Medicaid Accountability in the I-Suite

1. MedicaidAccountability in the I-Suite How to document Medicaid services in the I-Suite to assist with compliance with Medicaid standards. September 23, 2014

2. Criteria for Billing Compliance “What criteria must a child meet in order for the district to bill Medicaid under the SHARS program? • The child must: • be enrolled in a public school’s special education program; • be 20 years of age or younger; • Have an ARD/IEP documenting the medical necessity for services [Documentation requirements can be found in the current Texas Medicaid Provider Procedures Manual (TMPPM), in the Provider Enrollment and Responsibilities Section and in the SHARS Section]; • Have a disability or chronic medical condition; • Be Medicaid eligible. • Source: TEA SHARS Frequently asked questions 2011

3. SHARS Billable Services Review TMPPM – Billing Guidelines can be reviewed with Providers for training. • Services covered by SHARS includes: • Audiology services • Counseling • Nursing services • Occupational therapy (OT) • Personal care services (PCS) • Physical therapy (PT) • Physician services • Psychological services, including assessments • Speech therapy (ST) • Transportation in a school setting These services must be provided by qualified personnel who are under contract with or employed by the school district. Furthermore, the school district must be enrolled as a SHARS Medicaid provider in order to bill Texas Medicaid for these services. • Source: Texas Medicaid Provider Procedures Manual (TMPPM) 2011 published by TMHP

4. Record Retention • Retained for 7 years • Documentation • ARD/IEP documents (medical necessity; examples of SHARS services) • Attendance records • Assessment/evaluations • Provider qualifications (current licenses and certifications) • Written agreements (contract) for contracted service providers • Required prescriptions or referrals for services • Supervision logs • Session notes or service logs • Transportation documentation (daily trip logs; maintenance logs/records; bus documentation; documentation for cost report) • Claims Submittal and Payment Histories (R&S Reports and General Ledger) • Copies of signed/notarized quarterly Certification of Funds (COF) letters and supporting documentation, including quarterly COF Reports • Non-school SHARS provider affiliation letter and attachments (if applicable) • Cost Report Documentation • Source: TEA SHARS Frequently Asked Questions 2011

5. Medicaid ID “The child’s name and Medicaid number should appear on every page of the medical records (see the Provider Enrollment and Responsibilities Section of the current TMPPM). This would include each page of the ARD/IEP document, session notes and service logs, and evaluations.” • ARD Documents • Adding the Medicaid ID to forms needs to be turned on in File Maintenance. • Non-(SM)2 clients • Manually input the Medicaid ID into Student Information - General • (SM)2clients • Medicaid ID automatically inserted on all forms each month when Medicaid eligiblity is obtained. • Automatic label reminder can be turned on in FM – Options/Directories to print labels to stick on ARD documents • FM – Form Setup • Can indicate how many labels are needed per form. • Could be considered part of consent and if parent refuses number on forms then they are refusing to give consent to bill • Source: TEA SHARS Frequently Asked Questions 2011

6. Medicaid ID • Session Notes • (SM)2program keeps session notes. • Non-(SM)2clients need to collect and store separately. • Source: TEA SHARS Frequently Asked Questions 2011

7. Parental Consent “Are schools required to obtain parental consent prior to billing Medicaid for SHARS services?” • “Yes, Section 300.154(d) of the reauthorized IDEA 2004 requires districts to obtain informed parental consent. More guidance on this issue may be found on TEA’s Division of IDEA Coordination website at: www.tea.state.tx.us/special.ed/guidance/medserv.html “ • Source: TEA SHARS Frequently Asked Questions 2011

8. Parental Consent and SEM • Parental Consent is obtained in 2 places in SEM • ARD Signature page (pg. 7) • Should be obtained at EVERY ARD – not just the Annual • There is now an initial line next to consent. • SHARS Letter • Can be given when obtaining initial consent as it also includes the Right to Provider section. • Both locations provide space for a Consent Expiration date.

9. Parental Consent and SEM ARD Page 7 Note: If there is an error message when entering the SHARS letter, the district needs to enter the district specific information in the Popups in File Maintenance – SHARS Information.

10. Parental Consent and (SM)2 (SM)2 reads PC from signature page of ARD as well as SHARS Letter • Will not bill TMHP if there is no consent at the time of the service • Reports can be run to show who has consent and who does not • When the letter is returned signed, the dates need to be entered into (SM)2 Parental Consent Tracker or on the letter itself.

11. Parental Concerns • It may be reassuring to let parents know that: • • billing Medicaid is not a new process • • SHARS is reimbursement money to the schools • • their child’s ability to receive services outside of the school setting will not be • impacted • • SHARS is a program under EPSDT and is not subject to any type of limit or • “cap” on services • • they can withdraw permission at any time • “Could billing SHARS cause a child to exceed any ‘cap’ or lifetime maximum on their Medicaid benefits?” There is no lifetime benefit cap for Medicaid services to children 20 years of age or younger. SHARS is a program under the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) program. Under EPSDT, there are no set limitations or cap on Medicaid services to clients 20 years of age or younger, so long as the service is medically necessary. The Medicaid services the child receives at school do not affect the type or amount of Medicaid services the child receives outside the school. • Source: TEA SHARS Frequently Asked Questions 2011

12. Documenting the Need for PCS Personal Care Services (PCS) in ARD • “Indication of placement in a self-contained setting [i.e., Life Skills classroom, Preschool Programs for Children with Disabilities (PPCD), etc.] is not sufficient IEP documentation to support Medicaid reimbursement for PCS.” • Sufficient documentation should answer: • Is the service provided on a one-on-one basis or group or both; • examples of PCS; • when/where are the PCS needed; and • the reason(s) for PCS, such as medical necessity, etc. • Source: TEA SHARS Frequently Asked Questions 2011

13. Documenting the Need for PCS • SEM Options for documenting PCS • ARD Physical Section (pg 2) • Subject on Schedule Page (minutes of PCS are optional) • PCS Supplement • Documents time outside of the instructional day • Optional feature - (SM)2will not create a claim for a student with no PCS Supplement • Related Services • IEP • Deliberations • Transportation Information Form

14. PCS Supplement - SEM Refer to SHARS FAQ for examples of good documentation.

15. PCS Supplement - SEM This section of the PCS Supplement is to document exactly what the PCS look like in the school setting. This popup field can be edited by the district SEM Administrator. Refer to SHARS FAQ for examples of good documentation.

16. Transportation Information Form LOCATED IN SEM In addition to the PCS Supplement, the Transportation Info form documents the need for a bus aide or monitor which would be billed as Personal Care on the Bus.

17. Documenting the Need for PCS • Example of documentation in the IEP • Sufficient documentation • Assistance is required for one-on-one PCS for “Johnny”. PCS needs include observation and redirection of self-injurious behavior. PCS is required throughout the school day and during transportation to and from school on the bus. Johnny has bipolar disorder and gets angry, frustrated very easily. He often displays his anger and frustration • Insufficient documentation • Assistance is required for one-on-one PCS for “Sue”. Sue has cerebral palsy. • Source: TEA SHARS Frequently Asked Questions 2011

18. Documenting the Need for PCS • Example of documentation in the IEP • Sufficient documentation • PCS assistance is required for “Timmy” periodically throughout the day on a one-on-one basis. Timmy has mental retardation and needs periodic PCS to assist him in moving from class to class. Without PCS assistance, Timmy would wander off. • Insufficient documentation • PCS assistance is required for “Jane” periodically throughout the day on a one-on-one basis because she has visual impairment. • Source: TEA SHARS Frequently Asked Questions 2011

19. Documenting the Need for PCS • Example of documentation in the IEP • Sufficient documentation • Group PCS assistance is required for “Janice” throughout the day. Janice has ADHD. She has difficulty staying on task and is very impulsive. She requires constant cueing, prompting, and redirection. • Insufficient documentation • Group PCS assistance is required for “Janice” throughout the day because she has ADHD. • Source: TEA SHARS Frequently Asked Questions

20. Documenting PCS • Example of documentation in the IEP • Sufficient documentation • Group PCS assistance is required for “Janice” throughout the day. Janice has ADHD. She has difficulty staying on task and is very impulsive. She requires constant cueing, prompting, and redirection. • Insufficient documentation • Group PCS assistance is required for “Janice” throughout the day because she has ADHD. • Source: TEA SHARS Frequently Asked Questions 2011

21. Documenting the Need for PCS • Example of documentation in the IEP for group PCS with intermittent one-on-one PCS • Sufficient documentation • Sue is in a self-contained classroom and needs group PCS throughout the day. In addition, Sue needs individual assistance with ADLs, including eating, toileting, mobility, and transfers because she is unable to transfer herself to the toilet and during transportation to and from school on the bus. Sue has cerebral palsy and cannot navigate her chair, feed or toilet herself. • Insufficient documentation • Bobby needs group and one-on-one PCS throughout the day. Bobby is wheelchair bound. • Source: TEA SHARS Frequently Asked Questions 2011

22. PCS Provision Documentation • What is required for documenting services for PCS? • Must capture the minutes of the service with start and stop times, • Must have notation of specific type of PCS required, • Must identify type of PCS (one-on-one or group), • If PCS is provided throughout the day, the accumulation of all the PCS minutes for the day must be totaled and converted to units of service, and • Must include the signature of the individual that provided the PCS. (In group settings, each caregiver does not have to provide documentation for each child. Rather one caregiver can document for 2 or 3 students while another caregiver documents on the other 2 or 3 students. • Source: TEA SHARS Frequently Asked Questions 2011

23. Provision of PCS Services In (SM)2, Providers need to enter Date, Start Time, and End Time. System calculates Total Minutes and Units.

25. Documenting the Need for R/S Documenting Speech and Related Services in the ARD • ARD Schedule Page • Service type, frequency, and duration need to be listed. • Supports/Other line under subjects or related services. • IEP • Goals and objectives can be sufficient documentation for billing services • Deliberations • Services can also be explained/described here. • Counseling as a Related Service • ARD Schedule Page • “Counseling” is billed by LCSW or LPC • “Psychological Services” is billed by LSSP • “BIP is needed to bill for emergency services and should list the need for emergency counseling” • Source: TEA SHARS Frequently Asked Questions 2011

26. Documenting Speech & R/S on Schedule Page • Schedule Page of the ARD • Related Services • Speech Therapy • List time, frequency, and duration • Any additional information can be entered on the Supports/Other line. • Source: TEA SHARS Frequently Asked Questions 2011

27. Documenting Nursing Services - ARD • Nursing Services • ARD Physical Section (pg 2) • Adds service to Related Service section on Schedule Page • Specific services can be listed in the Other Physical box. • “The ARD minutes should include recommendations derived from the RN/APN or physician’s evaluation of the student’s nursing services needs. Nursing services need to be stated with the same level of detail as is provided for the other related services. But, due to the type of services, it may be appropriate to add language such as “as needed”. • Source: TEA SHARS Frequently Asked Questions 2011

28. Transportation Criteria Transportation services in a school setting may be reimbursed when they are provided on a specially adapted vehicle and if the following criteria are met: • Provided to or from a Medicaid-covered service on the day for which the claim is made • A child requires transportation in a specially adapted vehicle to serve the needs of the disabled • A child resides in an area that does not have school bus transportation, such as those in close proximity to a school • The Medicaid services covered by SHARS are included in the student's IEP • The special transportation service is included in the student's IEP • Source: Texas Medicaid Provider Procedures Manual (TMPPM) 2011 published by TMHP

29. Transportation - Specially Adapted Bus A specially adapted vehicle is one that has been physically modified (e.g., addition of a wheelchair lift, addition of seatbelts or harnesses, addition of child protective seating, or addition of air conditioning). A bus monitor or other personnel accompanying children on the bus is not considered an allowable special adaptive enhancement for Medicaid reimbursement under SHARS specialized transportation. Specialized transportation services reimbursable under SHARS requires the Medicaid-eligible special education student has the following documented in his or her IEP: • The student requires a specific physical adaptation or adaptations of a vehicle in order to be transported • The reason the student needs the specialized transportation • Source: Texas Medicaid Provider Procedures Manual (TMPPM) 2011 published by TMHP

30. Documenting Provision of Transportation • Transportation listed as a Related Service (SEM) • Transportation Eligibility Form (SEM) • Record medical necessity for the service • Record special adaptive equipment needed. • Transportation Information (SEM) • Transportation Special Needs Report (RU) • If student does not appear on this list with the special equipment needed listed, districts may not want to bill for that student’s transportation. • For all students that will not be billed for transportation, mark their Transportation Non-billable in (SM)2 • Entering all log data enables the system to calculate the transportation information for the SHARS Cost Report.

31. Transportation Eligibility Form This option needs to be selected and the textbox MUST document the specific equipmentTHIS STUDENT needs on THIS BUS. An additional adult or bus monitor is not special equipment. A bus monitor would fall under Personal Care on the bus.

32. Transportation Special Needs Report Found in the Report Utility (RU)

33. (SM)2 Transportation (SM)2 Administrator needs to mark which student’s bus routes are NOT billable.

34. Transportation Log Requirements • At a minimum, the transportation log should include: • The SHARS provider name (i.e., school district name) • First Name and Last Name of each student for each trip, along with each student's ID • One log per vehicle, indicating the route name/number [with documentation maintained somewhere that describes each route/trip as to the start and stop locations ] • Method for identifying the number of one-way trips per day (e.g., AM and PM trips) [with documentation maintained somewhere that describes the times for each trip] -- Remember that the number of one-way specialized transportation trips must be counted for calculating the one-way trip ratio for allocating specialized transportation costs to the Medicaid program. • Method for personal care services (PCS) provider, transportation aide, bus monitor, or assistant to verify own attendance for each trip and include a place for this person to sign and date the form. • Method for drive to verify own attendance for each trip and include a place for this person to sign and date the form. • Method for nurse to verify own attendance for each trip and include a place for this person to sign and date the form. • The log can be maintained per day and for several days, with applicable dates noted on the log. • Mileage needs to be maintained somewhere; but, not on the log. • Source: TEA SHARS Frequently Asked Questions 2011

35. (SM)2 Transportation Log

36. SHARS Cost Report (SM)2 can assist with the compiling of the data for the Cost Report. • Calculates the IEP Ratio • Identifies student who were Medicaid Eligible at ANY time during the year. • Identifies which students were receiving a SHARS service. • (SM)2knows which students actually receive PCS. • Transportation logs track the number of one-way trips

37. SHARS Cost Report IEP Ratio data

38. SHARS Cost Report Transportation Data

39. Common questions Can a SHARS provider provide services beyond the IEP requirements? • No, the IEP authorizes the maximum services that can be provided and billed. Under the Individuals with Disabilities Education Act (IDEA), districts are required to follow the IEP requirements. Any services billed to Medicaid in excess of those stated in the IEP could be subject to recoupment. • Source: TEA SHARS Frequently Asked Questions 2011

40. Common questions If a student needs constant monitoring all day, even during instructional time, is the entire day billable as personal care services? • The IEP should clearly justify the need for constant supervision or monitoring and any other PCS (such as toileting, feeding, etc.) required during the school day. The documentation needs to answer the following questions or provide the requested documentation: • (1) examples of PCS; • (2) when/where are the personal care services are needed; • (3) reason(s) for PCS (such as medical necessity, etc.); and • (4) why can’t the student perform the age appropriate task? • Source: TEA SHARS Frequently Asked Questions 2011

41. Resources • TEA SHARS site • http://www.tea.state.tx.us/SHARS.html • Frequently Asked Questions • Billing Guidelines • Join Listserv • TMHP Procedure Manual • http://www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_manual.aspx