HBS Topics of the Week

The recent announcement from the Ohio Department of Medicaid (ODM) and the Ohio Department of Education (ODE) that the Ohio Medicaid School Program (MSP) will begin requiring Physician Prescriptions effective August 1, 2016 has caused great concern among many School Districts and MSP Stakeholders. This ruling by ODM/ODE centers around the Federal requirement that the individual that “Orders, Refers, Prescribes” (ORP) medical services must be enrolled in the State Medicaid Program. Since the start of the Ohio Medicaid School Program back in 2009, MSP OTs, PTs, and SLPs were able to ORP based on language in Ohio’s State Plan Amendment (SPA) that considered MSP therapists to be “Licensed Practitioners of the Healing Arts”. ODM removed this language from the Ohio SPA effective January 1, 2014, which the Centers for Medicare and Medicaid Services (CMS) pointed out in their October 23, 2015 letter to ODM (attached).

We have been meeting with School Districts, Educational Associations (OASBO, BASA, OSBA, OESCA), Therapy Associations, and other Stakeholders, and we feel that there are other options available to Ohio that would be much less burdensome and costly for Ohio School Districts than requiring ongoing Physician Prescriptions. Some of those possible options are:

• The Ohio Department of Medicaid (ODM) could restore the previously removed language from the State Plan Amendment (SPA) which permitted MSP therapists (OT, PT, SLP) to be considered “Licensed Practitioners of the Healing Arts”. This would then require therapists to do a one-time enrollment in the State’s Medicaid Program as an ORP provider only. ODM has already modified their Medicaid Enrollment software to accommodate a scaled down “ORP Only” enrollment application.
• ODM could expand the list of ORP allowable providers to include Clinical Psychologists and School Psychologists. Every school district employs or contracts with one or more Psychologist, and Psychologists would be much more aware of the student needs than a Physician, who was not part of the evaluation and plan development team. This would only require the MSP Psychologists to do the one-time enrollment in the State’s Medicaid Program as an ORP provider only.
• Request an additional one-year waiver (2016/17 school year) from CMS of the ORP requirement. This would give ODM and ODE additional time to work with school districts to develop and implement a fully compliant ORP process. There are many questions that ODM/ODE has yet to answer, and time is running out with the August 1, 2016 deadline. The ORP requirement is a result of the Affordable Care Act (ACA), which may substantially change based on the upcoming presidential election. This extension would give additional time to modify the Ohio MSP ORP process based on any changes to the ACA.
• The final option is to require OT, PT, and SLP services to be prescribed by a Physician. Currently Ohio is allowing the MSP ORP provider to be a Physician, Physician Assistant, or an Advanced Practice Nurse. Physician Assistants and Advanced Practice Nurses must work under the direction of a Physician, so in reality, it is a Physician that would need to do the ORP. A few school districts have a physician on staff, and I know that several ESCs are looking into the possibility of providing this service to school districts. Our biggest concerns with this options is the timeline involved and finding enough physicians to write over 61,000 prescriptions, not to mention the ongoing prescriptions that would need to be obtained.

The intent of this ACA requirement is to cut down on “Waste, Fraud, and Abuse”, but it appears that the current ORP ruling does just the opposite. This CMS rule requires States to enroll ORP providers into their State Medicaid Program and screen the provider to make sure that their license is current. This direction that ODM/ODE is taking does not screen any current MSP providers, and the providers that it adds to the program (Physicians), would have already been screened in their physician practice. We also must address which students will require a prescription, just Medicaid students, or all students. If it is just Medicaid students, are we now asking billing vendors to share with districts who has Medicaid and who does not? If that is the case, what about the problem of treating one group of students differently than another? These questions and many more need to be answered as soon as possible. ODM/ODE received the CMS letter on October 23, 2015, told school districts on January 27, 2016, and today is February 12, 2016, and nothing additional has been communicated. The current CMS deadline is August 1, 2016, and the pace that ODM/ODE is taking just gets worse by the day.

What can your district do to help resolve this issue?

Contact your State Legislators.
Contact ODM and ODE.
Get with your therapists and get their opinions.
Contact your ESC and find out what their capabilities are.
Check with physicians in your area on their willingness to ORP.

Worthington City Schools is hosting an Interested Parties Meeting at 1:00 on February 25, 2016 (see attached invitation), and plans to have many School Districts, Legislators, Associations, Billing Vendors, and hope to get ODM and ODE to attend also. This critical issue requires school districts take an active role in order to get ODM/ODE to listen and take into account your concerns. The billing vendors often work together to resolve these types of issues on your behalf, but the State really wants to hear from school districts. Please use whatever contacts you have to help resolve this issue in a reasonable and timely fashion.

ODM/ODE Contact Information:

John McCarthy, Director
Ohio Department of Medicaid
50 West Town Street, Suite 400
Columbus, Ohio 43215
john.mccarthy@medicaid.ohio.gov

Dr. Sue Zake
Ohio Department of Education
25 South Front Street
Columbus, Ohio 43215
sue.zake@education.ohio.gov

On January 27, 2016, Dr. Sue Zake, Director, Office for Exceptional Children, Ohio Department of Education (ODE) and John McCarthy, Director, Ohio Department of Medicaid (ODM) presented a webcast pertaining to a change in the Ohio Medicaid School Program (MSP). In this webcast, they announced that effective August 1, 2016, physician prescriptions would be required for all OT, PT, Audiology, and Speech services billed under MSP.

I was very surprised by this announcement, as I was expecting that they would take a different approach to the issue. The issue at hand is how to comply with the Affordable Care Act (ACA) mandate that all State Medicaid agencies must require all Ordering, Referring, or Prescribing (ORP) providers to enroll as a participating provider in their State Medicaid program. That would require the ORP provider to obtain an NPI number and a State Medicaid Provider number. This led ODM to have discussions with the Centers for Medicare and Medicaid Services (CMS), regarding who the ORP provider is in the Ohio Medicaid School Program. If it could be the school district, that would be easy, because the district already has an NPI number and State Provider number. In the process of these discussions, CMS determined that Ohio was out of compliance.

Previously, the State Plan Amendment (SPA), in effect from 08/01/2009 through 12/31/2013), allowed licensed therapists in the Ohio Medicaid School Program to recommend services under the title “Licensed Practitioner of the Healing Arts”. Effective January 1, 2014, ODM filed a new SPA with the Centers for Medicare and Medicaid Services (CMS) removing the language that allowed therapists to recommend without a prescription. ODM also removed language from the MSP section of the Ohio Administrative Code (OAC) that made reference to “Licensed Practitioner of the Healing Arts”, which became effective 04/01/2015. I am not sure why ODM removed this language that we had fought so hard for in 2009 to be part of our program.

The Ohio Medicaid School Program is currently out of compliance because of “lack of an appropriate prescription or referral” and “lack of ORP NPI/Provider number on the billing claim”. This non-compliance will not affect current Medicaid reimbursement, but CMS has only given Ohio until August 1, 2016 to correct the issues. The big question is: How do you get prescriptions for 61,000 Ohio Medicaid students, or how do you get 3,000 therapists enrolled as a Medicaid provider in six months? Regardless of what direction this issue goes, Ohio needs to apply for a longer waiver.

In the past 24 hours I have spoken with school districts, ESC’s, educational associations, other billing vendors, lobbyists, and politicians. I attended the Joint Medicaid Oversight Committee (JMOC) hearing on January 28, 2016 at the Statehouse, where Dr. Zake and Director McCarthy spoke to committee members of the Ohio House and Senate on this ORP issue. Everyone has an opinion on this issue, but the most important opinion lies with our school districts. I encourage you to talk with your Special Education administrators and your therapists and get their opinions. What would be easier and more beneficial, a one-time therapist enrollment or ongoing prescription requirements? Please send your questions, comments, and suggestions to those who are making these decisions that will affect your school district.

John McCarthy, Director
Ohio Department of Medicaid
50 West Town Street, Suite 400            
Columbus, Ohio 43215                
john.mccarthy@medicaid.ohio.gov  

Dr. Sue Zake
Ohio Department of Education
25 South Front Street
Columbus, Ohio 43215
sue.zake@education.ohio.gov

I also encourage you to copy Barb Shaner at OASBO barbara@oasbo-ohio.org on your ORP correspondence. OASBO has always been strong advocates for the Ohio Medicaid School Program. The OT, PT, and SLP Boards are also very interested in this issue.

There are many questions to be answered and there are only six months until the CMS deadline. This ORP issue could affect all students and not just the students on Medicaid. There is nothing that you immediately need to do at this time other than sending your questions and comments to ODE, ODM, HBS, and any other advocacy contacts that you have.  We will continue to keep you updated on this issue and please let us know your thoughts.

Effective March 25, 2011, Federal regulation 42 CFR 455.410(b) required that:

“The State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers.”

What this means is that all Occupational Therapists, Physical Therapists, Speech Therapists, and any other direct service MSP providers are required to obtain an Ohio Medicaid Provider Number. Knowing that this enrollment would not be very popular with your therapists, HBS and HPC teamed up in 2014 and hired the firm of Squire-Patton-Boggs for a legal opinion and to lobby the Ohio Department of Medicaid (ODM) to fight this requirement. I have to commend ODM for their efforts, because as you can see from the attached letter from CMS, ODM did “go to bat” for Ohio school districts. Although we were able to delay this requirement for the past several years, we ultimately did not get the decision from CMS that we were hoping for. Beginning August 1, 2016, MSP direct service therapists will be required to obtain an Ohio Medicaid Provider Number. This requirement should not affect Nurses, because they provide services based on a physician prescription, or Psychologists, because they do not typically provide “Direct Services”.

CMS has given the Ohio Department of Medicaid two options:

1. Require school districts to obtain a physician prescription for all services.
or
2. Require therapists to obtain a State Medicaid Provider Number.

Obtaining physician prescriptions would require ongoing data collection from multiple sources, whereas the provider enrollment would be a one-time process. The online Medicaid enrollment process is a condensed version of the Medicaid application that school districts had to go through to get their Medicaid Provider Number. There will not be a state application fee for therapist enrollment.

On January 27, 2016, the Ohio Department of Education will be hosting a webcast regarding this change. We will wait until after this webcast to distribute information to your therapists, and we will have various tools in place that will make this a simple process for your therapists. We will have step by step instructions posted in our documentation system, on our website, and we will have YouTube training videos and an enrollment helpline.

The first step for your therapists is to apply for a National Provider Identification (NPI) number. This is a Federal Provider Number that most therapists have already obtained, which will be required for the State enrollment. Your quarterly “Documentation Received by Therapist” report indicates which therapists still have not obtained an NPI number.

I will caution you up front that therapists were not very happy to have to obtain the NPI number, and they will not be at all pleased with having to get the State Provider Number. This requirement is an Affordable Care Act (ACA) mandate and is designed to cut down on fraud and identity theft. This will provide therapists with another level of protection against someone using their license and identity to commit Medicaid fraud.

We will do whatever it takes to get all therapists enrolled by the August 1, 2016 deadline, and we will continue to put systems in place to make the Medicaid documentation process as efficient as possible. I will cover this issue in more detail after the January 27 webcast. If you have any questions, please contact our office.

See attachments:
10/23/2015 letter from CMS (Ohio-MSP-Letter-20151023)
01/21/2016 letter from ODE (Zake Email)