Iowa’s School-Based Medicaid Programs: An Interagency Collaboration

1. Iowa’s School-Based Medicaid Programs: An Interagency Collaboration NAME Convention Denver, CO September 26, 2003

2. Introduction • Dann Stevens Medicaid Program Consultant Iowa Department of Education Grimes State Office Building 400 East 14th Street Des Moines, IA 50319 Phone: 515-281-8505 Fax: 515-242-6019 e-mail: Dann.Stevens@ed.state.ia.us

3. Iowa Department of Education • Medicaid direct service reimbursement was mandated in 1988 by the Iowa State Legislature. • Medicaid Area Education Agency (AEA) program • Medicaid Administrative Claiming (MAC) reimbursement began in 1994. • First year claims were less than $1 million FFP. • Medicaid Local Education Agency (LEA) program for direct service reimbursement began in 2001.

4. Iowa Department of Education • MAC began with a pilot in one county. • Expanded to 20 counties by 1995. • Opened to remaining counties in the state in 1998. • A majority of the counties had local public health as the Lead Agency. • Program structure was introduced by a private consultant.

5. Initial MAC Participation WORTH HOWARD SIOUX CERRO GORDO PALO ALTO POCAHONTAS DUBUQUE BLACK HAWK BUCHANAN DELAWARE CALHOUN WEBSTER LINN MONONA MARSHALL GREENE CRAWFORD POLK SCOTT Public Health as Lead LEA as Lead TAYLOR Other agency as Lead

6. 2003 MAC Participation Distribution EMMET WORTH HOWARD KOSSUTH CERRO GORDO SIOUX PALO ALTO FLOYD FAYETTE CLAYTON BUENAVISTA CHEROKEE DUBUQUE BLACK HAWK BUCHANAN DELAWARE CALHOUN WEBSTER WOODBURY IDA HARDIN LINN BENTON MARSHALL CRAWFORD STORY POLK HARRISON JOHNSON MARION POTTAWATTAMIE MADISON MAHASKA LOUISA Public Health as Lead LEA as Lead TAYLOR DECATUR DAVIS LEE Other agency as Lead

7. Iowa Department of Education • Number of school districts participating increased to 135 out of 371 as of 2003. • From the beginning, Department of Public Health has been actively involved with the MAC program.

8. Introduction • Janet Beaman Community Health Consultant Iowa Department of Public Health Lucas State Office Building 321 East 12th Street Des Moines, IA 50319 Phone: 515-281-3052 Fax: 515-242-6384 e-mail: jbeaman@idph.state.ia.us

9. Iowa Department of Public Health • Involvement in MAC was initiated through Medicaid / IDPH Interagency Agreement for the EPSDT Program. • In Iowa, Title V Child Health agencies are responsible for assuring EPSDT informing, care coordination, and screening services for Medicaid enrolled children. • Agreement includes provisions for the MAC program. • To provide consultation, technical assistance, and training for lead agencies and sub-holders. • To participate in the local agency review process.

10. MAC Organizational Structure Centers for Medicare and Medicaid Services (CMS) Iowa Dept. of Education Iowa Dept. of Human Services Iowa Dept. of Public Health Interagency Agreement Technical Assistance Lead Agency Sub-agreement School Districts Public Health agencies Private non-profit agencies

11. Iowa Department of Public Health • Technical assistance is provided through: • E-mail • Phone conference • Written correspondence • Video conferencing via Iowa Communications Network (ICN) • On-site visits

12. Iowa Department of Public Health • For trainings • Prepare and update training materials and forms • Schedule and coordinate trainings • Typically schedule on-site at local agency • Use ICN with video taping when applicable • Types of trainings • Coding • Fiscal

13. Coding Agency participation Staff participation Process for time studies Coding structure Audit file Annual report Use of reimbursements Fiscal Cost pool construction Indirect costs Revenue for offset Determining Medicaid eligible percentage Required matching funds Required 10% reserve Iowa Department of Public Health Training Components

14. Iowa Department of Public Health • On-site review process • Developed Reviewer’s Guide to Medicaid Administrative Claiming • Gather information on • Type of agency and scope of programs • Staff involved in coding • Conduct coding interviews with representative staff • Provide verbal feedback on coding interview • Review written summary for lead agency

15. Iowa Department of Public Health • Other supports for MAC • Assist with development of language for interagency agreements with participating agencies • Review annual reports • Develop and disseminate communication with local agencies • Participate in interagency meetings with Department of Human Services and Department of Education • Promote awareness of program (e.g. School Nurse Conference & AEA Special Education Director meetings)

16. Introduction • Anieta O’Hair Medicaid Administrative Claiming Auditor Iowa Department of Human Services Hoover State Office Building 1305 East Walnut Des Moines, IA 50319 Phone: 515-281-5496 Fax: 515-281-6237 e-mail: aohair@dhs.state.ia.us

17. Iowa Department of Human Services • Audit for MAC • CMS mandated oversight of MAC program. • Medicaid State Agency (Department of Human Services) houses auditor position. • DHS created auditor position in late 2000. • DHS is authorized to retain up to 5% of MAC FFP for program oversight. • Role includes providing fiscal technical assistance.

18. Iowa Department of Human Services • Federal Reviews • Office of Inspector General (OIG) review spanned State Fiscal Years 1998-2001. • OIG review resulted in two separate reviews since 2000. • Primary monetary finding due to selected private non-profit agencies lacking public unrestricted funds as match. • No final report issued to date.

19. Iowa Department of Human Services • Desk Reviews • Prior to payment each claim is reviewed for: • Current MAC agreement • Cost pool construction • Time coding percentages • Reporting of revenues for offset • Medicaid eligible percentage • Accuracy

20. Iowa Department of Human Services • Coordinating On-site Reviews • DHS Medicaid Policy Specialist • DHS MAC Auditor • IDPH Community Health Consultant • On-site Reviews consist of • Interviews with fiscal staff • Developing summary reports • Approving corrective action plans

21. Iowa Department of Human Services • Fiscal On-site Review includes: • Administration of time studies • Cost pool construction • Indirect cost rate • Medicaid eligible percentage • Revenue offsets • Application of appropriate FFP • Appropriate matching funds • Retention fees held by lead agencies • Audit file

22. Iowa Department of Human Services • Additional oversight • Tracking of historical data on time study results • Tracking of historical data on Medicaid eligible percentages • Tracking of indirect rates for school districts • Tracking of Medicaid LEA reimbursements • Follow-up on inquiries on program compliance

23. Iowa Department of Human Services • New MAC Implementation Plan • Resulting from CMS Medicaid School-Based Administrative Claiming Guide of May 2003 • Participation limited to school districts • Time study methodology: Shift from Continuous Daily or Random Date Sampling to Random Moment Sampling • Time Codes: Adoption of modified CMS time coding structure • Medicaid Provider Percentage: New tracking methodology • Medicaid eligible percentages: Shift from Free and Reduced Lunch percentages to Medicaid enrolled

24. Iowa Department of Human Services • Implications of the Medicaid LEA program for MAC • Revenue Offsets • Time coding

25. Iowa Department of Education • LEA direct services were included in Iowa Medicaid State Plan in 2001. • As of June 2003, 95 of the 371 districts had a Medicaid LEA provider number. • Expect continued growth in participation. • Confusion among local school districts about the differences in the two Medicaid programs.

26. Iowa Department of Education • Department of Education provides the technical assistance for the Medicaid LEA & AEA direct service programs. • This allows each state agency to specialize in their area of expertise. • Both programs address CMS through the Medicaid state agency. • Greatest asset is the communication among the three agencies.