PBS and Medicaid. Comments about Medicaid

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Emory York
8 years ago
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1 PBS and Medicaid Comments about Medicaid Medicaid, as set out in the Social Security Act, is an aggravated assault on the English language, resistant to attempts to understand it. District Court, Schweiker v. Gray Panthers, 1981 and about Medicaid eligibility A determination of such eligibility requires an eye glazing examination of a labyrinthine maze of sections and seemingly infinite subsectionsof the Medicaid Act. 6th Circuit Court of Appeals 2 Basic Program Framework and Authority

Gray Panthers, 1981 and about Medicaid eligibility A determination of such eligibility requires an eye glazing examination

2 Basic Medicaid Framework Each State required to designate a Single State Agency Jointly Funded by Federal and State Joint oversight State Medicaid Plan outlines services, reimbursement methodologies and general program administration Cost Allocation Plan administered by State outlines administrative activities, costs, claims and their allocation across programs Federal agencies monitor program compliance and fiscal accountability 4 Administrative vs Fee For Service (FFS) Claims Administrative Claims Reimbursement for Activities that Support the Medicaid State Plan Paid at specified match amounts; generally 50/50 Fee For Service Claims Reimbursement for direct services rendered by qualified Medicaid providers to Medicaid eligible recipients Paid at FMAP rate; varies annually and by state All claims must be pre-approved by CMS and follow documentation rules, medical necessity and other criteria to qualify for payment. Mandatory vs. Optional Mandatory Benefits Inpatient hospital Outpatient hospital Physicians Nurse Midwives Lab and X-ray ANP s EPSDT Family Planning Services Pregnancy-related Nursing facility services Home Health (SNF qualified) Med/surg dental services Optional Benefits MH Rehab/stabilization Diagnostic/Screening/ Preventive Therapies (OT,PT,SLP) Inpatient psych <21 Drugs ICF/MR Personal Care Dental Other Home Health Other licensed practitioners Transportation TCM, etc. 6

compliance and fiscal accountability 4 Administrative vs Fee For Service (FFS) Claims Administrative Claims Reimbursement for Activities that Support the Medicaid State Plan Paid at specified match

3 Medicaid Administrative Funding Can support: Intensive PBS training development for professional facilitators Evaluation of project efforts for training, billing, and building evidence-based practice State-wide planning to facilitate interagency collaboration Schools and community organizations AMTHA Pilot Project School-based planning and policy development related to PBS (as integrated into existing MAC programs). 7 PBS Target Population Children who engage in socially inappropriate behaviors at such a frequency or intensity that they are at risk of out-of-home placement Eligibility criteria include: DD Autism Dx Typically developing children who fit behavioral criteria Children who have sustained a traumatic brain injury 8 PBS in Alaska Development similar to national history Multiple districts and organizations are already involved in implementation Individual PBS facilitation Special Education Service Agency PBS courses offered by UAA School-wide PBS implementation Stone Soup Group and SESA 9

4 Current Statewide Planning More sophisticated state-wide planning efforts are evolving from current schoolwide efforts Interagency collaboration evolving from state-wide planning UAA-CHD, SESA, Stone Soup Consortium Early childhood; adult service systems Juvenile Justice, child protection Schools, Mental Health and Developmental Disability agencies 10 A Vision for PBS To explore the Kansas Medicaid model in support of the following activities and agencies: School- and state-wide planning Organization-wide PBS state-wide planning pilot program including DD agencies CBHC agencies Involvement and support of stakeholders: Family support systems Early Learning and Intervention (ILP) Child Welfare Adult service for disabled individuals Mental Health Juvenile Justice Development of Training, Certification and Evaluation system through UAA-CHD in conjunction with SESA and Stone Soup Group 11 Alaska s Current Statewide Planning Initiative Helping to create unified policies in: Education Child welfare Early Childhood Mental Health Adult services Creating common language and training systems Developing 2-tiered training and certification and prior authorization system to qualify facilitators to bill for tertiary PBS services Creating program and certification evaluation system 12

Medicaid model in support of the following activities and agencies: School- and state-wide planning Organization-wide PBS state-wide planning pilot program including DD agencies CBHC agencies

PBS Pilot Project 4 sites; Rural and Urban Dillingham, Juneau, Sitka, Ketchikan Readiness planning for one MH and one DD agency Sites have current school-wide PBS projects Primary/secondary planning,

5 PBS Pilot Project 4 sites; Rural and Urban Dillingham, Juneau, Sitka, Ketchikan Readiness planning for one MH and one DD agency Sites have current school-wide PBS projects Primary/secondary planning, training & implementation Tertiary planning and preparation On-site training and planning facilitation Action planning and facilitator selection for training and certification 13 Training and Certification Implementation-Next Steps Design service descriptions and billing edits to implement Medicaid service codes. Define target population, certification standards and prerequisites, payment rate, case load limits, etc. Work with Medicaid agency to ensure programming in place for billing. 15

for training and certification 13 Training and Certification Implementation-Next Steps Design service descriptions and billing edits to implement Medicaid service codes.

6 Questions? Michelle Lyons-Brown (cell) 16

Florida Medicaid and Implementation of SB 2654

Florida Medicaid and Implementation of SB 2654 Shachi Mankodi Counsel to the Chief of Staff Florida Agency for Health Care Administration Autism Compact Presentation September 18, 2008 Overview What is