HBS Topics of the Week

The Medicaid Eligibility Rate (MER) data for the 2015/16 school year must be submitted to the Ohio Department of Medicaid by March 31, 2016. Billing vendors collect this EMIS information directly from the district, or from their Information Technology Center (ITC), and submit one mass file to ODM. The data submitted contains Student Name, DOB, Zip Code, and IEP Status, as of the 2^nd week in October, and is used to compute each district’s IEP Medicaid Eligibility Rate (MER) percentage. This is the only Cost Report factor that is district specific, and its accuracy is critical to maximizing MSP reimbursement.

The standard MER calculation is “Total IEP Medicaid Students” divided by “Total IEP Students”

Example: 48 IEP Medicaid Students divided by 100 Total IEP Students = 48% IEP MER.

Beginning with the 2014/15 school year Cost Report, the MER calculation has changed, and districts will now be penalized for not having a paid claim for all IEP Medicaid students. This is what I have been calling the “Interim Claiming Cost Adjustment”, and is why I have been stressing to districts to obtain a signed Parental Consent Form for all IEP students and make certain that Related Service Therapists are documenting for all MSP billable IEP services.

The new MER calculation will be “Total Number of IEP Students with a Paid Claim” divided by “Total Number of IEP Students with an MSP Billable Service.

Example: 75 Students with an MSP Paid Claim divided by 150 IEP Students with a Billable Service = 50% MER.

Here is an example of the new Cost Report IEP MER calculation. Keep in mind that not all IEP students receive “Billable MSP Services” (green section below), so those students need to be factored out of the equation (denominator).

*Note that the column in red is for AUP audit adjustments. When an auditor disallows a claim in the AUP audit, the “Number of IEP Students with a Paid Interim Claim” will be reduced by one, therefore additionally reducing the district MER.

We are getting ready to start the preparation of the 2014/15 MSP Cost Reports, and we need to get a list from each district that shows, as of the second week in October 2014, the IEP students that were receiving a Related Service, and a second list that shows the IEP Related Service students that were receiving “Consult Only” services. To maximize your MER percentage, we want our denominator to show only those students that received an MSP Billable Service. IEP Students that do not receive a Related Service or had “Consult Only”, would have no possibility of having an MSP Billable Claim, and therefore should not negatively affect the district IEP MER.

Not only are we going to use this new data to compute MER percentages, but we are also going to mark the students in our system as a “Related Service Student”, and make sure that there are claims for all related service students. This new methodology has the potential to reduce district’s overall MSP reimbursement, but at the same time, if tracked properly, it could actually increase overall Medicaid reimbursement. Three key components are:

• Provide an accurate list of IEP Related Service Students.
• Make sure that you are obtaining signed Parental Consent forms for all IEP students.
• Make sure that therapists are documenting for All Students.

Most of your IEP software programs should be able to accumulate this new information. IEP Anywhere has an “IEP Related Services Report” that should be able to provide this data. I would suggest accumulating the information for the 14/15 school year (October 2014), and the 15/16 school year (October 2015) at the same time.

It is extremely important that your district and your billing vendor understand this new methodology, and is working towards getting your “Total Number of IEP Students with a Paid Interim Claim” as high as possible. There are still several more months that districts could file Interim Claims for the 2014/15 school year (365 day filing limit). Claims can still be submitted for March, April, May, and June of 2015, but after that, your “Total Number of Students with a Paid Interim Claim” is final.

On February 25^th, Jeff McCuen, the treasurer for Worthington City Schools did a very good presentation on several important issues related to the Ohio Medicaid School Program (MSP). He presented to a large diverse audience made up of school districts, state legislators, educational associations, billing vendors, therapy associations, and representatives from the Ohio Department of Education and the Ohio Department of Medicaid. There were also over 80 viewers watching online. The four main issues covered were:

• Board Member Social Security number requirement for MSP re-enrollment.
• Extension of time beyond 08/01/16 to resolve “Order, Refer, Prescribe” (ORP) requirement.
• Removal of SLP’s, OT’s, and PT’s ability to be “Practitioners of the Healing Arts”, and ORP IEP services.
• Discontinuance of the monthly “MSP Stakeholder” meetings that had made great progress on resolving many MSP issues.

 

Nothing was resolved in the 2/25 meeting, but it did bring these issues to the attention of State Legislators, the State School Board President, and many other interested parties. The strong presence of school district representatives spoke loudly to the importance that the Medicaid School Program enhance the services that are provided to students with disabilities, but not hinder those services in the process. We have several important meetings scheduled in the coming weeks, but the most important issue is to get ODM to agree to an extension beyond the August 1 deadline. Many districts are ready to move forward with the prescription requirement, but we need to get many questions answered so that systems can be developed to meet the proposed requirement, or whatever the final requirements may be.

 

The ORP issue relates directly to another topic that I have been wanting to write about. Buried deep in the MSP rules is a requirement that districts have received very little guidance from ODE/ODM on, but could be a good first step in preparing for the proposed ORP requirement.

 

OAC 5160-35-06 (MSP Rules) states that:

 

(E) “The documentation for provision of each service shall be maintained for purposes of an audit trail. Documentation shall include:”

 

(7) “A description of efforts made to coordinate services with the eligible child’s medical home in accordance with the medicaid provider agreement.”

 

In this rule, “medical home” means “primary care physician”.

 

Care Coordination is an important component of all medical delivery systems. MSP Nursing Services already do care coordination, as their services already require a physician prescription. Many districts actively coordinate IEP services with the student’s primary care physician, but some do not. Most districts request the primary care physician information upon enrollment, but many do not keep this information current. I am gathering form examples from various districts, and I will be putting together a suggested process for meeting the care coordination requirement of the Ohio Medicaid School Program. Please share any examples that you have successfully used in your school district.

 

While we are waiting for ODE/ODM to answer questions, grant an extension, and hold stakeholder meetings, I do encourage districts to start looking at their internal systems and how they currently coordinate care for IEP services. Determine what physician information you already have for IEP students, and whether or not the information is current. In the coming weeks, I will be sharing with each district an all-inclusive form/system that would meet the current care coordination requirement and could easily adapt to meet a future physician prescription requirement.

 

I have not given up on the hopes of going back to allowing the therapists to ORP their services, but we must be proactive and address the care coordination requirement and be ready for any ORP requirement change.

 

Once again, I would like to thank Jeff McCuen from Worthington City Schools for bringing everyone together to discuss these important issues. Thanks also for all those who attended, watched online, and those who have sent letters and emails to ODE and ODM.

 

When a district initially enrolls in the Ohio Medicaid School Program (MSP), the first step is to complete an online “Provider Enrollment Application”. Based on this application, your district is given a State Medicaid Provider Number and an effective date of Medicaid Certification. It sometimes took several months to get certified, but the application process was very basic and required general data like district address, and the Superintendent and Treasurer names.

The Affordable Care Act (ACA), includes provisions that require States to revalidate provider agreements every five years (42 CFR 455.414). This same act requires the States to charge a fee for this re-enrollment, which is currently $553 in Ohio. The Ohio Department of Medicaid re-enrolled one MSP provider school district in 2015, and is scheduled to re-certify another 39 districts in 2016. The re-enrollment process is not overly difficult, but there is one piece of additional data that is now required that many school districts have been reluctant to provide.

42 CFR 455.104(4) requires that the Medicaid re-enrollment data contain “The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity”.

42 CFR 455.101(c) states that “Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.”

The Ohio Department of Medicaid (ODM) has defined “Managing Employee” in a school system to be the Superintendent, Treasurer, and the School Board Members. We have enrolled several districts recently and only included the Social Security Numbers of the Treasurer and Superintendent, and they were rejected because we did not report School Board Members. Once the school board member information was provided, the application was approved.

It is important that districts are aware of this issue because it ties in with the ORP/Provider Enrollment issue, and should be included in upcoming discussions with ODE/ODM regarding Physician Prescriptions. It will certainly be an important topic for discussion at the February 25^th “MSP Interested Party Meeting”, as Worthington City Schools is first on the list for 2016 MSP Recertification. (Worthington City School’s Medicaid certification expires March 31, 2016). I have attached a list of the MSP school districts that are scheduled for recertification in 2016. You should receive a letter from ODM several months before your revalidation is required.

I have personally lobbied both ODM and ODE many times over the past six months to reconsider whether a School Board Member “conducts the day-to-day operation of an institution”. I have suggested that it is the Superintendent and Treasurer that run the day to day operations of a school district, and that the School Board members only provide “direction and oversite”. ODM has rejected that argument, and currently the Name, Address, DOB, and SS# for all School Board Members are required on all MSP enrollment and re-enrollment applications.

2016 Recertification Districts