Shawna Dippman, Monroe County Intermediate School District, Michigan
Karen Thomas, Leon County School District, Florida

From a presentation for the 2023 NAME Annual Conference, Dallas, Texas – October 23, 2023

Largest Health Care Program in U.S.

Medicaid is a jointly funded health insurance program between the Federal and State government for low-income families and persons with disabilities.

Medicaid is the largest source of funding for medical and health services for people with low income.

School Based Services

Allows school districts to receive partial reimbursement for medically necessary services provided to students with disabilities under the Individuals with Disabilities Education Act (IDEA). Participation is voluntary and each state must have their own CMS approved plan. Know and understand YOUR state’s Medicaid Plan. Work closely with your State Medicaid Agency and possibly Department of Education. Michigan and Florida’s state plans have added Free Care expansion which now allows reimbursement for medically necessary services provided to ALL Medicaid eligible students.

Clinician types added for the first time

• Board Certified Behavior Analyst – 8
• Limited Licensed Master’s Level Psychologist – 10
• Licensed Masters Level Psychologist – 29
• Licensed master’s level school social worker – 107
• Licensed master’s level social worker – 168
• Limited Licensed Master’s Level Social Worker – 98
• Licensed Master’s Level Marriage and Family Therapist – 3
• Licensed Master’s Level Professional Counselor – 19
• Licensed Professional Counselor – 93
• Limited Licensed Counselor – 30
• Limited Licensed Master’s Level Professional Counselor – 17

Providers (Direct Service) Differ per State

Personal Care Services in Michigan

The following staff may be appropriate for inclusion in time studies if they are involved in Personal Care activities in the school setting:

• Bilingual Aides
• Health Aides
• Instructional Aides
• Paraprofessionals
• Program Assistants
• Teacher Aides
• Trainable Aides
  • Behavioral Health Aides

Random Moment Time Study

In accordance with the Centers for Medicare & Medicaid Services (CMS) reimbursement policy, some activities performed by medical professionals and School District staff in a school-based setting are eligible for federal matching funds.

• These activities may be performed by staff with multiple responsibilities.
• CMS reimbursement requirements include the use of a random moment time study (RMTS) as a component of the Medicaid reimbursement methodology.
• The time study results are used to determine the amount of staff time spent on
  Medicaid-allowable activities.

Michigan Reimbursement Formula

RMTS Questions Differ per State

Michigan

• Were you working during your sampled moment?

If yes, then…

• Who was with you?
• What were you doing?
• Why were you performing that activity?
• Is the service you provided part of the child’s medical plan of care or for which
  medical necessity has been determined?
  • Yes – IEP/IFSP
  • Yes – Medical plan of care other than IEP/IFSP (i.e. 504, student health plan,
    nursing plan, physician’s order, crisis intervention service)
  • Medical necessity established in other method
  • No or not applicable
• Are you the child’s case manager? (for targeted case management only)

Florida

• Who were you with at your moment? (Please provide titles of staff – no proper names or initials.)
• What activity were you doing at your moment? (Please indicate issues, ideas, or
  services conveyed.)
• Why were you doing this activity at your moment? (Please indicate the purpose of this activity.)

RMTS Training

Participants need to know that:

• Their answers are coded and reviewed by RMTS coding specialists
• They must be descriptive, so that the answers can be coded correctly
• If their answer can’t be understood or require further detail, someone will email to clarify their responses
• If you are not working with a student at the time of your moment, that is fine. You should still complete the moment and respond with the activity you were doing at that date and time.

Give Examples:

Which response best describes what you were doing ?

Be Descriptive – Who

Who was with you?

• A social worker / An OT / the student’s Case Manager
• A student [with a physical impairment]
• A group of ASD students
• A student’s parent(s)/guardian(s)

*Note – Do not include student names

Be Descriptive – What

What were you doing?

• Reviewing student behavior plan and IEP goals
• Redirecting a student to stay on task
• Meeting regarding accommodations for a student with a visual impairment
• Physical Therapy – range of motion – upper body

Assisting student(s) during a math assignment

• Okay (although not reimbursable) for a Case Manager
• Direct Service or Personal Care staff would might need to define assistance (assisting to stay on task, assisting with visual/perception task)

Be Descriptive – Why

Why were you doing this activity?

When responding to the “why” question, think about the intended outcome of the activity you were doing.

• Annual IEP – Speech and Social Work services will continue to address pragmatic language and self-regulation.
• Chronic behavior issues are impacting progress toward goals.
• Student requires visual aides to participate in classroom activities.
• Poor gross/fine motor skills impede mobility and ability to participate in classroom activities/assignments.

Focus On: Personal Care

• Monitoring swallowing as student ate their lunch.
• Physically assisting child with boarding a bus.
• Ensuring that student gets safely from one class to another.
• Monitoring student’s behavior and prompting to pay attention during a classroom activity.

Your role

1. Make sure the right people are on the SPL
   •Check staff licensure
   •Think about the job description and functions of the role
   •No two special education positions are the same in responsibilities
2. Train staff on how to complete the RMTS
3. Make sure ALL RMTS are completed

Documentation

SECTION 1.6 SERVICE EXPECTATIONS

The IEP/IFSP treatment plan must include the appropriate annual goals and short-term objectives, criteria, evaluation procedures, and schedules for determining whether the objectives are being achieved within an appropriate period of time (at least annually). All therapy services must be skilled (i.e., require the skills, knowledge, and education of a licensed occupational therapist, licensed physical therapist, or fully licensed speech-language pathologist or licensed audiologist).

Interventions expected to be provided by another practitioner (e.g., teacher, registered nurse), family member or caregiver are not reimbursable as occupational, physical, or speech, language and hearing therapy by this program.

To be covered by Medicaid, occupational, physical, and speech, language and hearing therapy must address a beneficiary’s medical need that affects his/her ability to learn in the classroom environment.

MDHHS does not reimburse for therapies that do not have medically related goals (i.e., handwriting, increasing attention span, identifying colors and numbers, enhancing vocabulary, improving sentence structure, and reading).

Group therapy or treatment must be provided in groups of two to eight. Services provided as part of a regular classroom activity are not reimbursable. When regularly scheduled attention is provided to one beneficiary who is part of the class currently in session, the service is not reimbursable

SECTION 10.1 DIRECT MEDICAL SERVICES DOCUMENTATION

For covered services, the school clinical record must include all of the following:

• Beneficiary name and birth date;
• Date of service/treatment;
• Type (modality) of service/treatment;
• The response to the service/treatment; and
• The name and title of the person providing the service/treatment and a dated
  signature.

For services that have time-specific procedure codes, the provider must indicate the actual begin and end times of the service in the school clinical record. The record must indicate the specific findings or results of the diagnostic or therapeutic procedures. The student’s school clinical record should include documentation of the implementation and coordination of services for the special education student.

Progress notes must be written monthly, or more frequently as appropriate, and must include:

• Evaluation of progress;
• Changes in medical or mental status; and
• Changes in treatment with rationale for change.

In other words, what is the RESULT of treatment?

Why is Staff Documentation Important?

Distribution of Medicaid dollars is based on the completed claim percentage.

• A completed claim includes billing for any student in a program with services.
• Missing documentation lowers the completed claim percentage.

• Justifies the employee costs reported on the staff pool list
• Provides the official audit trail for services provided
• Must maintain an 85% claim level to the previous year (this is different than the 85% RMTS compliance)
• Documentation now has an error rate assigned by the State of Michigan
  • 85% correct, no more than 15% incorrect
  • During an audit, an error rate greater than 15% will result in funds returned to the state

Medicaid Documentation overlaps into other areas

• Compliance requirements to show proof of service such as time and frequency
• Documentation to cover formal complaints
• All service programs covered by the Medicaid program
  • Direct Service Claiming
  • Caring for Students 31N/C4S (Michigan)
  • 504 – if using a Plan of Care
  • Health Care Plans (Florida)
  • Infant Family Service Plans

• Miscellaneous documentation can also be included in
  billing systems to eliminate the need for a separate
  documentation system.

PROFESSIONAL ORGANIZATIONS AND DOCUMENTATION

What does American Speech and Language Hearing Association
(ASHA) say about Documentation?
www.asha.org

What does National Association of School Nurses (NASN) say about
Documentation?
www.nasn.org

What does American Occupational Therapy Association (AOTA) say
about Documentation?
www.aota.org

What does the American Physical Therapy Association (APTA) say
about Documentation?
www.apta.org

What does National Association of Social Workers (NASW) say
about Documentation?
www.socialworkers.org

QUALITY ASSURANCE

Quality Assurance Plan Checklist

Providers must have a written quality assurance plan on file

• Purpose of the Quality Assurance Plan
• Necessary Elements
• Tools/ideas for Creating/revamping a
  Quality Assurance Plan

Purpose – Quality Assurance Plan

Purpose – Medicaid Provider Manual

“…to establish and maintain a process for monitoring and
evaluating the quality and documentation of covered
services, and the impact of Medicaid enrollment on the
school environment.”

Benefits of a Well-written Quality Assurance Plan

• Sets High Standards
• Establishes and Maintains a Compliant and Knowledgeable Environment
• Creates a Positive Team Atmosphere
• Successful Audits

Audit Checklist – Financial

✔Quality Assurance Plan
✔Chart of Accounts
✔Forms and Supporting Documentation
✔Ledgers, Supporting Documentation and Invoices for costs reported on the Quarterly Financials AND the Cost Reports
✔Contractor Records including Contracts and Invoices
✔Staff License and Qualifications
✔Transportation – Bus Inventory, Amortization, Expenditure Records and Invoices

Audit Checklist – Student Claims

✔Quality Assurance Plan
✔Signed Treatment Plan (IEP/IFSP/Other)
✔Special Education Evaluation & Assessment Reports
✔Services Records, Provider/Clinician Notes and Progress Reports
✔Group Therapy Documentation
✔Provider Certifications/Licensures/Supervision
✔Monthly Activity Checklist (Personal Care Services Log)
✔Prescriptions/Referrals/Authorizations
✔Attendance Logs
✔Transportation Logs

Medicaid Resources

▪ Centers for Medicare & Medicaid Services – https://www.medicaid.gov/
▪ Medicaid & School Health : A Technical Assistance Guide –
https://www.medicaid.gov/medicaid/financing-and-reimbursement/downloads/
school_based_user_guide.pdf
▪ National Alliance for Medicaid in Education Inc. – www.medicaidineducation.org
▪ Kaiser Family Foundation – http://www.kff.org/medicaid/
▪ State Medicaid Agency