From: Brown, Sharon J

From: Brown, Sharon J. (CMS/CMCS) [mailto:
Sent: Friday, January 27, 2012 11:57 AM
To: DSS-SBCH; Jarzyna, Barbara
Cc: Wallace, Judi (CMS/CMCS); Lavigne, Christopher A.; Heffernan, Jennifer M. (CMS/CMCS); Freeze, Janet G. (CMS/CMCS); Montemagno, Marie C.(CMS/CMCHO); Mills, Stephen C. (CMS/NC)
Subject: RE: Connecticut SBCH SPA #10-018 Time Study (Direct and Administrative Claim)

Barbara:

Below are CMS’ initial comments on Connecticut's revised SPA #10-018 SBCH Time Study materials, as submitted by the State 1/20. Please let us know if you’d like us to schedule a conference call to discuss. Thank you.

CMS Comments on CT SBS SPA #10-018 SBCH Time Study User Guide (Rec’d 1/20/2012)

Disclaimer: Please note that these comments are intended merely to facilitate further discussion and should not be construed as comprehensive or final.

1. Two of theitems submitted by the State appear to be the same document; specifically, the timestudy training document and the time study PDF document. Please identify the differences, if any,between the two documents.

Response:

The State initially used the same document for both the initial training and for the time study guide. The State developed a training specific PowerPoint presentation to be used for periodical training sessions. State shall utilize a Webinar type of training combined with sit-in training. See Attachment #2-SBCH Time Study Training Materials.

2. Page 10: Pleaselist all of the personnel types that perform direct service services but do not meet provider qualifications in the chart. Specifically, from the State's response to CMS Comment #2 in the last set of comments, please include the following in Position Title Code 213:Behavior Analysts performing evaluations based on PPT recommendations. Are any costs associated with this position titleclaimed as direct medical services? Is that permitted under the State plan despite their lack of provider qualifications?

Response:

The State does not permit services providers not qualified as a SBCH services provider to claim for direct services under SBCH program.

The State shall permit school districts to claim under the Administrative Claim for time spent performing evaluations based on PPT recommendations record by Position Title Code 213:Behavior Analysts if the Behavior Analyst is included in a universe of employees used for time study.

3. Page 10: Page 10 indicates thatCode NN (Overhead) is reallocable, however page 19 indicates the code is non-reimbursable. Please correct page 10 and consistently refer to Code NN as U (Unallowable) throughout the plan materials.

Response:

The guide was revised and activity coded to Code NN was removed from Re-Allocable activities (R) and included under Non-Claimable Activities (U).

Please see page 11 of the revised guide enclosed under Attachment #1.

4. Page 10: Code K is titled "Direct Claiming Activities". It would be more clear to title the Code "Direct Medical Services," to differentiate it from directly claimable administrative activities. Please change the Code name.

Response:

The guide was revised; Code K title was changed to “Direct Medical Services”. Please see page 11 of the revised guide, enclosed under Attachment #1.

5. Page 15: Please change Activity Code U (Medicaid Time Study Coordination, Statistics) from PM (Partial Medicaid) to R (Reallocated). Time school districts' employees spend on functions related to time studies and gathering Medicaid statistics is only indirectly reimbursable. The activities are not directlyallocable toMedicaid.

Response:

The Activity Code U was changed from PM to R throughout the guide

Description for Activity Code U was moved from page 15 to page 17 of the revised guide, enclosed under Attachment #1.

Additionally, the State changed Activity Code O (Medicaid Billing) from PM (Partial Medicaid) to TM (Total Medicaid). Medicaid Billing is 100% allocable to Medicaid. Please see page 16 of the revised guide enclosed under Attachment #1.

6. Please indicate in the plan why there are different instructions provided to each of the provider types.

Response:

The instructions to complete time study are uniform for all provider types.

7. Please include in the plan the State's response to CMS Comment #7 in the last set of comments.Specifically, that the IEP student ratio applied to activity code K is the product of the number of Medicaid Students with medical services included in IEP’s (numerator) divided by the number of Students with medical services included in IEP's (denominator). Both numbers are an average of the three quarters. The statistics are gathered every quarter (three quarters plus fourth quarter equal to the average of the three quarters of actual data). Please also define the Medicaid Eligibility Ratio in the plan, the periodicity with which it’s updated, and the Medicaid reimbursable codes to which it applies.

Response:

The guide was updated to include a description of Medicaid penetration rate (Medicaid Eligibility Ratio), how the rate shall be calculated. The rate shall be based on an average of statistical data gathered each quarter. The Penetration rate shall be updated annually. Please see pages 22 and 23 of the revised guide enclosed under Attachment #1. The rate shall be used to calculate Direct Cost Claim inclusive of Medicaid billing cost and Administrative Cost Claim.

The Medicaid reimbursable fee-for-service codes to which the Medicaid penetration rate shall apply are provided in a table below.

Activity Code / MSI Code / SBCH Service description
K / 12 / Medical Services-screening
K / 15 / Assistive Technology Assessment
K / 21 / Assessments-unlisted evaluation and management
K / 22 / Audiology-hearing screening
K / 23 / Audiology-hearing service
K / 24 / Optometric Service-Vision miscellaneous
K / 42 / Respiratory Care Service-individual procedure to increase muscle strength or endurance
K / 43 / Respiratory Care Service-individual procedure to improve respiratory function
K / 44 / Respiratory Care Service-group procedure to increase muscle strength or endurance or to improve respiratory function
K / 51 / Physical Therapy - Evaluation
K / 52 / Physical Therapy - individual therapeutic procedure
K / 52 / Physical Therapy - individual therapeutic procedure
K / 53 / Physical Therapy - group therapeutic procedure
K / 61 / Speech and Language - evaluation
K / 62 / Speech and Language - individual treatment procedure
K / 62 / Speech and Language - individual treatment procedure
K / 63 / Speech and Language - group treatment procedure
K / 63 / Speech and Language - group treatment procedure
K / 71 / Psychological and Counseling Service- Psychological testing, interpretation, reporting
K / 72 / Nursing Services - APRN or RN
K / 73 / Nursing Services - LPN or LVN
K / 81 / Psychological & Counseling Service-psychiatric diagnostic interview
K / 82 / Psychological & Counseling Service-individual psychotherapy
K / 83 / Psychological & Counseling Service-group psychotherapy
K / 84 / Psychological & Counseling Service-family psychotherapy
K / 91 / Occupational Therapy - Evaluation
K / 92 / Occupational Therapy - individual therapeutic procedure or exercise
K / 93 / Occupational Therapy - group therapeutic procedure or exercise

8. CMS will need to review the State’s training materials upon development. How often will the training occur?

Response:

The State developed training materials are enclosed, please see attachment #2. The State intends to make training available twice during a school year; once during the month of August and once during the month of October.

9. Please include in the plan the State’s response to CMS Comment #16 regarding the summer quarter. Specifically, that State intends to reconcile and settle annually for direct claim and administrative claim using statistical averages of three quarters. The State does not require school districts to provide statistical data for summer quarter.

Response:

The State added the following language to the guide:

The Department shall reimburse school districts on monthly bases for claimed direct services. The Department shall reconcile and settle annually for direct claim and administrative claim using statistical averages of three quarters. The State does not require school districts to provide statistical data for summer quarter.

Please see subsection 8 on page 5 of the revised guide enclosed under Attachment #1.

10. Regarding the Section V Q&As on pages 45-47, we have the following comments:

a. Question 9 indicates that time spent working on IEPs (writing goals, doing progress reports, etc.) should be claimed as Code K (Direct Medical Services). This is incorrect. These activities are mandates of the IDEA statute and not directly related to the provision of Medicaid covered IEP services. They should be coded as Activity Code M (School-Related and Educational Activities), the costs of which are unallocable.

b. Question 10 indicates that much of the IEP meeting time can be claimed as Code H (Referral, Coordination and Monitoring of Medicaid Services), which is a Medicaid administrative allowable function. However, in actuality, there are no costs associated with IEP meetings that are claimable as administration. They should be coded as Activity Code M (School-Related and Educational Activities), the costs of which are unallocable. As stated in CMS’ 2003 Medicaid School-Based Administrative Claiming Guide, the IEP is a requirement of the IDEA, the primary purpose of which is to facilitate the child’s education. Because it is an education requirement, Medicaid does not pay for the administrative activities associated with the IEP. Once the IEP is established and implemented, however, Medicaid can pay for administrative activities that are directly related to the provision of those Medicaid covered services that are identified in the IEP, and which are furnished to Medicaid eligible children. Please correct this Q&A.

c. For Q&A #11, please add a third option identifying Code M (School-Related and Educational Activities) as the correct code for other types of school-day meetings.

d. Regarding Q&A #12, what is a pre-referral meeting?

Response:

The State provided the following options to be chosen to record time spent at a pre-referral meeting”:

· use activity H code 103 when making referrals for, coordinating, or monitoring the delivery of Medicaid covered services. Also, use this code when informing parents of appropriate programs, in accordance with 42 CFR Section 441.61(c) to help ensure an effective school based child health program. Both written and oral methods may be used.

· use Activity Code M for time spent working on IEP not directly related to the provision of Medicaid covered IEP services. These are a School-Related and Educational Activities which are un-allocable to Medicaid.

As stated in CMS’ 2003 Medicaid School-Based Administrative Claiming Guide, the IEP is a requirement of the IDEA, the primary purpose of which is to facilitate the child’s education. Because it is an education requirement, Medicaid does not pay for the administrative activities associated with the IEP.

· If neither of above descriptions meet an actual description of what was a purpose of a pre-referral meeting, then please type on a blank line of a time study a pre-referral meeting, record time spent on pre-referral meetings on that line and send an e-mail addressed to with a brief description of what was the purpose of a pre-referral meeting. The Department shall classify time accordingly and notify the district regarding a used activity code choice.

The State shall provide CMS with a description(s) of a pre-referral meeting once the State obtains such a description from school districts.

e. For Q&A #13, the in-service workshop is a training activity, not an outreach activity. Therefore, it should claimed as Activity Code G (Medicaid/Medical Related Training), which is PM not TM. Also, the training would need to focused on the Medicaid covered services within the IEPs, not just the IEP program, in order to be allocable to Medicaid. Please correct.

Response:

The State added CMS’ interpretations/corrections to the Q/A section of the guide. Additionally, the State has added the following Q/A to the guide:

28. Time spend writing reports following speech evaluations leading to development of an IEP;

A: use Activity Code K

29. After delivery of a medical service included in an IEP a follow-up with parents or teachers via e-mail, phone or face-to-face;

A: use Activity Code K

30. Time spend developing, specifically time spend on writing medical services to be included in an IEP using the IEP Direct;

· use Activity Code H to record time spend developing/writing medical services to be included in an IEP using the IEP Direct

· use Activity Code M to record time spend developing an IEP using the IEP Direct;

31. Time spent discussing with parents benefits of a Medicaid covered service;

· use Activity Code B to record time spent discussing with parents benefits of a Medicaid covered service

· used Activity Code H to record time spent discussing with parents benefits of a Medicaid covered service included in students IEP

Please see pages 52 through 56 of the revised guide, enclosed under Attachment #1.