Current through Register Vol. 50, No. 9, September 20, 2024
A. Cost
Reporting. Settlement payments for EPSDT school-based medical direct, therapy,
behavioral health, and PCS services shall be based on the most recent school
year's actual costs as determined by desk review and/or audit for each LEA
provider.
1. Each LEA shall determine cost
annually by using LDH's cost report for medical service cost form based on the
direct services cost report.
2.
Direct costs shall be limited to the amount of total compensation (salaries,
vendor payments and fringe benefits) of current medical service providers as
allocated to medical services for Medicaid beneficiaries. There are no
additional direct costs included in the rate.
3. ...
4. To determine the amount of EPSDT services
costs that may be attributed to Medicaid; the ratio of total Medicaid students
in the LEA is multiplied by total direct (direct plus indirect) cost. Cost data
are subject to certification by each LEA. This serves as the basis for
obtaining federal Medicaid funding.
B. Licensed master social workers practicing
under the supervision of a licensed clinical social worker, and certified
school psychologist practicing under the supervision of a licensed psychologist
that has the authority to practice in the community/outside of schools will be
required to show proof of verification when the cost report is monitored.
1. - 6. Repealed.
C. For the EPSDT services the participating
LEA's actual cost of providing the services shall be claimed for Medicaid
federal financial participation (FFP) based on the following methodology.
1. Develop Direct Cost-The Payroll Cost Base
and Vendor Cost Base. The state shall gather actual expenditure information for
each LEA through its employee payroll/benefits and vendor accounts payable
system. Total annual salaries and benefits paid, as well as contracted (vendor)
payments, shall be obtained initially from each LEA's payroll/benefits and
accounts payable system. This data shall be reported on LDH's direct services
cost report form for all direct service personnel (i.e., all personnel
providing LEA medical services covered under the state plan).
2. Adjust the Payroll and Vendor Cost Base.
The payroll and vendor cost base shall be reduced for amounts reimbursed by
non-state and local funding sources (e.g., federal grants). The payroll and
vendor cost base shall not include any amounts for staff whose compensation is
100 percent reimbursed by a funding source other than state/local funds. This
application results in total adjusted employee salary and vendor
cost.
3. Determine the Percentage
of Time to Provide All EPSDT Services. A time study, which incorporates the
CMS-approved Medicaid administrative claiming (MAC) methodology for direct
service employees, shall be used to determine the percentage of time EPSDT
service providers spend on EPSDT direct services and general and administrative
(G and A) time. This time study will assure that there is no duplicate
claiming. The G and A percentage shall be reallocated in a manner consistent
with the CMS-approved Medicaid administrative claiming methodology. Total G and
A time shall be allocated to all other activity codes based on the percentage
of time spent on each respective activity. To reallocate G and A time to EPSDT
services, the percentage of time spent on EPSDT services shall be divided by
100 percent minus the percentage of G and A time. This shall result in a
percentage that represents the EPSDT services with appropriate allocation of G
and A. This percentage shall be multiplied by total adjusted salary cost as
determined by the adjusted payroll cost base to allocate cost to school-based
services. The product represents total direct cost.
a. A sufficient amount of EPSDT service
providers' time shall be sampled to ensure results that will have a confidence
level of at least 95 percent with a precision of plus or minus 5 percent
overall.
b. Time study moments are
to be completed and submitted by all participating LEA participants.
Participants will have 48 hours (not counting weekends or holidays) from the
time of the moment to complete each moment. Reminder emails will be sent to the
participant and the Medicaid coordinator each morning until the moment expires.
Once a time study moment has expired, it will no longer be able to be completed
and will be deemed not returned. Any LEA that fails to return at least 85
percent of its moments from the time study for two quarters in a cost report
year for any program, will be suspended from that program for the entire cost
report year.
c. Unsupported Time
Study Moments. LEAs will be penalized the lessor of $1,000 times the number of
unsupported moments or 50 percent of their cost report. This only applies to
LEAs that cannot support at least 50 percent of the moments selected for
testing.
d. The time study
percentage used for cost reimbursement calculation is an average of the four
quarterly statewide time study results for each school-based Medicaid program.
LEAs must participate in all four time study quarters to be reimbursed all
costs for the fiscal year. Any LEA that does not submit a cost report for any
program for which any billings were submitted will be required to pay back any
billing dollars received for that cost report year. This will be handled in the
school based claiming cost settlement process.
e. Vendors are not subject to the time study
process. Vendors are only at a school to provide the direct service enumerated
in the contract. Vendors are not expected to perform G and A tasks and will be
reimbursed based on a rate per service. This rate per service should include
all direct and indirect costs. The rate per service should cover the time spent
providing the direct service, administrative time and any other time related to
tasks related to that service.
4. Determine Indirect Costs. Indirect costs
shall be determined by multiplying each LEA's indirect unrestricted rate
assigned by the cognizant agency (the Department of Education) by total
adjusted direct cost. No additional indirect costs shall be recognized outside
of the cognizant agency's indirect rate. The sum of direct costs and indirect
costs shall be the total direct service cost for all students receiving EPSDT
services.
D. Allocate
Direct Service Costs to Medicaid. To determine the costs that may be attributed
to Medicaid, total direct service cost (employee and vendor) shall be
multiplied by the ratio of Medicaid enrolled students in the LEA to all
students in the LEA. This results in total cost that may be certified as
Medicaid's portion of school-based EPSDT services cost. The Medicaid enrolled
student ratio is calculated one time in each cost report year. This calculation
is based on the statewide student count performed in October each year.
1. - 9. Repealed.
E. Reconciliation of LEA Certified Costs and
Medicaid Management Information System (MMIS) Paid Claims. Each LEA shall
complete applicable service cost report(s) and submit the cost report(s) no
later than five months after the fiscal year period ends (June 30), and
reconciliation should be completed within 12 months from the fiscal year end.
All filed cost reports shall be subject to desk review by the department's
audit contractor. The department shall reconcile the total expenditures (both
state and federal share) for each LEA's therapy, behavioral health services,
personal care services, nursing services, and other medical direct services.
The Medicaid certified cost expenditures from the cost report(s) will be
reconciled against the MMIS paid claims data and the department shall issue a
notice of final settlement, after all reviews, that denotes the amount due to
or from the LEA. This reconciliation is inclusive of all services provided by
the LEA.
F. Interim Billing. The
Centers for Medicare and Medicaid Services (CMS) requires each LEA to bill for
all Medicaid services provided. CMS and the Office of Inspector General (OIG)
rely on interim billing data for documentation of the number of services
provided by each LEA and gives them a mechanism to compare the cost reimbursed
to the number of services being provided. If there are no claim submissions
within an 18 month period, Medicaid management information system (MMIS)
automatically terminates eligibility of a provider number making the LEA
Medicaid ineligible. Any LEA that is Medicaid ineligible will have all interim
claims denied and its cost report for all programs in which the LEA
participated will be rejected.
G.
Cost Settlement Process. As part of its financial oversight responsibilities,
the department shall develop a risk assessment and an audit plan to ensure cost
reasonableness and accuracy in accordance with current CMS guidelines. Based on
the audit plan, the department will develop agreed upon procedures to review
and process all final settlements to LEAs. The agreed upon procedures will be
performed to review cost reports submitted by LEAs.
1. The financial oversight of all LEAs shall
include reviewing the costs reported on the EPSDT services cost report against
the allowable costs, performing desk reviews and conducting limited
reviews.
2. The department will
make every effort to audit each LEA at least every four years. These activities
shall be performed to ensure that audit and final settlement occurs no later
than two years from the LEA's fiscal year end for the cost reporting period
audited. LEAs may appeal audit findings in accordance with LDH appeal
procedures.
3. The department shall
adjust the affected LEA's payments no less than annually, when any
reconciliation or final settlement results in significant underpayments or
overpayments to any LEA. By performing the reconciliation and final settlement
process, there shall be no instances where total Medicaid payments for services
exceed 100 percent of actual, certified expenditures for providing LEA services
for each LEA.
4. If the interim
payments exceed the actual, certified costs of an LEA's Medicaid services, the
department shall recoup the overpayment from current and following years cost
report settlement until the amount due is zero.
5. If the actual certified costs of an LEA's
Medicaid services exceed interim Medicaid payments, the department will pay
this difference to the LEA in accordance with the final actual certification
agreement.
6. Type 1 and 3 charter
schools in Orleans Parish will be required to submit acceptable documentation
(board minutes, letter from the school board, etc.) that authorizes the charter
to act as its own LEA, upon enrollment. Likewise, in order to receive a cost
settlement, confirmation that the authorization is still in good standing with
the school board will be required to accompany the submission of the cost
report. Failure to provide this documentation at the time the cost report is
filed may cause the cost report to be rejected and not be considered as timely
filed.
H. Delinquent Cost
Report Penalty. Cost reports must be submitted annually. In order to be
eligible to submit a cost report, LEAs must participate in all four time study
quarters for the fiscal year.
1. The due date
for filing annual cost reports is November 30. There shall be no automatic
extension of the due date for filing of cost reports. If an LEA experiences
unavoidable difficulties in preparing its cost report by the prescribed due
date, one 30-day extension may be permitted, upon written request submitted to
the department or its designee prior to the due date. The request must explain
in detail why the extension is necessary. Extensions beyond 30 days may be
approved for situations beyond the LEA's control.
2. Delinquent cost reports that have not been
received by November 30 and an extension was not received, will be deemed
non-compliant and may be subject to a non-refundable reduction of 5 percent of
the total cost settlement. This reduction may be increased an additional 5
percent each month until the completed cost report is submitted or the
penalties total 100 percent. LEAs that have not filed their cost report by six
months or more beyond the due date cannot bill for services until the cost
report is filed.
I. State
Monitoring. If the department becomes aware of potential instances of fraud,
misuse or abuse of LEA services and Medicaid funds, it will perform timely
audits and investigations to identify and take necessary actions to remedy and
resolve the problem.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
