Current through Register Vol. 41, No. 3, September 23, 2024
A. Definitions. The following words are terms
when used in this section shall have the following meanings unless the context
clearly indicates otherwise:
"CMS" means Centers for Medicare and Medicaid
Services.
"DMAS" means Department of Medical Assistance
Services.
"FAMIS" means Family Access to Medical Insurance Security
Plan.
"FFP" means Federal Financial Participation.
"IDEA" means Individuals with Disabilities Education
Act.
"IEP" means Individual Education Plan.
"LEA" means Local Education Agency.
"MMIS" means Medicaid Management Information System.
B. Effective for services on or
after July 1, 2006, the following methodology will determine the reimbursement
for Local Education Agency (LEA) providers. The methodology described below
applies to reimbursement for the following services delivered by LEA providers.
These services are described in 12VAC30-50-135.
1. Speech therapy;
2. Audiology and hearing services;
3. Physician services for medical evaluation
services;
4. Occupational
therapy;
5. Physical
therapy;
6. Psychiatric and
psychological services;
7. Personal
care services;
8. Skilled nursing
services; and
9. Special
transportation.
C.
Medical services provided by LEA providers for special education students. The
following methodology will determine the reimbursement for (LEA) providers.
1. For each of the IDEA-related school-based
medical services covered under the State Plan other than specialized
transportation services, the LEA provider's actual cost of providing the
services shall be certified and the FFP shall be paid to LEA providers based on
the methodology described in subdivisions 2 through 7 of this subsection. For
the rate year ending June 30, 2007, cost will be reported on a cash basis; for
all succeeding years cost will be reported on an accrual basis. All costs to be
certified and used subsequently to determine reconciliation and final
settlement amounts as well as interim rates are identified on the CMS-approved
Medical Services Cost Report. Final payment for each school year is based on
actual costs as determined by desk review and/or audit for each LEA
provider.
2. Step 1: Develop the
personnel cost base for medical services. Total salaries and benefits paid as
well as contracted (vendor) payments shall be obtained initially from each
LEA's payroll/benefits and financial system for each quarter of the fiscal
year. This data shall be reported on the DMAS Medical Services Cost Report form
for all direct service personnel (i.e., all personnel providing medical
services covered under the State Plan). Total computable personnel costs are
reduced by any reimbursement that is not from state or local funding sources.
The personnel cost base does not include any amounts for staff whose
compensation is 100% reimbursed by a funding source other than state or local
funds. The application of Step 1 results in total adjusted salary
cost.
3. Step 2: Determine medical
services personnel cost using a time study. A time study that incorporates the
CMS-approved time study methodology shall be used to determine the percentage
of time medical service personnel spend on IEP-related medical services and
general and administrative (G&A) time. This time study shall assure that
there shall be no duplicate claiming relative to claiming for administrative
costs and no more than 100% of practitioner time is reported. G&A time
shall be allocated to medical services based on the percentage of time spent on
medical services. To reallocate G&A time to medical services, the
percentage of time spent on medical services shall be divided by 100% minus the
percentage of time spent on G& A. This shall result in a percentage that
represents the medical services with appropriate allocation of G& A. This
percentage, which shall be determined quarterly, shall be multiplied by the
personnel cost base as determined in Step 1 to allocate personnel cost to
medical services. The product represents medical services personnel cost for
all payers and not just Medicaid. A sufficient number of medical service
personnel shall be sampled to ensure time study results that will have a
confidence level of at least 95% with a precision of plus or minus 5.0%
overall. The time study is CMS-approved and may not be modified unless prior
approval is received from CMS. Quarterly personnel costs are summed for the
fiscal year and reported on the DMAS Medical Services Cost Report.
For claims submitted after the effective date of July 1,
2006, and prior to the implementation of the CMS-approved time study only, cost
will be identified in accordance with a methodology developed by the department
and approved by CMS that utilizes the quarterly results of the prospectively
approved time study and applies them to the prior period claims.
4. Step 3: Develop medical
services nonpersonnel costs. Nonpersonnel costs used in the delivery of medical
services, detailed as line items on the CMS-approved cost report, shall be
obtained from each LEA's financial system. Capital costs must be equal to or
exceed $5,000 and have a useful life greater than two years. The straight line
method of depreciation is used for capital costs. Total computable nonpersonnel
costs shall be reduced by any reimbursement that is not from state or local
funding sources.
5. Step 4:
Determine indirect costs. Indirect costs shall be determined by multiplying
each LEA's unrestricted indirect rate assigned by the cognizant agency (the
Department of Education) by total direct costs as determined under Steps 2 and
3. No additional indirect costs shall be recognized outside of the indirect
costs determined by Step 4.
6. Step
5: Total medical services costs. Total medical services costs shall be
determined by adding costs from Steps 2, 3 and 4.
7. Step 6: Allocate total medical services
costs to Medicaid, Medicaid expansion and FAMIS. To determine the Medicaid,
Medicaid expansion, and FAMIS medical services costs to be certified, total
medical services costs shall be multiplied by the ratios of Medicaid, Medicaid
expansion and FAMIS recipients with an IEP to all students with an
IEP.
D. Special
transportation services provided by LEA providers for special education
students.
1. The participating LEA's actual
cost of providing special transportation services shall be claimed for Medicaid
FFP based on the methodology described in subdivisions 2 through 6 of this
subsection. Special transportation refers to transportation on buses modified
and dedicated for special education. All costs to be certified and used
subsequently to determine the reconciliation and final settlement amounts as
well as interim rates shall be identified on the CMS-approved Special
Transportation Cost Report. Final payment for each school year shall be based
on actual costs as determined by desk review or audit for each LEA
provider.
2. Step 1: Develop
special transportation nonpersonnel costs. The costs for special transportation
includes fuel, repairs and maintenance, rentals, contract vehicle use costs,
and other costs as approved by CMS and shall be obtained from the LEA's general
ledger and reported on the Special Transportation Cost Report form.
Nonpersonnel costs shall be reduced by any reimbursement that is not from state
or local funding sources. All costs shall be reported on an accrual
basis.
3. Step 2: Develop special
transportation personnel costs. Total annual salaries and benefits paid as well
as contract costs (vendor payments) for special transportation services shall
be obtained from each LEA's payroll/benefits and financial systems. This data
shall be reported on the Special Transportation Cost Report form for all direct
service personnel. The included personnelare specified on the approved CMS cost
report.
To the extent that any allowed cost for transportation is
reported as shared between regular and specialized transportation, there must
be an allocation of cost between the programs. For example, a mechanic may work
on buses for both programs but his salary may not be reported as such in the
accounting records. In these instances, the provider should allocate cost using
the ratio of specialized buses/vehicles owned by the provider to total regular
transportation buses/vehicles owned by the provider.
4. Step 3: Determine indirect costs. Indirect
cost shall be determined by multiplying each LEA's unrestricted indirect rate
assigned by the cognizant agency (the Department of Education) by total special
transportation costs as determined under Steps 1 and 2. No additional indirect
costs shall be recognized outside of the indirect costs determined by Step
3.
5. Step 4: Total special
transportation costs. Total special transportation services costs shall be
determined by adding costs from Steps 1, 2 and 3.
6. Step 5: Allocate total special
transportation services cost to Medicaid, Medicaid expansion, and FAMIS.
Special transportation drivers or other school personnel shall maintain logs of
all students transported on each one-way trip. These logs shall be used to
calculate reimbursable percentages for Medicaid, Medicaid expansion and FAMIS.
The denominator shall be the total annual one-way trips on special buses. The
numerator shall be Medicaid, Medicaid expansion or FAMIS special transportation
one-way trips. To qualify as a special transportation trip, the student must be
eligible for Medicaid, Medicaid expansion or FAMIS; transportation must be
included in the IEP; and the student must have received a covered medical
service on the day of the special transportation. To allocate special
transportation costs to Medicaid, Medicaid expansion and FAMIS, total special
transportation cost as determined under Step 4 shall be multiplied by the
reimbursable percentages described above.
E. Reconciliation of the total computable
interim payment for medical costs to total incurred cost.
1. Each LEA provider will complete the
Medical Services and Special Transportation Cost reports and submit the cost
reports no later than five months after the end of the LEA's fiscal year. All
cost reports shall be reviewed and reconciled to final costs within 180 days
(11 months from the end of the rate year) of the receipt of a completed cost
report . DMAS may conduct additional desk or field audits up to two years after
the fiscal year-end based on risk assessment developed by DMAS. LEA providers
may appeal audit findings in accordance with DMAS appeal procedures.
2. DMAS shall issue a settlement notice at
the time of the reconciliation that denotes the amount due to or from the LEA
provider. This reconciliation shall be inclusive of both medical services and
special transportation services provided by the LEA provider. The state will
settle with each provider, using one of the methods described below for either
under- or overpayment associated with school-based services. Settlement will be
limited to recovery or payment of only the federal financial participation
associated with total computable cost.
a. If
the interim payments exceed the FFP of the certified costs of an LEA's
Medicaid, Medicaid expansion or FAMIS services, DMAS shall recoup the
overpayment in one of the following methods:
(1) Offset all future claim payments from the
affected LEA until the amount of the overpayment is recovered;
(2) Recoup an agreed upon percentage from
future claims payments to the LEA to ensure recovery of the overpayment within
one year; or
(3) Recoup an agreed
upon dollar amount from future claims payments to the LEA to ensure recovery of
the overpayment within one year.
b. If the FFP of the certified costs exceed
interim payments, DMAS shall pay the difference to the LEA provider.
F. Interim rates. At
the end of each settlement, interim rates for each LEA provider shall be
determined by dividing total medical services cost and special transportation
services cost by an estimate of the number of units of service. For the initial
interim rates or for new providers, interim rates shall be based on pro forma
cost data. Interim rates shall be provisional in nature pending completion of
the cost report.
G. Billing. Each
LEA provider shall submit claims in accordance with the school division manual
and shall be paid an interim rate for approved claims.
H. State monitoring. If DMAS becomes aware of
potential instances of fraud, misuse or abuse of services and funds, it shall
perform timely audits and investigations to identify and take the necessary
actions to remedy and resolve the problems.
I. Other services. EPSDT well child
screenings provided to Medicaid, Medicaid expansion, and FAMIS recipients and
described in
12VAC30-50-130 shall be reimbursed
according to the agency fee schedule for all providers. These costs shall not
be reimbursed through the cost report.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
