Hawaii's DOE agreement with DHS maximizes Medicaid reimbursement for special ed students

Reading the Department of Education update on its medicaid reimbursement program soon after speaking with the administrator of the state's school based claiming (SBC) program and after reading Laura Brown's articles on potential fraud within the DOE procurement process, has been an interesting process.

The state auditor reports, released in February 2009, found a "culture of disregard" for procurement laws and regulations.

On December 3, DOE submitted it's report to the Board of Education on the progress of its federal reimbursement maximization program.  This is about the work that has been contracted out to the University of Massachusetts Medical School.  They're going back to January 15 of 2006, and submitting claims to Medicaid for everything they can identify as reimbursable.

The report states they already had $1.15 million in what is supposed to be a revolving account.  The report goes on to say "once operational, administrative claiming will significantly increase SBC [school based claiming] reimbursement" and they expect to generate $7 million in reimbursements by 2013.

I asked DOE in October for an accounting of all reimbursement sought and received on my daughter's behalf.  I have been told by the person who administrates the school based claiming program that the school based claiming program has not submitted any claims to Medicaid on my daughter's behalf.

I tried asking about programs other than the SBC, but the verbal response remained worded the same each time.

Mind you as of November it seems that the SBC was not completely operational, so it's possible there could be a "not yet" attached to that claim. The DOE said that as of November 2009 "interaction with MQD was initiated to review strategies for the implementation of an administrative claiming program."

The individual I spoke with said that DOE cannot bill Medicaid for my daughter because she's in a Medicaid waiver program.  I found that interesting given that CMS has stated clearly that Medicaid waiver services are intended to supplement EPSDT, not the other way around.

Another interesting issue brought up by the DOE report is the recruitment process DOE has conducted to enroll more children in EPSDT.  Parents may not realize this has happened, and may not be aware of all the benefits their children are entitled to under EPSDT.  The DOE report states that "the parental authorization process as conducted three times throughout the year producing an eligible population of approximately 2500 students."

I'm not sure what if any relationship there is between this "parental authorization process" and the reverse approval letters DOE sent out twice that I'm aware of.  Those letters stated that if the letter was NOT responded to, the parent was giving their permission for Hawaii to bill Medicaid on their child's behalf.  The first letter I saw went out in December 2008.

EPSDT mandates that states conduct extensive outreach and education to parents and caregivers on EPSDT benefits and rights.  This doesn't always happen the way it's supposed to, as witnessed by the health plan information booklets prepared by Evercare and Ohana which almost dismiss EPSDT as just shots and normal developmental screens.  Somehow they leave out everything else, such as home nursing, durable medical equipment, speech, occupational and physical therapy, individual case management and many more benefits.

So if DOE is claiming they've recruited 2500 children for Medicaid reimbursement does that mean new enrollees or existing enrollees?  Are these children being enrolled in either Evercare or Ohana in order to be covered under Medicaid and therefore eligible for DOE reimbursement? That could increase the monthly capitated income the two for-profit Medicaid agencies receive from Hawaii, with little if any way to track actual spending on individual students.

Once again, I'm left with more questions than answers.