SCHOOL HEALTH AND RELATED SERVICES

SCHOOL HEALTH AND RELATED SERVICES

(SHARS)

2008 COST REPORT TRAINING

Updated: January 12, 2009

Introduction

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Housekeeping

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Today’s Training Goals

• How to get help with SHARS-related questions

• Review of Medicaid-allowable costs for SHARS

• Understand elements of an acceptable SHARS cost report

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Three Facets to SHARS

Claims and

Reimbursement

Cost Reportand

Cost Settlement

Random MomentTime Study

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Contacts

District-Specific Interim Rates and Cost Report Questions

• Cathy Rutherford, Rate Analyst, HHSC(512) 491-1361: E-mail: [email protected]

or: [email protected]

• SHARS Program/Policy/Certification of Funds/Payment Questions

• Clarice Cefai, Senior Policy Analyst, HHSC(512) 249-3736; E-mail: [email protected]

Contacts

mailto:[email protected]

Contacts

IEP and Other IDEA/Educational Questions

• Robert Vitela, Director of Interagency Coordination, TEA (512) 463-9283; E-mail: [email protected]

• Tammy Wooten, Program Specialist, TEA(512) 463-9283; E-mail: [email protected]

Cost Report System and Website Questions

• Fairbanks Hotline (888) 321-1225; E-mail: [email protected]

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Contacts

RMTS and MAC Questions

• Regions 2,3,5,6,12,13,20 –• contact Amanda Hudson at (512) 491-1198 or

[email protected]

• Regions 1,4,7,8,15,16,19 -• contact Sandra Brabandt at (512) 491-1314 or

[email protected]

• Regions 9,10,11,14,17,18 –• contact Renee Elliott at (512) 491-1740 or [email protected]

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Cost Report Information

• HHSC cost report information (including training) and district-specific interim rates can be found on the HHSC Rate Analysis SHARS website:www.hhsc.state.tx.us/Medicaid/programs/rad/AcuteCare/Shars/Shars.html

• Information about RMTS and cost report data entry can be found on the Fairbanks website: www.fairbanksllc.com/

• Information about SHARS can be found on the TEA website: www.tea.state.tx.us/interagency/shars.html

Other Information

• Provider notifications for general SHARS information are distributed by TEA SHARS ListServ and Fairbanks

• Provider notifications for SHARS Cost Report Information are distributed by Fairbanks

• Sign up for TEA ListServ at: http://miller.tea.state.tx.us/list/

PLEASE make certain your district contact information is accurate on the TEA and Fairbanks websites …

THANK YOU!!!

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Other Information

• Texas Medicaid Provider Procedures Manual (TMPPM): TMHP website at http://www.tmhp.com

• For help with TPI/NPI numbers, resolution of payment issues, or Certification of Funds issues, call TMHP Customer Services: 1-800-925-9126 or your TMHP Provider Relations Representative

• Provider Information Change (PIC) Form (to change district name, address to send Certification of Funds letters, etc.):

http://www.tmhp.com/C12/Changing%20Provider%20Information/default.aspx



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What Direct Services are Reimbursed by SHARS?

Direct Medical Services Include:

1. Audiology and Hearing, including evaluations and therapy sessions

2. Physician Services

3. Occupational Therapy, including evaluations and therapy sessions

4. Physical Therapy, including evaluations and therapy sessions

5. Psychological Services, including assessments and therapy sessions

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Services (cont’d)

6. Speech and Language Services, including evaluations and therapy

sessions

7. Nursing Services, including routine medication administration

services

8. Counseling Services

9. Personal Care Services

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Services (cont’d)

“Who” can provide these direct services?

Answers and examples can be found at:

TMPPM Manual (Chapter 42) at the TMHP website at:

http://www.tmhp.com

TEA SHARS website (FAQs and Billing Guidelines):

www.tea.state.tx.us/interagency/shars.html

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Services (cont’d)

Specialized Transportation Services

– Vehicle must be specially adapted

– Special Education student must require the special adaptation(s)

Student’s need for the special adaptation(s) must be documented in his/her IEP

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What is the Purpose of the Cost Report?

Medicaid will not pay School Districts, as governmental entities, more than their Medicaid-allowable costs to provide SHARS.

– The cost report is used for the cost reconciliation and settlement processes.

– The cost report data will be used to calculate future district-specific interim rates.

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The Texas Health and Human Services Commission (HHSC) has been granted approval by the Centers for Medicare & Medicaid Services (CMS) for the 2008 SHARS cost report to cover 13 months (09/01/2007 - 09/30/2008) in order to transition to the federal fiscal year for the 2009 SHARS cost report (10/01/2008 - 09/30/2009) and future cost reports (10/1 – 9/30).

The 2008 SHARS cost report will be due on or before April 1, 2009.

All future cost reports will be due April 1 of the year following the cost report period.

SHARS Cost Report to Cover Federal Fiscal Year (FFY)

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Relationship of Claims to Cost Report

Claims and

Reimbursement

Cost Reportand

Cost Settlement

Random MomentTime Study

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Relationship of Claims to Cost Report

How many days from the date of service does a school have to bill for reimbursement?

A school district must file all initial claims within 365 days of the date of service or 95 days after August 31st (December 4, 2008), whichever comes first for dates of service covering September 1, 2007 through August 31, 2008.

A district cannot bill for services delivered before its SHARS provider enrollment date.

All “claims” for September 2008 should be submitted as soon as possible.

All “costs” for dates of service covering September 1, 2008 through September 30, 2008 must be included on your 2008 Cost Report.

Claims not submitted will be paid through the cost report settlement process.

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Relationship of COF to Cost Report

The cost report is the final settle up process in which Medicaid payments already received are verified and subtracted from the balance of Medicaid-allowable costs. The cost report certification is based on actual costs and actual rates.

Certification of Funds (COF) is required in order to draw down federal funding for quarterly SHARS interim payments and is based on estimated rates.

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Relationship of COF to Cost Report

Recommended documentation/steps for the COF process are located on the Rate Analysis Website at:

http://www.hhsc.state.tx.us/Medicaid/programs/rad/AcuteCare/Shars/Shars.html

Reminder: A district can be put on vendor hold for failure to submit the quarterly COF.

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Relationship of RMTS to Cost Report

Claims and

Reimbursement

Cost Reportand

Cost Settlement

*Random MomentTime Study

Question: How important is RMTS to my district’s funding?

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Answer: *RMTS is a critical component of SHARS.

The CMS approved SHARS State Plan language requires that providers submit an annual cost report, with cost reconciliation and cost settlement processes.

The State Plan language also requires that providers must participate in the timestudy in order to bill for SHARS.

The results of the timestudy are the basis for the calculation of the direct medical services timestudy percentage that is used during the cost reporting process to allocate costs to the Medicaid program.

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In order to remain eligible for SHARS reimbursement, adistrict must participate in RMTS. Participation includes but is not limited to:

• Ensuring RMTS Program Contact has been trained

• Ensuring the RMTS Participant List is updated/certified EACH quarterly (OD, JM, and AJ)

• Meet the 85% participation/response requirement

Information about RMTS can be found on the Fairbanks website at:www.fairbanksllc.com/

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RMTS Purpose & Process

DeterminewhoperformsMAC/SHARSactivities

DeterminewhoperformsMAC/SHARSactivities

MeasurestheamountoftimespentoneligibleandreimbursableactivityforSHARSandMAC

MeasurestheamountoftimespentoneligibleandreimbursableactivityforSHARSandMAC

ParticipantIdentificationParticipantIdentification TimeStudyTimeStudy

MACFinancialDataCollection

Determineactualcostsassociated

withtheseactivities

MACFinancialDataCollection

Determineactualcostsassociated

withtheseactivities

MACClaimCalculation

Applyreimbursementrates(TS,MER,

IDCR)tocalculateaclaim

MACClaimCalculation

Applyreimbursementrates(TS,MER,

IDCR)tocalculateaclaim

DeterminesSHARSeligibility

anddirectmedicalpercentagefor

CostReportcalculations

DeterminesSHARSeligibility

anddirectmedicalpercentagefor

CostReportcalculations

SHARSCostReportisusedto

reconcileandcostsettleSHARS

paymentsandtosetDistrictSpecific

InterimRates

SHARSCostReportisusedto

reconcileandcostsettleSHARS

paymentsandtosetDistrictSpecific

InterimRates

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Choosing the Correct RMTSCategory

Please use the following process to determine which category to report individuals:

YES

YES

NO

NO

Report in the Applicable

DS & Admin category Is the

person billing

SHARS?

Report name under the applicable Admin Only

category Does the person spend ~10% of

their time performing

administrative activities?

Do not report on participant list

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Eligible Categories of Staff - Direct Service & Administrative Cost Pool

Registered Nurses (RN) Licensed Vocational Nurses (LVN) Advanced Practice Nurses (APNs), Delegated Nursing Services Physicians (MDs) Licensed Audiologist Licensed Assistant in Audiology Licensed Occupational Therapist (OT) Certified Occupational Therapy

Assistant (COTA) Licensed Physical Therapist (PT) Licensed Physical Therapy Assistant

(LPTA) Licensed Psychologist Licensed Specialist in School

Psychology (LSSP)

Licensed Psychiatrist ASHA-Equivalent Speech Language

Pathologist (SLP) with Texas license and master's degree

ASHA SLPs with Texas Licenses Grandfathered SLP with Texas License

and no master's degree TEA- or SBEC-Certified Speech

Therapists Licensed Assistant in SLP Licensed SLP Intern Licensed Professional Counselor (LPC) Licensed Marriage and Family

Therapist (LMFT) Licensed Clinical Social Worker

(LCSW) Personal Care Service Providers

TEA = Texas Education AgencySBEC = State Board of Educator CertificationASHA = American Speech-Language-Hearing Association

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Eligible Categories of Staff - Administrative Cost Pool

Physician Assistant Licensed Bachelor of

Social Work Licensed Master of Social

Work Service Coordinator/Case

Managers Interpreter/Translator/

Bilingual Specialist

Pregnancy, Education & Parenting Program Personnel

Orientation & Mobility Specialist

Outreach Workers Psychology Intern Behavioral Counselor

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The RMTS Direct Service Cost Pool/Participant List should include:

• Direct Service Providers (including):

– Federally-Funded Employees

– Contractors (list all positions that will perform services but are not employed by the school district, including shared services employees)

Example: If ABC Home Health Agency provides 2 RNs, 3 LVNs/LPNs, 2 PTs, and 2 OTs per month, you can enter these contractors into the PL as ABC HHA RN #1, ABC HHA RN #2, ABC HHA LVN/LPN #1, ABC HHA PT #1, ABC HHA OT #1, and so on.

– Vacant Positions that will be filled during the quarter


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The RMTS Direct Service Cost Pool/Participant List should not include:

• Bus Drivers (unless they also provide another direct service)

• SBEC-or TEA-Certified School Counselors

• Educational Diagnosticians

• Vacant Positions that will not be filled during the quarter

Note: If SBEC or TEA Certified School Counselors and Educational Diagnosticians qualify under one of the Admin Cost Pool eligible categories and spend at least 10% of their time annually performing the qualifying activities they may be included in the Administrative Cost Pool.


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RMTS Sampled Moment

The activity description should be a detailed response, as to what the participant was doing. Please keep in mind that the person coding the moment has no idea of the participant’s job description, tasks performed or why they are performed. It is up to the participant to provide the information needed for those independent coders to code the response accurately.

Please train your Time Study Participants to provide the definition of any acronyms they may use in describing their activity on their sampled moments.

If the participant was not working, the moment should indicate whether the participant was on paid or unpaid time off.

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Quarterly Certification of RMTS Participant List

Effective January 1, 2009 an HHSC trained RMTS Program Coordinator that is an employee of the District or a contractor/designee of the District may certify the quarterly RMTS Participant List.

A contractor/designee may be District staff, SSA, Co-Op/Fiscal Agents, and/or a Vendor.

Each District is responsible for the designee’s actions and/or non-action.

District’s must document the authorization and provide documentation if requested.

HHSC recommends that the authorization to certify the quarterly participant list may be incorporated into the contract with the authorized entity.

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Medicaid-Allowable Costs IEP RATIO

Individualized Education Program (IEP) ratio fordirect medical services:

Total Medicaid students with IEPs requiring direct medical service(s)

divided by

Total students with IEPs requiring direct medical service(s)

Medicaid-Allowable Costs IEP RATIO

• To calculate the IEP ratio, first compile an unduplicated list of all Special Education students for the entire reporting period.

• From that list, compile a list of the students whose IEPs document the need for one or more direct medical services. That number is the denominator.

• From the second list, compile a list of the students that were Medicaid at any time during the cost-reporting period. That number will be the numerator.

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Individualized Education Program (IEP) Ratio

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Medicaid-Allowable Costs ONE-WAY TRIP RATIO

One-way trip ratio for specialized transportation services:

Total number of one-way trips for Medicaid Students with IEPs requiring specialized transportation services

divided by

Total number of one-way trips for all students with IEPs requiring specialized transportation services


• When calculating the one-way trip ratio:– The same definition must be used for both the numerator and

denominator– The only difference being that the numerator is Medicaid one-way trips

and the denominator is all one-way trips

• Definition of one-way trip: – Vehicle must be specially adapted– Special Education student must require the special adaptation(s)– The student’s need for the special adaptation(s) is documented in his/her

IEP– The student received at least one other direct medical service on the

same day as the trip

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• From the list that was used to determine the denominator for the IEP ratio, compile a list of the students whose IEPs also document the need for specialized transportation services. Those are the students for which you need to count all the one-way trips. That number of one-way trips will be the denominator.

• From the list that was used to determine the numerator for the IEP ratio, compile a list of the Medicaid students whose IEPs also document the need for specialized transportation services. Those are the students for which you need to count all the one-way trips. That number will be the numerator.

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Medicaid-Allowable Costs Direct Medical Services

Direct Payroll Costs

• Gross Salary/Contractor Payments

• Payroll Taxes

– FICA

– Medicare

– Unemployment

• Workers Compensation Costs

• Employee Benefits

– Insurance (Health, Life, Disability, Dental, Other)

– Retirement

– Other

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A. Take direct costs (payroll and other) and subtract federal funding• DO NOT SUBTRACT MEDICAID ADMINISTRATIVE CLAIM (MAC) FUNDING OR

MAINTENANCE OF EFFORT (MOE) PAYMENTS• Subtract IDEA federal payments and any other payments from federal grants associated

with the costs

B. Take the result of “A” and multiply by the district’s specific unrestricted indirect cost rate (UICR) to calculate indirect costs and add that amount to “A” (or multiply by 1 plus the UICR).

C. Take the result of “B” and multiply by the direct Medical services percentage from the time study (estimated at 55%).

D. Take the result of “C” and multiply by the district’s Individualized Education Program (IEP) ratio for direct medical services.

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EXAMPLE #1

• Total direct costs (payroll and other) = $50,000

• Total federal payments for those costs = $ 20,000

• District-specific UICR = 8.179%

• Direct medical services percentage from time study = 55%

• IEP Ratio = 28.5%

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Example #1 (ANSWER):

• $50,000 - $20,000 = $30,000

• $30,000 * 1.08179 = $32,453.70

• $32,453.70 * 55% = $17,849.54

• $17,849.54 * 0.285 = $5,087.12

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Example #2

• Total direct costs = $75,000

• Total federal funding to be subtracted = $ 25,000


• Direct medical services percentage from time study = 55%

• IEP Ratio = 30.5%

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Example #2 (ANSWER)

• $75,000 - $25,000 = $50,000

• $50,000 * 1.10 = $55,000

• $55,000 * 55% = $30,250

• $30,250.00 * 0.305 = $9,226.25

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Medicaid-Allowable Costs Specialized Transportation Services

A. Take direct costs (payroll and other) and subtract all applicable federal funding– Subtract IDEA federal payments and any other payments from

federal grants associated with the costs– DO NOT SUBTRACT MAINTENANCE OF EFFORT (MOE)

PAYMENTS

B. Take the result of “A” and multiply by the district’s specific unrestricted indirect cost rate (UICR) to calculate indirect costs and add that amount to “A” (or multiply by 1 plus the UICR).

C. Take the result of “B” and multiply by the district’s one-way trip ratio for specialized transportation services

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Medicaid-Allowable Costs for Specialized Transportation Services

Example #1

• Total direct costs = $80,000

• Total federal funding to be subtracted = $ 35,000


• One-way trip ratio = 38.3%

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Medicaid-Allowable Costs for Specialized Transportation Services

Example #1 (ANSWER)

• $80,000 - $35,000 = $45,000

• $45,000 * 1.034 = $46,530

• $46,530 * 0.383 = $17,820.99

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Medicaid-Allowable CostsSpecialized Transportation Services

Allocation of Shared Transportation Costs

Transportation costs that cannot be direct-costed to specialized

transportation services (e.g., fuel, insurance, and/or vehicle mechanic

costs) can be allocated based on the number of specialized

transportation vehicles divided by the total number of transportation

vehicles.

Medicaid-Allowable CostsOther Costs

Other Costs

Staff travel costs to provide direct medical services; required continuing education costs; other direct medical services materials and supplies (from Appendix A); depreciation from other direct medical services equipment can all be reported on the cost report.

Example: Costs for shared computers, defibrillators, etc (from Appendix A) for all (including special education) students can be reported on the cost report.

If costs are known to only be applicable to students other than Special Education students, those costs should not be reported on the cost report.

All costs, including shared costs, will be allocated to the Texas Medicaid Program by using the direct medical services percentage and the district's IEP ratio.

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Reconciliation and Settlement

• Desk Review

• IEP Ratio

• One-way trip ratio calculation and specially-adapted vehicle ratio

• Staff costs and paid hours– Payroll costs (salaries/compensation, payroll taxes, and employee

benefits) must be maintained at individual staff level and may be requested

– Staff must match RMTS Participant List

• Other direct costs– Invoices must be maintained

• Items costing $5,000 or more – Proof of purchase date for depreciated items (e.g., specially-

adapted vehicles, equipment, etc.)

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Reconciliation and Settlement• Corrections

• May be made during the desk review process– Send written request to: [email protected]

• Settlement

• If Medicaid-Allowable Costs exceed payments– HHSC will pay the federal share of the difference to the provider

• If payments exceed the Medicaid-Allowable Costs, amount of overpayment must be fully recouped within one year of provider notification by

– Payment by check for full amount – Recouping an agreed upon percentage from each future payment– Recouping an agreed upon dollar amount from each future payment

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Reconciliation and Settlement

Important Reminder

If the district's Medicaid-allowable costs are less than its total Medicaid payments (federal and state shares), the district either needs to spend more time to locate and report additional Medicaid-allowable costs on the cost report prior to submission or pay back the federal share (See FMAP) of the difference after the reconciliation and settlement processes are completed.

For detailed calculation/steps refer to the Q&A document located at:http://www.hhsc.state.tx.us/Medicaid/programs/rad/AcuteCare/Shars/Shars.html

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Timelines

DatesDates ActivityActivity

12/4/08 Last day to file SHARS claims for dates of service (9/1/07 – 08/31/08)

1/31/09 Target date to file SHARS claims for (9/01/08 – 9/30/08)

4/1/09 2008 Cost report due for FFY dates of service (9/01/07 – 9/30/08)

5/1/09 –1/31/10 Cost report desk reviews

2/1/10 – 9/30/10 Cost reconciliation and cost settlement

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Timelines

The 2007 SHARS Cost Reports must be cost reconciled and settled by August 31, 2009 (i.e., 24 months after the end of the reporting period).

District will get a letter showing the results of the cost reconciliation and cost settlement processes, including the amount reported, any amounts adjusted and why, and the resulting amounts due to the state or due to the district.

The letter gives the district 30 days to agree or request an informal review to dispute the adjustments.

If the district tells us it agrees with the information in the letter and the district is owed money, the district should receive the additional payment in 4-6 weeks from the time we receive the district's agreement.

If the district owes money, arrangements will need to be made for repayment.

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Timelines

Settlement

– If Medicaid-Allowable Costs exceed payments• HHSC will pay the federal share of the difference to the provider

– If payments exceed the Medicaid-Allowable Costs, amount of overpayment must be fully recouped within one year of provider notification by

• Payment by check for full amount • Recouping an agreed upon percentage from each future payment• Recouping an agreed upon dollar amount from each future payment

Timelines

All SHARS Cost Reports will be subject to cost reconciliation and cost settlement processes.

These processes have to be completed 24 months after the end of the reporting period.

Example: 2008 Cost Report by 9/30/10

2009 Cost Report by 9/30/11

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Timelines

What if my cost report is not completed by APRIL 1?

Failure to file a completed and acceptable cost report by the cost report due date in accordance with applicable instructions and guidelines may result in the placement of a vendor hold on the provider's SHARS payments until an acceptable cost report is received by HHSC.

If a vendor hold is placed on a district’s SHARS payments, it will be released once an acceptable cost report is received by HHSC.

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Cost Report InformationTo avoid common SHARS Cost Report processing issues please remember to:

• Have the proper employee of the district sign the certification forms. The person signing the cost report certification forms (2) for the SHARS Cost Report should be the district's Chief Financial Officer (CFO), Business Officer, Superintendent, or other official that has signatory authority for the district.

• Sign and notarize both SHARS Cost Report certification forms. There are two forms:

– Cost Report Certification– Claimed Expenditures

• Signer and Notary dates must be no earlier than the electronic cost report submission date.

• Ensure that the Signer and Notary dates are the same. The notary language on the Certification page reads “Subscribed and sworn before me.” This means that the date signed by the Signer and the Notary must be the same.

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Cost Report Information

Send HHSC the form (s) that contains original signatures for both the Signer and the Notary.

Mail original notarized certification forms (2) to:

REGULAR MAIL HHSC Rate Analysis Mail Code H-400 PO Box 85200 Austin, TX 78708-5200

SPECIAL DELIVERY HHSC Rate Analysis Braker Center, Building H Mail Code H-400 11209 Metric Blvd. Austin, TX 78758-4021

HHSC recommends the Cost Report Certification pages be sent via courier, overnight, or certified mail so you will have a tracking that shows it has been delivered successfully.

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QUESTIONS

All questions and updates related to the SHARS Cost Report and SHARS Cost Report Trainings will be posted on the SHARS website at:

http://www.hhsc.state.tx.us/Medicaid/programs/rad/AcuteCare/Shars/Shars.html

Documents

SCHOOL HEALTH AND RELATED SERVICES