State of Alabama. School Based Medicaid Claiming Overview

Transcription

1 State of Alabama School Based Medicaid Claiming Overview

2 What is Medicaid? Medicaid was created on July 30, 1965, through Title XIX of the Social Security Act Medicaid provides health coverage or nursing home coverage to certain categories of income individuals, including: children pregnant women parents of eligible children people with disabilities elderly Each state administers its own Medicaid program while the federal Centers for Medicare and Medicaid Services (CMS) monitors the state run programs and establishes requirements for service delivery, quality, funding, and eligibility standards Medicaid is jointly funded by the state and federal governments, however is managed by the states 2

3 Medicaid & Schools In the educational setting, school personnel often become involved in identifying, coordinating, delivering and monitoring students needs for health and related services Although school staff typically associate these activities as supporting an educational need, many of these functions are reimbursable through the schoolbased Medicaid programs School systems are uniquely positioned to share information regarding Medicaid and covered health services, assist in child enrollment, and the provision and coordination of services The Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) Program is Medicaid s provision for providing preventative child health services for individuals under the age of 21: Periodic health screening Dental Services Vision services Hearing Services 3

4 Fairbanks Introduction Fairbanks team has designed, implemented and managed Medicaid claiming in 15 states, representing 8,000 LEAs and 10 million students Experienced in statewide implementations Both local and national expertise Offer extensive policy and legal knowledge in school based claiming The Fairbanks system provides a completely web based approach to each step in the Medicaid Program quarterly processes, enabling: Simplified participation and management for both school system and state personnel Data quality checks on all program requirements Built in audit and compliance testing Fairbanks brings significant state and federal audit experience, including: Statewide contracts to serve as a school based Medicaid compliance vendor for technology reviews, program reviews and audit plans Develop, implement and monitor statewide compliance plans consent of Fairbanks LLC 4

5 Program Background In October 1999, Medicaid Administrative Claiming (MAC) was implemented for Alabama school systems The Tallassee City Schools Consortium was formed to enable Alabama school systems to participate in a cost effective MAC program that captures efficiencies afforded by economies of scale, random stratified sampling, and cost allocation principles There are currently 136 participating school systems Alabama Medicaid and Fairbanks have recently implemented a new Direct Service Cost Report Program, which utilizes the same participant list, time study and financial data as the MAC program Both of these programs represent beneficial federal revenue to the schools, while incurring no cost to the state MAC generates $22 25 M annually Cost Report will generate approximately $12 M annually 5

6 Medicaid School Based Services Below are the two distinct Medicaid reimbursement programs that the Alabama school systems participate in: Medicaid School Based Services Medicaid Administrative Claiming (MAC) Federal Medicaid Reimbursement for administrative activities such as: Coordination of medical and mental health related services covered by Medicaid Linking students to Medicaid services Monitoring the delivery of medical and mental health services performed in the school district Direct Service (FFS/Cost Report) Federal Medicaid Reimbursement for direct medical services such as: Speech Therapy Physical Therapy Occupational Therapy 6

7 Medicaid Program Coordination Outreach Identification Referral (MAC) Direct Service (Cost Report) Follow up Coordination Monitoring (MAC) consent of Fairbanks LLC 7

8 MAC & Cost Report Program Roles State Medicaid Agency of Alabama (SMA) The State Medicaid Agency of AL is responsible for MAC/Cost Report program oversight, claims processing, and ongoing audits and desk reviews. Alabama State Department of Education (ALSDE) ALSDE assists/provides feedback in the administration of the MAC/Cost Report programs and provides some of the quarterly data needed for Medicaid claims, i.e. IDCRs. Alabama Association of School Boards (AASB) AASB is an advocate for MAC/Cost Report programs at state agency and federal level to influence policy decisions. They ensure program continuation, and provide oversight to Medicaid program consultant (Fairbanks). This ensures program requirements are appropriately met; therefore reducing school system risk. Fairbanks Fairbanks coordinates with the state agencies, provides MAC/Cost Report program expertise, and administers the quarterly processes, including claim filing, assisting with desk reviews/audits, and providing ongoing training and program support. consent of Fairbanks LLC 8

9 Fairbanks Responsibilities Support the implementation and operation of MAC & DS Cost Reporting, including: Participant List Collection Quarterly MAC Claim Calculation Web based RMTS Quarterly DS Cost Report Collection Quarterly Financial Reporting Annual Cost Report Settlement Offer program knowledge and assistance in policy changes Conduct ongoing quarterly training Manage the operation of web based MAC & DS Cost Reporting claiming system Provide ongoing program and system support through a dedicated Alabama team and a knowledgably staffed Call Center 9

10 School System Responsibilities Serve as liaison between Fairbanks and your school system Designate an RMTS Program Contact who will be responsible for completing the Participant List and reaching Time Study compliance Designate a Financial Contact who will be responsible for submitting the quarterly financial report Participate in training (Quarterly training provided by Fairbanks) Utilize the web based software to: Submit quarterly Participant Lists Ensure system reaches Time Study compliance Submit quarterly financial reports Maintain appropriate audit documentation 10

11 Quarterly Processes Participant List RMTS Time Study Financial Data Collection MAC Claim & Cost Report Calculation Determine who performs Medicaid administrative & direct service activities Determine how much reimbursable activity is performed Determine actual costs associated with these activities Apply appropriate rates to calculate a claim consent of Fairbanks LLC 11

12 Process Efficiencies with Cost Reporting The quarterly participant list has been expanded to include additional categories to cover those participants performing direct services(cost Report) Current Random Moment Time Study (RMTS) results can be used to measure time spent on administrative activities (MAC) as well as direct service activities (Cost Report) Since RMTS also captures the percentage of time spent on direct service activities, this ratio can be applied to those costs collected (quarterly Financial Submission) for those participants on the expanded participant list Claim calculation now occurs simultaneously for both the MAC quarterly claim and direct service Cost Report 12

13 Participant List Process School systems submit a list of eligible participants to include in the time study each quarter, based on provided guidelines The Participant List is used to sample individuals who will participate in the RMTS each quarter The Participant List drives the number of participants eligible for financial reporting The Participant List process is a critical part of ensuring your program receives the appropriate level of MAC and Cost Report reimbursement. 13

14 Random Moment Time Study (RMTS) The random moment time study measures the amount of time spent by eligible staff on both MAC (Administrative) and Direct Service activities RMTS results are used in both the administrative and direct service programs Random time study moments are sampled throughout the quarter: A moment represents one minute at a particular time, and the results are used to determine the reimbursable activities that occur If a participant is sampled, they document what they were doing for a precise moment by answering three questions online Participants may be sampled more than once in a quarter The RMTS methodology has a sample size based on a CMS approved sampling methodology Fairbanks web based RMTS assists in the management of the time studies 14

15 Financial Collection Process To participate in the MAC and Cost Report programs, financial information must be collected, certified, and submitted to Fairbanks each quarter. At the end of each quarter, school systems can begin to report costs via online financial reporting. Eligible costs are reported for staff/positions included on the participant list for the same quarter. Eligible costs can also be reported for Direct Support staff. (This applies to MAC only.) Other purchased services, materials and supplies, and rentals and operating leases are reported via the allocated costs page. (This applies to MAC only.) Reporting all allowable costs ensures MAC claims and Cost Report reimbursements are accurate. Upon completion of financial reporting, Fairbanks begins the claim calculation process using the time study results, reported costs, and reimbursement rates to submit a claim on your behalf. consent of Fairbanks LLC 15

16 Alabama s Dedicated Team Lisa Carnes, Principal Phone: E Mail: [email protected] Brian Mooney, Project Manager Phone: E Mail: [email protected] Cathy Loverde, Project Analyst Phone: E Mail: [email protected] Fairbanks Client Information Center Phone: E Mail: [email protected] 16