Author: Dan Thomas

On February 25^th, Jeff McCuen, the treasurer for Worthington City Schools did a very good presentation on several important issues related to the Ohio Medicaid School Program (MSP). He presented to a large diverse audience made up of school districts, state legislators, educational associations, billing vendors, therapy associations, and representatives from the Ohio Department of Education and the Ohio Department of Medicaid. There were also over 80 viewers watching online. The four main issues covered were:

• Board Member Social Security number requirement for MSP re-enrollment.
• Extension of time beyond 08/01/16 to resolve “Order, Refer, Prescribe” (ORP) requirement.
• Removal of SLP’s, OT’s, and PT’s ability to be “Practitioners of the Healing Arts”, and ORP IEP services.
• Discontinuance of the monthly “MSP Stakeholder” meetings that had made great progress on resolving many MSP issues.

 

Nothing was resolved in the 2/25 meeting, but it did bring these issues to the attention of State Legislators, the State School Board President, and many other interested parties. The strong presence of school district representatives spoke loudly to the importance that the Medicaid School Program enhance the services that are provided to students with disabilities, but not hinder those services in the process. We have several important meetings scheduled in the coming weeks, but the most important issue is to get ODM to agree to an extension beyond the August 1 deadline. Many districts are ready to move forward with the prescription requirement, but we need to get many questions answered so that systems can be developed to meet the proposed requirement, or whatever the final requirements may be.

 

The ORP issue relates directly to another topic that I have been wanting to write about. Buried deep in the MSP rules is a requirement that districts have received very little guidance from ODE/ODM on, but could be a good first step in preparing for the proposed ORP requirement.

 

OAC 5160-35-06 (MSP Rules) states that:

 

(E) “The documentation for provision of each service shall be maintained for purposes of an audit trail. Documentation shall include:”

 

(7) “A description of efforts made to coordinate services with the eligible child’s medical home in accordance with the medicaid provider agreement.”

 

In this rule, “medical home” means “primary care physician”.

 

Care Coordination is an important component of all medical delivery systems. MSP Nursing Services already do care coordination, as their services already require a physician prescription. Many districts actively coordinate IEP services with the student’s primary care physician, but some do not. Most districts request the primary care physician information upon enrollment, but many do not keep this information current. I am gathering form examples from various districts, and I will be putting together a suggested process for meeting the care coordination requirement of the Ohio Medicaid School Program. Please share any examples that you have successfully used in your school district.

 

While we are waiting for ODE/ODM to answer questions, grant an extension, and hold stakeholder meetings, I do encourage districts to start looking at their internal systems and how they currently coordinate care for IEP services. Determine what physician information you already have for IEP students, and whether or not the information is current. In the coming weeks, I will be sharing with each district an all-inclusive form/system that would meet the current care coordination requirement and could easily adapt to meet a future physician prescription requirement.

 

I have not given up on the hopes of going back to allowing the therapists to ORP their services, but we must be proactive and address the care coordination requirement and be ready for any ORP requirement change.

 

Once again, I would like to thank Jeff McCuen from Worthington City Schools for bringing everyone together to discuss these important issues. Thanks also for all those who attended, watched online, and those who have sent letters and emails to ODE and ODM.

 

When a district initially enrolls in the Ohio Medicaid School Program (MSP), the first step is to complete an online “Provider Enrollment Application”. Based on this application, your district is given a State Medicaid Provider Number and an effective date of Medicaid Certification. It sometimes took several months to get certified, but the application process was very basic and required general data like district address, and the Superintendent and Treasurer names.

The Affordable Care Act (ACA), includes provisions that require States to revalidate provider agreements every five years (42 CFR 455.414). This same act requires the States to charge a fee for this re-enrollment, which is currently $553 in Ohio. The Ohio Department of Medicaid re-enrolled one MSP provider school district in 2015, and is scheduled to re-certify another 39 districts in 2016. The re-enrollment process is not overly difficult, but there is one piece of additional data that is now required that many school districts have been reluctant to provide.

42 CFR 455.104(4) requires that the Medicaid re-enrollment data contain “The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity”.

42 CFR 455.101(c) states that “Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.”

The Ohio Department of Medicaid (ODM) has defined “Managing Employee” in a school system to be the Superintendent, Treasurer, and the School Board Members. We have enrolled several districts recently and only included the Social Security Numbers of the Treasurer and Superintendent, and they were rejected because we did not report School Board Members. Once the school board member information was provided, the application was approved.

It is important that districts are aware of this issue because it ties in with the ORP/Provider Enrollment issue, and should be included in upcoming discussions with ODE/ODM regarding Physician Prescriptions. It will certainly be an important topic for discussion at the February 25^th “MSP Interested Party Meeting”, as Worthington City Schools is first on the list for 2016 MSP Recertification. (Worthington City School’s Medicaid certification expires March 31, 2016). I have attached a list of the MSP school districts that are scheduled for recertification in 2016. You should receive a letter from ODM several months before your revalidation is required.

I have personally lobbied both ODM and ODE many times over the past six months to reconsider whether a School Board Member “conducts the day-to-day operation of an institution”. I have suggested that it is the Superintendent and Treasurer that run the day to day operations of a school district, and that the School Board members only provide “direction and oversite”. ODM has rejected that argument, and currently the Name, Address, DOB, and SS# for all School Board Members are required on all MSP enrollment and re-enrollment applications.

2016 Recertification Districts

The recent announcement from the Ohio Department of Medicaid (ODM) and the Ohio Department of Education (ODE) that the Ohio Medicaid School Program (MSP) will begin requiring Physician Prescriptions effective August 1, 2016 has caused great concern among many School Districts and MSP Stakeholders. This ruling by ODM/ODE centers around the Federal requirement that the individual that “Orders, Refers, Prescribes” (ORP) medical services must be enrolled in the State Medicaid Program. Since the start of the Ohio Medicaid School Program back in 2009, MSP OTs, PTs, and SLPs were able to ORP based on language in Ohio’s State Plan Amendment (SPA) that considered MSP therapists to be “Licensed Practitioners of the Healing Arts”. ODM removed this language from the Ohio SPA effective January 1, 2014, which the Centers for Medicare and Medicaid Services (CMS) pointed out in their October 23, 2015 letter to ODM (attached).

We have been meeting with School Districts, Educational Associations (OASBO, BASA, OSBA, OESCA), Therapy Associations, and other Stakeholders, and we feel that there are other options available to Ohio that would be much less burdensome and costly for Ohio School Districts than requiring ongoing Physician Prescriptions. Some of those possible options are:

• The Ohio Department of Medicaid (ODM) could restore the previously removed language from the State Plan Amendment (SPA) which permitted MSP therapists (OT, PT, SLP) to be considered “Licensed Practitioners of the Healing Arts”. This would then require therapists to do a one-time enrollment in the State’s Medicaid Program as an ORP provider only. ODM has already modified their Medicaid Enrollment software to accommodate a scaled down “ORP Only” enrollment application.
• ODM could expand the list of ORP allowable providers to include Clinical Psychologists and School Psychologists. Every school district employs or contracts with one or more Psychologist, and Psychologists would be much more aware of the student needs than a Physician, who was not part of the evaluation and plan development team. This would only require the MSP Psychologists to do the one-time enrollment in the State’s Medicaid Program as an ORP provider only.
• Request an additional one-year waiver (2016/17 school year) from CMS of the ORP requirement. This would give ODM and ODE additional time to work with school districts to develop and implement a fully compliant ORP process. There are many questions that ODM/ODE has yet to answer, and time is running out with the August 1, 2016 deadline. The ORP requirement is a result of the Affordable Care Act (ACA), which may substantially change based on the upcoming presidential election. This extension would give additional time to modify the Ohio MSP ORP process based on any changes to the ACA.
• The final option is to require OT, PT, and SLP services to be prescribed by a Physician. Currently Ohio is allowing the MSP ORP provider to be a Physician, Physician Assistant, or an Advanced Practice Nurse. Physician Assistants and Advanced Practice Nurses must work under the direction of a Physician, so in reality, it is a Physician that would need to do the ORP. A few school districts have a physician on staff, and I know that several ESCs are looking into the possibility of providing this service to school districts. Our biggest concerns with this options is the timeline involved and finding enough physicians to write over 61,000 prescriptions, not to mention the ongoing prescriptions that would need to be obtained.

The intent of this ACA requirement is to cut down on “Waste, Fraud, and Abuse”, but it appears that the current ORP ruling does just the opposite. This CMS rule requires States to enroll ORP providers into their State Medicaid Program and screen the provider to make sure that their license is current. This direction that ODM/ODE is taking does not screen any current MSP providers, and the providers that it adds to the program (Physicians), would have already been screened in their physician practice. We also must address which students will require a prescription, just Medicaid students, or all students. If it is just Medicaid students, are we now asking billing vendors to share with districts who has Medicaid and who does not? If that is the case, what about the problem of treating one group of students differently than another? These questions and many more need to be answered as soon as possible. ODM/ODE received the CMS letter on October 23, 2015, told school districts on January 27, 2016, and today is February 12, 2016, and nothing additional has been communicated. The current CMS deadline is August 1, 2016, and the pace that ODM/ODE is taking just gets worse by the day.

What can your district do to help resolve this issue?

Contact your State Legislators.
Contact ODM and ODE.
Get with your therapists and get their opinions.
Contact your ESC and find out what their capabilities are.
Check with physicians in your area on their willingness to ORP.

Worthington City Schools is hosting an Interested Parties Meeting at 1:00 on February 25, 2016 (see attached invitation), and plans to have many School Districts, Legislators, Associations, Billing Vendors, and hope to get ODM and ODE to attend also. This critical issue requires school districts take an active role in order to get ODM/ODE to listen and take into account your concerns. The billing vendors often work together to resolve these types of issues on your behalf, but the State really wants to hear from school districts. Please use whatever contacts you have to help resolve this issue in a reasonable and timely fashion.

ODM/ODE Contact Information:

John McCarthy, Director
Ohio Department of Medicaid
50 West Town Street, Suite 400
Columbus, Ohio 43215
john.mccarthy@medicaid.ohio.gov

Dr. Sue Zake
Ohio Department of Education
25 South Front Street
Columbus, Ohio 43215
sue.zake@education.ohio.gov