Area Special Education Cooperative

Procedures for Completion of Third Party Billing

District and Case Manager Responsibility

 

ASEC Revision

8/18/2016

 

Why do we bill MA for IEP Health Related Services?

Since 1989, Medicaid funds have been available to pay for health related services provided by MN public schools and included in a child’s IEP or IFSP. A federal program, administered by MDHS, which provides school districts with additional funds that help support special education programs. MA reimbursement dollars are exclusively used for special education (MN Statute 125A.21, subd. 3).

These federal funds are considered a separate "pot" of MA monies. They do not affect any other Medical Assistance* or MinnesotaCare* a student/family may be receiving.

(MN Statutes 125A.21, 125A.74, 125A.744 and 256B.0625, subd.26).

MA Payments for IEP Services

It’s The Law

"Beginning July 1, 2000, districts shall seek reimbursement from insurers and similar third parties for the cost of services provided by the districts whenever the services provided by the district are otherwise covered by the child’s health coverage."

(MN Statutes 256B.0625, subd. 26, 125A.74, 125A.744)

SO WHY DO WE HAVE TO DO THIS AGAIN?

Since reimbursement efforts

began in 2000 for ASEC districts:

$3.5 Million has been received

District Responsibility

Each district must establish a system for maintaining records to document billing Medical Assistance/MNCare for certain IEP/IFSP covered services. This responsibility is generally the function of the district bookkeeper or business manager. For your district specific information See MA District Contacts and Supervisors of PCAs list (attached at the end)

 

 

 

 

District IEP Case Manager Responsibility

Step 1-Check student eligibility list on SpEd Web and determine if consents are on file

To check who is eligible in your assigned student list:

  1. Log on to SpEd Web at https://16.spedforms.org/0997/ and enter your user name and password.
  2. Access your student list, go to "Quick Links" click MA Forms and go into the student’s MA setup. You will then be able to see if the student is eligible or not eligible. You must do this for each student in your caseload.
  3. If listed eligible, then proceed to Signature on File, if that is check marked YES, there is the required one time consent on file. If it is not checked or there is a NO indicated, then NO consent is on file. Please do NOT change any information in this section.

If you see that the "Signature on file" indicates NO then you will need to either print off the MA Parental Consent for in the MA forms section (see Step 3 on obtaining permission) or email the MA biller for a completed Adobe PDF format that will be emailed to the case manager AND THIS WILL NEED TO BE PRINTED.

Step 2-Determine if the student has MA billable service

Now that you have access to the list you will need to see if any of those students receive or will receive one of the following services:

Step 3-Obtain MA Parental Consent to bill DHS (IMPORTANT)

When you receive/print the consents you will need to get parent’s signature. This is best done at the end of an IEP meeting or if timing doesn’t allow for that please obtain the parents signature however works best for that parent.

See Attachment B-"Third Party Cookbook"-example recommendations for introducing third party billing with parents,

When to Seek Permission for a Billable Service

The procurement of health insurance information and consent to bill occurs at the conclusion of the IEP process. Therefore seeking consent from parents should not occur until after the IEP plan has been developed. It is important to explain that the services will not be increased or decreased based on the parent's decision. The staff member approaching the parent to obtain permission will generally be the case manager

Informed Consent

After the IEP meeting give the parent the MA Parental Consent form/packet. Assure the parent that they do not need to make a decision immediately however inform them that this is a funding source for the district that will help the district pay for special education services. Emphasize that school based MA does not impact their regular MA services nor are there any cost to the parent to allow the school to access school based MA.

Obtaining Permission
S
ee Attachment C-sample consent forms

Student information has been entered on the MA Parental Consent form by the MA Biller. The first page is the only required paperwork if parents are willing to give the ONE TIME consent.

Section 1 & 2-For All MA Eligible Students

Section 1: auto-filled via information put into the SpedForms student set up

Section: 2: Date to release to share data should indicate at least before the billable service started. You can ask the MA biller to complete this or you can complete this section. It is important that you pay attention to this date. MHCP Member number is auto filled if eligibility has been determined.

Section 3: NO LONGER NEED COMPLETED. MDE now provides the MA biller/districts with the needed information to bypass getting parent consent with MA eligible students with private health insurance. WE NEVER BILL PRIVATE INSURANCE.

Section 4: For initial consent, the third page is required only if the parent denies consent to share information with the Department of Human Services. They need to sign and date the top section of the form.

Denial

If the parent indicates that they do not want to give permission, simply have the parent sign the section of the permission form that states they do not give permission (Section 4 of the MA Parental Consent form: "I choose to not let the district share information with the Minnesota Department of Human Service to get paid for covered IEP health related services"). Send the original form to the district bookkeeper, send a copy to the ASEC MA Biller and keep a copy in the working file as reference for the next year. Parents who refused to give consent should be asked every year for permission. If the parent continues to deny consent inform the ASEC MA Biller.

Distribution of completed consent form

IMPORTANT-After the necessary Consent forms have been signed, send the original to the district bookkeeper and email/mail/fax a copy to the ASEC MA Biller. (EMAIL IS PREFERRED)

Once the consent form is complete you need to COPY the consent and give the original to the MA district contact that is listed in the MA District Contacts and Supervisors of PCA List (at the end of this procedure guide). The MA district contact will keep the original in the district MA files. You then need to get the COPY to the MA biller.

Send copy to: Email: lea@asec.net (PREFERRED METHOD)

ASEC, Attn: Lea Duckstad, 1505 Central Ave NW, East Grand Forks, MN 56721

Or fax to 218-773-0924

 

 

Provide access to service providers on SpEd Web

If a student has a billable service it is important that you give access to the service providers on the student’s IEP team. You can do this by going to Student’s "Sharing/Transfer" button and check mark the MA box. The following service providers should have access:

  • School Psychologist
  • Occupational Therapist
  • Physical Therapist
  • Speech-Language Pathologist

If there is a billable PCA that needs access to the student’s online MA activity logs, the Third Party Biller will set that PCA up and give access. Some districts have established a bookkeeper to enter the student’s trip logs and the Third Party Biller will set up the bookkeeper to have access to the student’s MA trip logs. If you should have any questions about who should have access please don’t hesitate to contact the Third Party Biller.

 

PCA Services

Determining if the child has a billable PCA service:

Eligible Recipients

To be eligible for PCA services in school, the child or youth must be dependent and need assistance for one or more of their activities of daily living (ADL), or require intervention or redirection from another person for Level 1 Behavior(s).

A child may not be found to be dependent in an activity of daily living if the child’s need for assistance is age appropriate.

Covered Services

Activities of Daily Living (ADLs)

Dependent in an ADL means the child requires cuing and stand-by supervision or hands-on assistance from a personal care assistant to begin and complete an activity of daily living.

Activities of daily living include health and hygiene needs that are part of daily living, as well as activities integral to the activity (for example, cleaning up spills, laundering soiled clothing, and cleaning up toileting accidents). ADLs include the following:

• Dressing: Assistance with choosing, putting on and changing clothing and with application of special appliances, wraps, or clothing

• Grooming: Assistance with basic hair care, oral care, shaving, applying cosmetics and deodorant; ensuring clothes are clean and properly fastened; care of eyeglasses and hearing aids (confirming batteries work, positioning aids). Nail care is included, except for a child or youth who has diabetes or poor circulation

• Bathing: Assistance with basic personal hygiene and skin care

• Eating: Assistance with hand washing and applying orthotics required for eating, transfers and feeding

• Transfers: Assistance with transferring the child or youth from one seating or reclining area to another

• Mobility: Assistance with ambulation, including use of a wheelchair. Mobility does not include providing transportation for a child or youth

• Positioning: Assistance with positioning or turning a child or youth for necessary care and comfort

• Toileting: Assistance with bowel or bladder elimination and care, including transfers, mobility, positioning, feminine hygiene, use of toileting equipment or supplies, cleansing the perineal area, inspection of the skin, and adjusting clothing

Level 1 Behaviors

A child or youth qualifies as having the need for assistance from a personal care assistant through observation, redirection, or intervention of a behavior episode if the episode is due

to a medical or mental health condition and requires the immediate response of another person to prevent injury to self or others, or damage to property.

Behaviors may occur at different levels and in different situations. To qualify for PCA services, the display of a Level 1 Behavior must be current, and determined to be either daily or episodic and ongoing (for example four times a week).

Level 1 behaviors are defined as:

• Physical aggression toward self (self-injurious behaviors)

• Physical aggression toward others (physical injury to others)

• Destruction of property

Examples of Level 1 Behaviors

Self-Injurious

Physical Injury to Others

Destruction of Property

Hitting

Hitting

Breaking windows, lamps or furniture

Biting oneself

Biting

Tearing clothes

Head banging

Pinching

Setting fires

Burning oneself

Scratching

Using tools or objects to damage property

Self-poking or stabbing

Kicking

 

Ingesting foreign substances

   

Pulling out hair

   

Suicide threats

   

When determining the level of need for behavior intervention, address the following considerations:

• Are the behaviors related to the medical need that qualified the child for IEP services?

• How current are the behaviors?

• Are there times when the behavior does not occur?

• Are there identifiable triggers that are likely to induce the behavior?

• Is it possible to modify the school or classroom environment to avoid the triggers that might make the behavior more likely?

• What are the reasonable expectations of the behavior reoccurring throughout the school day?

If a current, but infrequent, (less than four times per week or less than once daily) level 1 behavior is identified in the IEP plan that will require the immediate response of another person to intervene and redirect the physical aggression toward self or others or destruction of property, a personal care assistant may be assigned to intervene or redirect the child or youth during that episode. Medical Assistance (MA) will pay for this response time. The time allowed is when the personal care assistant is fully engaged, working face-to-face or hands-on with the child or youth.

Once a child or youth qualifies for PCA services, he or she may also receive assistance from a personal care assistant for redirection or intervention during a behavioral episode, when the child or youth displays increased vulnerability due to cognitive deficits or socially inappropriate behaviors, and for other delegated health related procedures and tasks.

Determine how the lack of cognitive skill or vulnerability is affecting the child or youth behavior and what assistance must be provided to redirect or intervene during a behavioral episode.

For example: A child with Down syndrome has qualified for PCA service for two ADLs: toileting and eating. Because the child qualifies for PCA services, the child or youth can receive PCA services because of their increased vulnerability due to cognitive deficits. The child has a history of elopement (wandering away) from the past school year and is currently displaying episodes of elopement when given the opportunity. In this case it may be necessary to have a personal care assistant with the child, during times such as recess, lunch, in the halls and going to the restroom. During these times, there is a reasonable expectation that the child may find the opportunity to elope and MA will cover PCA services during these periods.

However, once the child is in the classroom, a teacher or paraprofessional is watching over the room and a personal care assistant does not need to be available to observe the child in case the child may elope.

Other situations may require a personal care assistant to assist with ADLs and monitor a child for health related concerns for the full day at school. Such situations may be for a child or youth who is medically fragile and needs assistance with multiple ADLs, needs constant intervention or redirection of behaviors, or both. Documentation must clearly identify the child‘s or youth’s specific medical needs, why constant continuous care is needed throughout the school day, and how the services provided relates to the child or youth’s medical needs. MHCP does not pay to have a PCA sit with a child or youth to watch for a behavior that occurs infrequently or to keep the child on task with their educational activities or assignments.

The increased vulnerability due to cognitive deficits or socially inappropriate behavior of a child and youth who is verbally aggressive or resistive to care must relate back to:

• The medical need of the child or youth

• Whether the need would otherwise prevent the child or youth from attending school

• Whether the behavior would put the child or youth, another person, or property in harm’s way that is beyond what is expected for the child’s age

If the child or youth is not staying on task with the lesson plan, listening to the teacher, or is speaking out of turn, making comments out loud, grabbing for other children’s property or generally disrupting the class, it is the responsibility of the school to have the teacher, teaching assistant or paraprofessional assigned to the classroom or to that child or youth to keep the child or youth on task for his or her educational needs and classroom behavior protocol. Classroom support of this type is not an MA covered PCA service.

Other Health-Related Procedures and Tasks

Health-related procedures and tasks may be delegated or assigned by a licensed health care professional under state law to be performed by a person providing PCA services.

Document the delegation of health-related procedures and tasks and training in the PCA plan of care for the child or youth and in the file of the person providing the PCA services. These PCA services include, but are not limited to the following:

• Range of motion and passive exercise to maintain a child’s or youth's strength and muscle function

• Assistance with self-administered medication, including reminders to take medication, bringing medication to the child or youth, and assistance with opening medication containers under the direction of the child or youth, including medications given through a nebulizer. A PCA must not determine the medication dose or time for medication.

• Interventions for seizure disorders that occur more than two times per week and require physical assistance to maintain safety

• Procedures for complex health-related needs, including tracheostomy suctioning, services to a child or youth needing ventilator support and other direct cares. These are covered PCA services if delegation, training and supervision is by a registered nurse (RN), the service can be competently and safely completed, training is specialized and individualized to the needs of the child or youth, and delegation and training are documented.

Noncovered services

MHCP does not cover the following:

• Assistance provided to a child or youth by a personal care assistant who is not qualified as a personal care assistant or has not been trained or supervised by a QP

• Services provided by substitutes who have not received the required training and supervision

• Services provided by a parent, stepparent, paid legal guardian or foster parent

• Care that requires the skill of a trained nurse or other trained medical professional, for example, re-inserting g-tubes; sterile procedures; giving injections; administering medication; nurse assessments either delegated or provided by someone who is not a nurse

• Classroom support by a paraprofessional to ensure children stay on task

• Hearing aid check (programming such as setting and resetting volume, calibrating or making other adjustment)

• Services that are provided to a child or youth that would reasonably require assistance for a child of that age

• Helping a child or youth with school assignments and class activities or redirecting, cueing and intervening to help a child stay on task to complete school assignments, projects or activities

• Monitoring and assisting the child or youth to perform assigned "jobs" at school, job training or coaching or vocational services

• Services provided to a child or youth as a before and after school activity, including sports, clubs, class projects, tutoring, music lessons and child care

• Activities that teach anything, including teaching a child to grocery shop, manage finances, get around in the community by taking buses

• Instrumental Activities of Daily Living (IADL)

• Continuous monitoring or observation in case a child might run away if there is no reasonable expectation that the child will have the opportunity to elope (for example, in a classroom setting where a teacher and paraprofessional are present)

• Continuous monitoring or observation of a child who may have a behavioral episode occur infrequently

• Monitoring juvenile offenders to prevent harm to others or inappropriate behavior

• Restraining a child or youth, applying restraints or monitoring a child or youth who is placed in isolation or time-out

• Services provided by drivers of vehicles used to transport eligible children

• Services provided by a bus monitor

• Services provided in the home of the child or youth, including but not limited to direct service, homemaker services, babysitting or child care

• The work of a mental health behavioral aid provided by a personal care assistant

 

Procedure if initial permission is sought for a Personal Care Assistant (PCA)

See Attachment D for Sample IEP Language

 

  1. If the team anticipates or knows that the student has a medical diagnosis, and may or does need support for the above services, please email Julie Aumock (and CC the MA biller) to review the IEP and verify possible eligibility for billing. A DHS required ANNUAL time study will be conducted by PCA/s with instruction from the PCA supervisor. Once the 10 day time study is completed please contact the PCA supervisor immediately. The results of the time study will be shared with ASEC admin, case manager, PCA supervisor, PCA, and the MA biller. It is ideal if the time study is conducted PRIOR to the IEP meeting so that the most accurate billable time and services are documented in the IEP.
    1. Remember that the duties of the PCA need to be clearly spelled out on the IEP. If you have any question about the services that are billable review the guideline descriptions above or call or email Julie Aumock.
    2. If the PCA is for redirection and intervention for behavior, the requirement is rather specific as to what may be billed. Please document on the IEP that the time being billed is for Level 1 and specifically describe the behavior. If there are questions on how the need is documented contact Julie Aumock for guidance. You also need to note in your Services and Modifications section of the IEP that the PCA will be supervised by a qualified professional.
  2. If it has been determined that the student has a billable PCA service it is REQUIRED BY DHS that the PCA has the DHS certification. There are attached directions on how to assist in making sure the PCA completes the certification in a timely manner.
  3. The case manager will then provide SpEd Web access to the PCA for that student. If the PCA is new or has not been given previous MA PCA access the case manager should contact the MA Biller to add the individual to the MA PCA access list.
  4. Notify the supervision person (either the MA billable speech therapist in the district or OT) so that required supervision of the PCA occurs at the specified intervals. The supervisor will in-service the PCA on how to complete the log. If the PCA has questions, refer the PCA to Lea at the ASEC office for further clarification.

Monthly Activity Logs

Each month the service provider (i.e. billable speech therapist or PCA) will complete and finalize the activity log on SpEd Web, print and sign the form and send the monthly Activity Log to the district bookkeeper. It is important to finalize the log at the end of the month so that the ASEC biller knows that log is completed. Whoever has been identified within the district to document transportation miles for authorized students must also complete the Trip log. At the end of the month the trip log should be printed and turned into the district bookkeeper. The trip log must match the student’s attendance report for that month and have received a billable MA service for each day transported (i.e. either PCA or billable MA speech service).

The district must maintain the following original records on each student for at least five years for auditing purposes. Specific records include:

  • Consent Form to Seek Reimbursement for IEP Health Related Services
  • IEP/IFSP Service Trip Logs, SIGNED and DATED

 

Payments

School districts will receive payments for the federal share of the health related services provided. Minnesota's federal share changes yearly, however it is generally around 50-53%. School districts are responsible for the non-federal share and this amount will be deducted from the payment and appear as part of the gross adjustment on the Remittance Advice (RA).

The percentage of expenses for Medical Assistance covered services for which federal funds are used as payment or reimbursement to the district is reviewed and adjusted annually. At the end of the fiscal year the data on the IEP/IFSP Activity Logs will be compiled for each billable staff person by the ASEC biller and submitted to the state. This data will establish the district's reimbursement rates for each billable service for the following year.

 

Further Information

For further information or clarification contact Lea Duckstad at lea@asec.net or for additional information go to www.asec.net and click the Third Party Billing tab.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Care Attendant Department of Health Certification Training

Your district may bill MA for services that a PCA provides to a MA eligible IEP student.

A new requirement is in place now that any PCA involved in the MA process must complete standardized PCA training to satisfy MN law.

ASEC is asking that the case manager who has a PCA or PCA sub involved in MA billable services be the support for the PCA/Sub to complete the requirement for certification.

(PCA supervisors will NOT be able to assist in this process; they will continue to supervise as always per DHS guidelines.)

The training is open to anyone and is available online for free 24/7.

Training

There are 9 modules that make up the training course with a certification test. Registration is

not required to view the modules, but there is a registration process for the certification test

portion. The modules can be viewed in any order. Return to the info in the modules as needed.

The PCA is not required to view the modules before taking the test.

Testing

Registration is required to take the test and receive certification for completion. A passing score is 80%. This means the PCA must answer 20 out of 25 questions correctly to receive a passing score. The PCA can take the test as often as needed to pass. However, they must register each time the test is taken. If they take the test more than one time, the questions may look different each time. The questions are from a question bank and generated randomly.

When the PCA or PCA sub registers for the test online, she/he will be required to provide an email address. DHS uses the email address to send the certificate after the test is completed.

The email allows you to access and print the certificate. ASEC must have completed certificates

emailed to lea@asec.net or faxed to ASEC, attention: Lea.

Lea will print out one for the ASEC DHS file. PCA’s should also give a copy of their completed certificate to their supervising staff member at the school.

1st STEP:

Find the course

Open Minnesota Department of Human Services Online Registration at http://registrations.dhs.state.mn.us/ to access the course or register for the test.

Click the Individual Personal Care Assistant Training link located UNDER the Continuing

Care –Disability Services. This takes you to the Individual Personal Care Assistance Training Home Page

MAKE A CHOICE-Take the course OR register to take the test - recommended

To take the course, click:

1. Take the course (this opens a new browser window and has the 9 module selections)

To register to take the test, click:

1. The drop down arrow to the right of the EVENT box (bottom of page)

2. Click on the PCA option

3. Click the NEXT-Register button. This opens the registration page. Complete the registration information (fields and questions with an asterisk * are required and you must complete them)

Enter and confirm a valid email address.

Read the agreement box.

Check the box beneath the agreement if you understand the terms of the agreement (you cannot continue if you do not check the box).

Click the submit button to complete you registration.

After you submit your registration, the next page will give you a confirmation number. Using the email link allows you to take the test as many times as needed without registering again.

You may register more than once to take the test, but using the confirmation email link is easier.

Take the TEST

You must answer 20-25 questions correctly to pass the test. You may take the test as many

times as needed. There is no required wait time between tests. Again, there is a link provided

to proceed to the test immediately after you register or you can use the link in the confirmation

email Lea forwards to you.

As you answer each question, the system will tell you if the answer is correct or incorrect. The

system will not tell you the correct answer. After you answer the last question, you will go to

the RESULTS page where you will receive your score and whether or not you have passed the

test.

Test result page

The Test Results page follows the last question on the test. This page shows:

• The number of questions you answered correctly

• Your test score

• If you passed the test

• Where the email certification link will be sent

• A link to the certification

• What modules you should review if you do not receive a passing score

Certificate of Completion

When you pass the test, you may print the certificate of completion right away. Print one or

more copies for you and the district’s records. Make sure ASEC receives a copy as well.

If you have any questions or issues, please email Lea and she will get back to you within 24

hours. (lea@asec.net)

 

 

 

 

Instructions for Completing Initial MA Consent Forms