admin Activities Cost Report Calculation Allowable Costs for Covered Services RMTS Results (Statewide per pool) Medicaid Eligibility Rate (LEA-specific) Gross Medicaid Reimbursable Amount 27

28 Expansion Cost Report calculation 3 Therapy Pool Example Allowable Costs for Covered Services Allowable Costs for Covered Services IEP Services RMTS Results (Statewide Therapy Pool) Medicaid Eligibility Rate (LEA-specific for students on IEPs) Non-IEP Services RMTS Results Medicaid Eligibility Rate (Statewide Therapy Pool) (LEA wide) Gross Medicaid Reimbursable Amount for Therapy Green indicates new RMTS pool and percentage and new MER 28

29 Takeaways 4 Expansion challenges Suggested questions before submitting your own SPA 29

30 4 Challenges Shared Language around Covered vs. Reimbursable Services Covered Services: Services that are claimable under the SBMP Massachusetts State Plan Amendment Reimbursable Services: Covered Services provided consistent with program requirements Billable Procedure Codes: The CPT codes that LEAs use to submit interim claims after the provision of Reimbursable Services 30

31 Challenges Reimbursable Services requirements for non-iep services 4 If a Covered Service is delivered, the following requirements must be met to be considered a Reimbursable Service: 1. Practitioner RMTS Direct Service Pool Participation 2. Practitioner Licensure Qualifications 3. Medicaid Medical Necessity 4. Service Authorization 5. Service Documentation 31

32 Challenges Parental Consent 4 DESE determined FERPA requires consent before an LEA can share information with MassHealth; this is a federal education requirement, not a Medicaid requirement. Restrictions include: Eligibility information for MER for direct service claiming Claim submission This directly impacts on revenue since MER is used in Cost Report and claims submission is required for inclusion in cost report DESE issued updated guidance and a new parental consent form for both IEP and non-iep services for all children in a family Continued with one time consent policy (with annual notification) Guidance from DESE available here: DESE assisting LEAs with strategies to obtain consent from families not currently part of the IEP-based reimbursement program 32

33 Challenges LEA involvement Historically it could be challenging to get LEAs directly involved (rather than depending on billing vendor) Began with outreach efforts and getting LEAs to attend the trainings in September (90% success rate!) Updated contact requirements requiring LEA direct involvement in most processes/components of the program Emphasizing that LEAs are the contracted provider and LEA representatives certify the public expenditure so it is the LEAs responsibility Reminder that ultimately LEAs are the entities audited by MassHealth, CMS, OIG, etc. 4 33

34 Challenges Interim Billing and Contracts 4 Interim Billing New services and new procedure and diagnosis codes Without interim claims, costs cannot be claimed in cost report On an IEP claim vs. non IEP claim basis Claims modifiers are used to indicate whether claims are pursuant to or outside of an IEP Contracts Previously 6-8 months required to execute contracts Challenge avoided due to preparation year Reimbursable Services requirements directly impact claim submission 34

35 Challenges TPL & Managed Care 4 TPL not an issue. The SBMP program upon initial implementation was excluded from TPL requirements because private insurers do not cover services provided in the school setting. We provided documentation from all the major insurers stating that exclusion and therefore our LEAs do not work with TPL at all. MCOs and ACOs not an issue. The SBMP program is carved out from MCOs and ACOs. 35

36 Potential Questions to Take Back to Your Agencies 4 Relationships How is the program currently doing? Could the LEAs handle a major change like expansion/free care? Are they currently engaged with the program? How is our website/externally facing materials? How are our cross-agency relationships? DPH? Dept. of Ed? Since this impacts local aid, do we need to work with the legislature? Are there advocacy groups that we should talk/work with (e.g. nursing associations, parent groups)? How will we manage expectations with LEAs and other internal and external stakeholders? Contracts Will new or amended contracts be required? 36

37 Potential Questions to Take Back to Your Agencies 4 Services and Provider Types What services and provider types would we want to include in a SPA? FERPA What services are currently provided and by whom? Restrict to specific plans such as Section 504? Include otherwise medically necessary services? Are/could LEAs, particularly nurses, be ready to apply state and federal medical necessity requirements outside of a plan structure? Do legal teams consider FERPA to apply in this case? What is the current IEP consent process? What would new consents look like and how would it impact expansion/free care? Eligibility rate or billing only? 37

38 Potential Questions to Take Back to Your Agencies 4 Technical Elements What RMTS structure makes the most sense? What data is available to help model financial impact? What data can we get by thinking ahead before SPA submission? What changes would need to be made to infrastructure? RMTS system? Cost report filing? Admin claiming system? LEA systems? How would interim billing be impacted? 38

39 Expansion firsts 4 39

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