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School Based Services 101: the Unique Partnership of Medicaid and Education To Michigan’s Special School Based Services 101: the Unique Partnership of Medicaid and Education To Michigan’s Special Education Advisory Committee January 9, 2008 Jane E. Reagan, MPA Michigan Department of Education MDE-OSE/EIS

Medicaid School Based Services (SBS) is Important Because Almost 1 M Michigan children/students have Medicaid School Based Services (SBS) is Important Because Almost 1 M Michigan children/students have Medicaid coverage for health care Schools sending out notes about this Program to parents Medicaid is ‘one more program’ all parties need to understand, deal with, adapt to Knowing about it may help in discussions with friends, parents, at work MDE-OSE/EIS

Medicaid School Based Services Reimburses ISDs For a portion of some health care services Medicaid School Based Services Reimburses ISDs For a portion of some health care services (PT, OT, speech, nursing, developmental testing, service coordination, transportation, etc. ) For some children and students—only those who have Medicaid eligibility For some children and students—only those with IEP / IFSP For some “outreach services” that inform families about the Medicaid Program Helps offset ISDs’ huge $$ costs of special education services—sharing small amount of costs YOUR tax dollars helping more kids, families MDE-OSE/EIS

Agenda 1. Brief Overview of Medicaid 2. How School Based Services Works 3. New Agenda 1. Brief Overview of Medicaid 2. How School Based Services Works 3. New Requirement of IDEA for Parental Consent to bill Medicaid eff Oct. 2006 4. Talking it over MDE-OSE/EIS

School Based Services is really about finding Common Ground Medicaid MDE-OSE/EIS Special Education School Based Services is really about finding Common Ground Medicaid MDE-OSE/EIS Special Education

What is Medicaid? It is not MEDICARE, which Generally is for persons 65 and What is Medicaid? It is not MEDICARE, which Generally is for persons 65 and over (45 million persons!!) Covers hospital costs (45%), some physician, out-pt (35%), HMOs (15%) and now Rx drugs Mostly federally funded. $$ from your earnings taxes, premiums & deductibles, & state Medicaid agencies pay some premiums Does not generally cover check ups, nursing home costs (NHs) MDE-OSE/EIS

What is Medicaid? Jointly funded Federal-State program to finance health coverage (mostly kids) and What is Medicaid? Jointly funded Federal-State program to finance health coverage (mostly kids) and long term care / nursing home services For low-income individuals and families Costs shared between State and Fed govt Fed pays at least 50% of costs – like a discount —average federal share is 56% Michigan pays ~42% of costs—Federal pays ~58% Mississippi pays ~24% of costs—Federal pays ~76% MDE-OSE/EIS

What is Medicaid? Has become the largest public health care program in America Coverage What is Medicaid? Has become the largest public health care program in America Coverage for over 58 M persons in 2007 44 million people in low-income families—our nation’s sickest and poorest 14 million elderly and/or persons with disabilities and to fill in gaps of Medicare coverage, as safety net 30 million children (1/4 of all kids are on Medicaid) Pays for over 1. 5 M births annually (37% of all US births) 70% of NH beds Medicaid-financed MDE-OSE/EIS

What is Medicaid? Medicaid has become the financing vehicle for state and local health What is Medicaid? Medicaid has become the financing vehicle for state and local health care (h/c) In 2005 total spent was $329 B Medicare $325 B Unparalleled support as health care safety net For those who would have no h/c ins Largest single source of federal grants to states — comprises 44% of all federal funds to states (> $4 B / yr comes to Michigan) MDE-OSE/EIS

What Does Medicaid Pay For? ~60% for acute care (in-pt, out-pt hospital services), physician, What Does Medicaid Pay For? ~60% for acute care (in-pt, out-pt hospital services), physician, midwife, nurse, x-ray, home health, dental, Rx, HMOs ~35% for NH care for folks with both Medicare and Medicaid coverage ~2% for Medicare premiums & deductible costs for over 7 M persons <1% for some costs for children / students with IEP / IFSP (such as: speech, OT, PT, nursing, social work, assessments, transportation, etc. ) MDE-OSE/EIS

Where Do Medicaid $$ Go? MDE-OSE/EIS Where Do Medicaid $$ Go? MDE-OSE/EIS

How Does Medicaid Work? Medicaid is like insurance company, structured according to “provider group” How Does Medicaid Work? Medicaid is like insurance company, structured according to “provider group” i. e, hospitals, dentists, nursing homes, HMOs, ISDs, not by services, not by diagnosis or disability Each “provider” agrees to deliver list of published services for payment Payments to providers reflect cost-sharing: for $100 claim, Michigan general fund pays $42, and federal dollars pay $58 So when h/c costs go up, more people enrolled (w/ high unemployment), Medicaid costs go up MDE-OSE/EIS

Medicaid Costs Impact States’ Budgets In 2001 -03, almost all States faced their worst Medicaid Costs Impact States’ Budgets In 2001 -03, almost all States faced their worst budget crises since WW II when Medicaid enrollment and spending growth spiked. Growth in spending has not increased at same rate since, but still goes up yearly. % of State Budget (general fund revenue) spent on Medicaid Fiscal Year MI Budget National Average 1980 8% 8% 1990 18% 13% 2000 19% 2004 28% 20+% ie, note larger pieces of entire states’ budget ”pies” have been going to Medicaid budget item MDE-OSE/EIS

Percent of State Budget (GF revenue) Spent on Medicaid What percent of SOM budget Percent of State Budget (GF revenue) Spent on Medicaid What percent of SOM budget is for Education? MDE-OSE/EIS

Authority for Medicaid Authorized by Congress in 1965 as federal law: (Title XIX of Authority for Medicaid Authorized by Congress in 1965 as federal law: (Title XIX of the Social Security Act) More details in Federal Regulations (Code of-CFR) Title 42, Part 430 Not many changes to these over years Each state has enabling statutes and published policy with even more details MI policy is over 1600 pages! MDE-OSE/EIS

Administration Dept of Health and Human Services (HHS) Huge Department (FDA, CDC, Ao. A, Administration Dept of Health and Human Services (HHS) Huge Department (FDA, CDC, Ao. A, HRSA, NIH, Indian Health Service, SAMHSA) Centers for Medicare & Medicaid Services (CMS) HIPAA, SCHIP (aka Mi Child health insurance) Michigan Medicaid Agency, in Dept Community Health Supervises the administration, sets policy, pays $ Each State usually has counties help administer Mich Dept Human Services (formerly FIA) case workers do intake, determine eligibility for 30+ programs, help family enroll & renew. Located in NHs, some schools, county health departments MDE-OSE/EIS

How Does Medicaid Work? Some mandatory services and populations Basic dental services for kids How Does Medicaid Work? Some mandatory services and populations Basic dental services for kids under 21 yrs, those on SSI (special protected group), foster care kids Income based (% of federal poverty level) Some optional services and populations Pre-and post-natal services, pregnant women, new babies (higher income individuals), dental o 21 Discretion for each State results in 50+ “different” Medicaid Programs in U. S. , territories MDE-OSE/EIS

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How are Medicaid and Special Education Similar? Special Education Individuals with Disabilities Education Act How are Medicaid and Special Education Similar? Special Education Individuals with Disabilities Education Act Individualized Education Program State Performance Plan Some fed funding FERPA Service coordination MDE-OSE/EIS Medicaid Social Security Act Treatment plan Medicaid State Plan At least half fed funding HIPAA Targeted case management

Medicaid and Special Education Similarities, cont’d Special Education Medicaid US Dept Ed, OSEP US Medicaid and Special Education Similarities, cont’d Special Education Medicaid US Dept Ed, OSEP US Dept HHS, CMS Child find Outreach Data Collection, Documentation in pt reporting record Focused Monitoring Financial Auditors Mission expanded, less resources High stds for all staff High stds for ‘providers’ Increasingly complex MDE-OSE/EIS

Medicaid School Based Services Medicaid is obligated to cover its enrollees Special Education /Early Medicaid School Based Services Medicaid is obligated to cover its enrollees Special Education /Early On are obligated to provide FAPE for all eligible children and students Why not share the costs to deliver high quality health care and related services, for children with disabilities? Congress agreed, 1988 amended Medicaid law MDE-OSE/EIS

Brief Evolution of Medicaid School Based Services 1970 s de-institutionalization nationally—included children—most headed to Brief Evolution of Medicaid School Based Services 1970 s de-institutionalization nationally—included children—most headed to public schools Schools were not in business of delivering health care—believed others, like health insurers— should be paying for the necessary services Legal action forced resolution—schools started footing these new $$ bills 1988 Congress acknowledged fiscal burden health care imposed on schools, and amended Social Security Act, Title XIX Section 1903(c) via the Medicare Catastrophic Coverage Act (PL 100360) to allow schools to bill Medicaid first MDE-OSE/EIS

Medicaid School Based Services Is NOT one of the Medicaid programs that have contributed Medicaid School Based Services Is NOT one of the Medicaid programs that have contributed to the States’ budget crises over the years Because SBS brings in Federal funds to State, and at virtually no additional cost to the State budget MDE-OSE/EIS

Medicaid School Based Services In Michigan, ISDs are enrolled with Medicaid and sign “provider Medicaid School Based Services In Michigan, ISDs are enrolled with Medicaid and sign “provider agreement” to follow all rules, comply w/ audits, reviews ISDs are at risk for auditor findings and would have to return $$ if errors ISDs determine how their program will operate, try to keep up with never-ending changes MDE-OSE/EIS

For what does Medicaid reimburse ISDs? Direct Care Services Children/students w/ IEP/IFSP & Medicaid For what does Medicaid reimburse ISDs? Direct Care Services Children/students w/ IEP/IFSP & Medicaid PT, OT, speech, SW, nursing, assessments Only by clinicians who meet qualifications All services included in fed-approved State Plan Reimbursement per student, per date, per service, in record MDE-OSE/EIS Administrative Outreach Student status not pertinent—ALL kids For activities that support admin of Medicaid Any staff: refer, inform, assist family, organize Implementation plan Based on quarterly time studies done by staff

Parental Consent for Schools to bill Medicaid SBS been in Michigan since 1993 Delivery Parental Consent for Schools to bill Medicaid SBS been in Michigan since 1993 Delivery of services has not changed much Only change is parental consent requirement, effective October 2006 ISD staff expected to explain complex Medicaid program When is best time to discuss paying for services? MDE-OSE/EIS

Parental Consent for Schools to bill Medicaid IDEA statute re-authorized 2004 IDEA Regs proposed Parental Consent for Schools to bill Medicaid IDEA statute re-authorized 2004 IDEA Regs proposed by US Dept of Education in 2005 included a new provision requiring parental consent for schools to bill Medicaid Why this new regulation? What was problem? Came out of blue, to inform parents of billing FERPA has requirements for release of info Medicaid not same as private insurance—Medicaid has no caps on coverage, no co-pays for kids MDE-OSE/EIS

Parental Consent for Schools to bill Medicaid Virtually no comments in support Final rule Parental Consent for Schools to bill Medicaid Virtually no comments in support Final rule published in Federal Register Aug 14, 2006, effective Oct 13, 2006 http: //www. access. gpo. gov/su_docs/fedre g/a 060814 c. html (307 ppg) ISDs on Mich Medicaid Work Group took lead and developed template for implementation, sent it out Feb 2007 MDE-OSE/EIS

Parental Consent for Schools to bill Medicaid 34 CFR § 300. 154 (d)(2)(iv) says: Parental Consent for Schools to bill Medicaid 34 CFR § 300. 154 (d)(2)(iv) says: (A) the public agency (school district): “Must obtain parental consent, consistent with § 300. 9, each time that access to public benefits or insurance is sought; and (B) Notify parents that the parents’ refusal to allow access to their public benefits or insurance does not relieve the public agency of its responsibility to ensure that all required services are provided at no cost to the parents. ” 300. 9 Consent says: (a) Inform parent; (b) consent must be in writing and describe records to be released and to whom; (c)(1) consent is voluntary and may be revoked anytime; (2) revocation is not retroactive Note: nothing in 300. 9 re: frequency of obtaining consent MDE-OSE/EIS

Parental Consent for Schools to bill Medicaid Former OSEP Director Posny attempted to clarify Parental Consent for Schools to bill Medicaid Former OSEP Director Posny attempted to clarify She answered Q re: frequency of obtaining consent in her “informal guidance” letters, sent during 2007 “. . consistent with the timeframe of the IEP…consent at the initial development of the IEP and its subsequent reviews…” “…to obtain parent consent for a specified amount of services for a specified period of time would be sufficient to enable parents to make an informed decision…” “This consent may be obtained one time for the specific services, and duration of services identified in a child’s…(IEP)…” “However, if. . . the IEP (is) being revised…the public agency must obtain parent consent…” MDE-OSE/EIS

Parental Consent for Schools to bill Medicaid How is it working in districts? Because Parental Consent for Schools to bill Medicaid How is it working in districts? Because this is new, no ‘model format’ Mass mailings to families of All kids; All kids with IEPs; Medicaid kids with IEPs; combination of above Discussions prior, during IEP meetings Handled by local director, IEP team leader or Medicaid coordinator MDE-OSE/EIS

Parental Consent for Schools to bill Medicaid How is it working in districts? Many Parental Consent for Schools to bill Medicaid How is it working in districts? Many questions from parents There are rumors about dangers of signing consent form Impact on private insurance benefits or other programs MDE-OSE/EIS

So, is SBS Worth the Challenges? More paperwork, documentation to meet both IDEA and So, is SBS Worth the Challenges? More paperwork, documentation to meet both IDEA and Medicaid requirements ISDs must understand two bureaucracies, languages, priorities, budget pressures Each year, millions of federal Medicaid dollars come to Michigan via SBS ISDs received 60% MI Medicaid general fund received 40% MDE-OSE/EIS

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Time to talk? Thank you Jane E. Reagan, MPA MDE, OSE-EIS Reagan. J@michigan. gov Time to talk? Thank you Jane E. Reagan, MPA MDE, OSE-EIS Reagan. [email protected] gov 517 -335 -2250 MDE-OSE/EIS

Sources Governor-Elect Granholm’s Michigan Medicaid Summit of 11 -21 -02 ---Michigan. Medicaid. org -Tom Sources Governor-Elect Granholm’s Michigan Medicaid Summit of 11 -21 -02 ---Michigan. Medicaid. org -Tom Clay, Citizens Research Council of Michigan, presenter -Vernon Smith, Ph. D, Health Management Associates, presenter -Paul Reinhart, (then) State of Michigan Budget Office, presenter Michigan Department of Community Health, Medical Services Administration (Medicaid) -michigan. gov/mdch MDE-OSE/EIS

Sources, cont’d Kaiser Family Foundation and Kaiser Commission on Medicaid and the Uninsured “Fact Sources, cont’d Kaiser Family Foundation and Kaiser Commission on Medicaid and the Uninsured “Fact Sheets” (KFF. org) Scully, Thomas, CMS Administrator in 2003. Comments to House Energy and Commerce Committee Subcommittee on Health (10 -8 -03) Smith, Vern K, Ph. D. , Health Management Associates (Health. Management. com) Presentation of 2 -1 -05 Thompson, Jacquelyn, Ph. D, Director, Michigan Department of Education Office of Special Education and Early Intervention Services under resources, presentations (Michigan. gov/mde) MDE-OSE/EIS

Sources, cont’d Varvel, Gary, “Lance Armstrong cartoon” used with permission from the author for Sources, cont’d Varvel, Gary, “Lance Armstrong cartoon” used with permission from the author for Educational purposes only. Obtain permission for any other purposes through Creators Syndicate. (www. creators. com/editorialcartoons. html) MDE-OSE/EIS