Medicaid for K-12 Transportation Services

Tyler Podcast Episode 38, Transcript

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Episode Summary

This episode is part of our series on school transportation and today we are talking specifically about Medicaid and Medicaid reimbursements for K-12 transportation services. Kim Rentner, our School Transportation subject matter expert here at Tyler, speaks with Casey Gayer. Casey currently oversees Medicaid and special education program operations for Frontline Education’s partner districts nationwide. She received a B.A. in international relations from UC Davis, with a focus on public policy. Casey's experience spans hundreds of districts across the country, making her a subject matter expert in both Medicaid and special education program rules and regulations. She also has experience working for a grants research firm, where she previously led a team of analysts that researched and published articles on Federal, State and foundation RFPs and congressional legislation that impacted local government funding.

Transcript

Casey Gayer: And then by proxy, once those services are deemed medically necessary by the school through an IEP or other type of plan, then the trip to and from becomes medically necessary as well should the student's disabilities, again, require that specially adopted vehicle.

Jeff Harrell: From Tyler technologies, it's the Tyler Tech podcast, where we talk about issues facing communities today and highlight the people, places, and technology making a difference. My name is Jeff Harrell. I'm the director of content marketing for Tyler. And I'm so glad you joined me. Well, today's episode is part of our series on school transportation. And today we are looking specifically at Medicaid and possible Medicaid reimbursement for K12 transportation services. Kim Rentner, our school transportation subject matter expert here at Tyler will be speaking with Casey Gayer. Casey currently oversees Medicaid and special education program operations, software implementations, and training for Frontline Education's partner districts nationwide. She received a B.A. in international relations from UC Davis with a focus on public policy. Her experience spans hundreds of districts across the country, making her a subject matter expert in both Medicaid and special education program rules and regulations. Casey oversees the implementation of claiming programs and EIP systems and works closely with Frontline software development team to ensure all systems meet state and federal regulations. Before working at frontline, she was a senior research analyst for eCivis, a grants research firm, where she led a team of analysts that researched and published articles on federal, state, and foundation RFPs and congressional legislation that impacted local government funding. Quite a resume. So with that, here is Kim Rentner's conversation with Casey Gayer.

Kim Rentner: So Casey, thank you for talking with us this afternoon. We're going to get right into it. Jeff gave us your impressive bio. Can you tell the listeners a little bit more about what you do and what you do on a daily basis?

Casey Gayer: Absolutely. So I currently work for Frontline Education. I am the director of client success there. I also play a dual role as a product manager for our Medicaid software. So on a day to day basis I oversee our implementation consultants who implement a range of special education systems from IEP, ELL to of course, Medicaid billing. And then I work with our development teams to build out our Medicaid and documentation tools from anything from contractor billing to just peer documentation, to transportation trip logging.

Transportation and Medicaid

Kim Rentner: So today we're going to be talking about Medicaid, and possible Medicaid reimbursement for K12 transportation services. Firstly, what makes transportation billable to Medicaid or eligible to be billable, I guess is the word

Casey Gayer: Well, yeah, that's a pretty interesting question. So everything in school based Medicaid really stems from the Medicaid program in general. It all has to fall within those requirements. So if you are just a Medicaid eligible person in our country and you need to go to a service, go to a hospital or a doctor's office. You have some level of disability that impacts your ability to access public transportation or something like that, you can get reimbursed for your trip to and from that service as part of your Medicaid reimbursement, your Medicaid allocation. And so the same thing applies to school districts. If there's a student that cannot ride in a regular bus to school and they need to be transported to and from school on a specially adapted vehicle, then the district can seek reimbursement if there was a service on that day.

Kim Rentner: Okay. And I think on that day is something that we'll want to remember for the rest of our talk, for sure.

Casey Gayer: Absolutely.

Identifying Disability

Kim Rentner: That's helpful. So I have a two part question for you. The first part is how is a disability identified? Because I'm sure there's some policy around that and it can't just be anyone. And then a lot of our audience who work in transportation may understand that the vehicles need adaptations, but much of our audience who aren't necessarily in the bus every day may not think of those things. So if you could talk about the adaptations for the vehicle and how the disability is identified.

Casey Gayer: Well. So the identification of a disability really is infused into the special education process within a school district. So if a student is identified as needing some additional help in the classroom to access their general education access [inaudible 00:05:00], they're given a screening of some sort. There's different names in every state for these types of meetings and events. But essentially what happens is they're put through a process where they are assessed by stakeholders in the district for various disabilities, occupational therapists, physical therapists, speech, nursing, psychology, et cetera. And if they are found to have a disability that impacts their general education, then they are given services. Those often have to be signed off by a doctor. A plan of care has to be established to allow for medical necessity for those services. And then by proxy, once those services are deemed medically necessary by the school through an IEP or other type of plan, then the trip to and from becomes medically necessary as well, should the student's disabilities, again, require that specially adapted vehicle.

Casey Gayer: So then we get into what is a specially adaptive vehicle? And that does vary state to state. Each state has their own set of Medicaid regulations. The federal government has a broad guidance and then the states are allowed to narrow down within that on several different levels. So the federal government has, for example, a list of services that can be billed and a state can choose from within those which services they want to be billed. And then they make the more specific guidance on what qualifies as a specially adapted vehicle. The most universal one you see is if the vehicle requires some type of wheelchair lift or adaptation there. That would qualify as a specially adapted vehicle because not every single bus has that. You also see regional differences. So in Texas, for example, where high heat is a major issue and a health concern, air conditioning qualifies that bus as a specially adapted vehicle.

Kim Rentner: Yes. I've seen lots of things, even tinted windows, bite guards, things like that. Is it fair to say that if they need door to door service, that that also qualifies or is that something different?

Casey Gayer: That would be something different. In a lot of cases, if you have a monitor or an aide that's required to help the student get to the bus, that's not considered a specially adapted vehicle. It's just a special service on top of that trip.

Kim Rentner: That makes sense. What kind of requirements are there for record keeping? Are they different throughout the states? Also kind of wondering what's the same throughout the states? I think part of our theme here is to get this information out to everybody to know that record keeping could really possibly help them find some reimbursement.

Casey Gayer: Absolutely. Record keeping, there's a few different types and it really depends on which Medicaid program you're talking about. Transportation comes into play mostly in two programs for Medicaid and schools, fee for service and cost reconciliation. And those are two separate streams of funding for school districts.

Kim Rentner: And can you tell us what is the differences between the two?

Casey Gayer: Absolutely. So fee for service, let me liken those to a doctor's office. Fee for services. I come in for an appointment. I have a cough and I see a doctor. They see me for 30 minutes. They submit that time, that 30 minute window to my insurance company. And they bill that time. They bill that appointment. That's that's fee for service. So in a school district, this would be something like a 30 minute speech therapy session. And then when it comes to transportation, the trip is essentially the visit. It's what you bill. You bill a trip unit. Then cost reconciliation is a process where the district can actually submit what they paid to actually provide these services. So they can submit their salaries. They can submit bus costs, they can submit a whole bunch of other items and they get paid what they spent on the services and on the trips and on the buses and the drivers and whatever else went into treating these Medicaid students, of course minus what they were already paid fee for service.

State by State

Kim Rentner: Okay. And like you said, those two items can be different throughout the states. Is that correct?

Casey Gayer: That is absolutely correct. So in fact, cost reconciliation, for example, isn't offered in every state and then the record keeping requirements and what you need in each state to bill fee for service, or to produce a cost report that leads to that cost reconciliation revenue vary as well. Now there are some general rules though. So for example, fee for service, just to enable the claiming process to Medicaid, get the data collected that you need to submit a Medicaid claim, you need documentation of the date of the trip. You need the driver that drove the student. You need to have the attendance on the bus. And then in some states you can bill both the fact that the trip happened and additional mileage, if the trip was longer than your normal route. And there, you would also need to be able to track that mileage. So these are kind of called trip logs. They do need some level of signature and dating to confirm that it happened just as a requirement. Now, all of those signatures and all those logs though, they're only checked in the event of an audit. So it's really important that school districts keep these records on hand if there's somebody that claims to Medicaid, because you can be audited federally up to seven years. And if you can't back up the claims that you submitted with logs, with dates, with signatures, then you may have your funding recouped.

Kim Rentner: That's really good to know. Thank you for sharing that it's seven years. Many of us in transportation know that there's a lot of things seven years, that we have to keep for audits, whether it was from the state or Department of Transportation. So we're used to that, but I'll tell you what, luckily there's some technology now to help us be paperless, right? Who has a place to store all that? But I know that we are capturing ridership electronically, which I think is just amazing. Besides increasing the level of safety and service, if you imagine being a driver and having all these sheets of paper and trying to keep track, did they actually ride to and from, that's the important piece. What benefits have you seen when it comes to Medicaid reimbursement?

Casey Gayer: For me, the benefits are really that it eliminates the logistical issues of paper trip logs. We've seen a high degree of variation across the districts in how buses are dispersed to drivers. Everything from a driver comes into a depot with their car. They collect their keys, and then they take their bus out for the day. And they return those at the end of the day and go home, leaving the bus keys there. And so if you are asking your driver to document trips, you're handing him a piece of paper. He doesn't have a laptop. He doesn't have a computer. He likely has a smartphone or something like that. But if the driver isn't coming in every day or every week or something like that, then districts often have to find a different way to deliver paper logs for that trip, capture those signatures, et cetera. And then there is also a processing that has to be built around the translation of those paper logs into an electronic system for claiming. So when you can capture electronic ridership, you eliminate those logistical issues. However, a lot of electronic ridership doesn't meet the electronic signature requirements, or hasn't been approved by state Medicaid. We do encounter plenty of scenarios where the electronic ridership doesn't have a signature. It just is a scan by the student and the driver isn't signing off. Medicaid requires a driver's sign off. So unless that can be built in as some kind of additional feature in electronic capture system, then the driver is essentially double documenting the attendance that's already being scanned in as the student enters the bus.

Kim Rentner: We don't want to double the work. And I think the important thing is if you're considering capturing that ridership electronically, it is a fabulous thing, but make sure your choice has all of the elements that are acceptable for turning in this information. Super important. Thank you. Are transportation fees covered everywhere by every state?

Casey Gayer: Sadly no. So this kind of circles back to what we were discussing earlier was the federal government allows transportation to be billed, but not every state elected to include transportation as part of its available services to bill to Medicaid for school districts. And then where it is available in states, it's not always available in the same manner. So we discussed before that there's the fee for service element. And then there's the cost reconciliation element where transportation's the main player or, sorry, not the main player, but transportation is usually played out through one of those two scenarios. In some states it's both. In other states, you'll only see transportation come in through cost reconciliation. You do have to log trips because part of that calculation of your buses, your gas, your salaries, of course only pays for the ratio of Medicaid students that are on that bus since you're going to have students that are non-Medicaid. So you have to provide a trip ratio along with your cost to say here's the trips that we offer to special education students overall. Here's the trips that we offer to Medicaid students that are special education. You get paid that subset of money.

Casey Gayer: And then in other states, you can bill that. Plus you can bill the fee for service trips, which would be of course, deducted from your cost reconciliation payment. We do also see this. In a few states, there's an administrative claiming process where transportation is covered. That is pretty rare though. But we are also seeing that change a little bit over time as federal and state regulations are changing pretty rapidly right now, actually in the Medicaid world for schools.

Kim Rentner: That's good to hear. Hopefully it's all good. What happens when that revenue goes back to the district? Probably I'm thinking most of us don't know.

Casey Gayer: So that also varies by state. In most state regulations, there is some guidance on where revenue should go. Typically it goes to the school district's general funds. It can be spent on regular teacher salaries. It can be spent on special education. Some states do require that Medicaid revenue does go back to service the special education department. And then we also see instances where a consortium of individual stakeholders from parents to therapists, to teachers all have to gather together as a committee and make decisions on where that funding is sent in the school district.

Who should lobby?

Kim Rentner: Oh, okay. States are revisiting these services and what they mean to their students. Why is now the right time to lobby for this and who should be lobbying for it? And where can people get more information?

Casey Gayer: States should be lobbying for this right away and right now. So what we're seeing currently is a bit of a transformation in Medicaid regulations. In 2014, the federal government issued new guidance that's commonly referred to as free care. And essentially what this means is that school districts who previously were limited to billing for services related to an IEP could now start billing for medically necessary services that are outside an IEP based on say a 504 program, an RTI program, MTSS, or perhaps even a behavioral plan. And what we're seeing as a byproduct of this, is that to enact these free care regulations and to expand billing to additional programs, states are required to submit a state plan amendment to their state Medicaid plan. And they're taking this opportunity to also build in new services that they didn't have before.

Casey Gayer: So Nevada, for example, through PT60, which is a school district billing type, you couldn't bill personal care services, you couldn't bill transportation and you could only bill behavioral services through a different PT that they had to follow a more traditional hospital level model to even enact and most districts could not follow. They took this opportunity not only to expand services to multiple programs outside the IEP, but to add personal care, to add transportation as fee for service, and to add behavioral health. So as your state is going through this process of amending their state plan, now's the time to reach out to the state officials and say, "What's in the state plan, are you considering this?" And then a lot of states actually can't even do that until legislation is passed. So it's worth, if you are reaching out to someone, to contact your state congressional representative, and let them know that there are opportunities for billing that school districts do not have allowance to. These are federal dollars that the school districts got, not state dollars. These are federal dollars that come to school districts for revenue that could easily be applied if the states can open up their regulations and bring more services in, including transportation.

Kim Rentner: It's amazing to know that it's there. Do you see parents also getting involved to help lobby for these things?

Casey Gayer: I don't see parents getting involved to lobby for these things. And I think that's not necessarily a bad thing. One of the stipulations of Medicaid is of course that you do need parental consent, not just to bill, but to even collect eligibility for a student. And part of that consent that school districts need to get, always outlines two items. Number one, that this does not affect parents' Medicaid personally, in any way, shape or form. This doesn't affect their spend down. This is a completely separate bucket. And so they're protected from any concerns there. And the other is that if they say yes or no, it does not impact the level of service that their child is about to receive. And I think that's one of the most important things is that the parents should be outside of this. This is for the school districts to get back revenue for the services that they provide to the public.

Kim Rentner: Absolutely. Thank you for letting me pick your brain on that one, because I know that you help many people when it comes to giving the parent information, getting parent consent and things of that nature. So that's most important, like you said, to know that they're not going to have any less quality of service. Where can people reach out to you or your company or within their own state? Do you have some recommendations on where they can go to look up this information?

Casey Gayer: Absolutely. Actually Frontline Education has a wonderful website. It's a Medicaid resource guide with blog articles and other links and information that can give you a overview of everything and anything you would want to know around school-based Medicaid.

Kim Rentner: Perfect. That makes it easy on them. So thank you for that. I know that my takeaways from our conversation are the information has to be kept for seven years. Recording did the student actually ride to and from, driver's signatures, dates, all of that pertinent information. Of course, check with your own state on what the guidelines are and recommendations as well. Get involved. Right. But I definitely have to ask you one last important question and it's very important to myself and all the listeners. Casey, could you tell us what your favorite lunch was when you were in school?

Casey Gayer: Oh, my favorite lunch in school is still my favorite food to this day, pizza.

Kim Rentner: High five on that one, definitely. Well, I really hope to have you back. You have helped us so much with this information. Appreciate everything that you do. And thanks for being here today.

Casey Gayer: Thank you. It's a pleasure.

Jeff Harrell: Thank you, Kim and Casey for helping us better understand Medicaid reimbursement for K12 transportation. And Casey I'm with you on the pizza. Love me some pizza at school or otherwise. Well, thanks for joining another episode of the Tyler Tech podcast. We drop a new episode every other Monday and have a lot of great episodes planned for you. So please subscribe. Until next time, this is Jeff Harrell, director of content marketing for Tyler Technologies. We'll talk to you soon.