Medicaid Administrative Claiming

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Medicaid Administrative Claiming
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MAC

• 2008-2009 Train-The-Trainers Workshop

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Oregon DHS Support
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• The Oregon Department of Human Services
• Medicaid Administrative Claiming
• Division of Medical Assistance Programs
• Linda Williams
• SBHS Medicaid Operations and Policy Analyst
• [phone]
• Lasa Baxter
• DHS Contracted SBHS Medicaid Specialist
• [phone]

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Presentation Materials
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• 2008-2009 MAC Power Point Presentation
• School-Based Medicaid/OHP Administrative Claiming
  Coding Guide
• Approved Medicaid/OHP Services
• Audit Support Document

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Presentation Overview
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• Medicaid in Schools
• Connecting the Puzzle Pieces
• Trainer Responsibilities
• Provider Participation
• Activity Code Review
• Points of Clarification - Handouts
• MAC Claiming Coding Guide - Handout
• MAC Activity Codes
• CMS Action

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Trainer Responsibilities
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• Trainers must attend a MAC train-the-trainers
  workshop annually.
• Trainers must schedule and provide training and
  training tools/materials to local staff no less
  than once annually.
• Require staff to sign a training sign in sheet.
  Maintain a copy of the training sign-in sheet for
  a period of seven years.

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Trainer Responsibilities
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• Complete a review of the survey results and
  obtain any necessary supporting documentation
  from staff prior to the submission of MAC claims
  to DHS.
• Maintain any supporting documentation for the MAC
  claim for a period of seven years.
• Provide contact information and be available to
  DHS for review of MAC claims.

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Medicaid in Schools
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• Established in 1965 under Title XIX of the Social
  Security ACT, Medicaid provides medical
  assistance for low-income Americans through
  Federal grants to States.
• Since 1988, Medicaid has been authorized by
  Congress to reimburse for IDEA-related medically
  necessary services on a Fee-for-Service basis.

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Medicaid in Schools
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• While schools are legally liable to provide
  IDEA-related health services at no cost to the
  eligible students Medicaid reimbursement is
  available for these services because section 1903
  (c) of the ACT requires Medicaid to be primary to
  the U.S. Department of Education for payment of
  the health-related services provided under IDEA.
• CMS 2003 Administrative Claiming Guide

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MAC Jointly Funded
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• Federal Government Center for Medicare and
  Medicaid Services (CMS)
• State Government
• Oregon Department of Human Services (DHS)

CMS 50
DHS 50
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Connecting the Puzzle Pieces
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SBHS Fee-For-Service
MAC
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Connecting the Puzzle Pieces
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• Fee-For-Service School-Based Health Services
  (SBHS) is a cost-sharing (Federal Financial
  Participation (FFP) matching) program in which
  the Education Agency (EA) as an enrolled public
  entity is responsible for paying the non-federal
  matching share of the amount of the claims
  submitted to DHS for medically necessary services
  provided in an education setting specified on a
  Medicaid-eligible childs IEP or IFSP.
• Section 1903 of the Social Security Act
• Authorizes states with an approved State plan to
  access reimbursement for Medicaid covered
  School-Based Health Services (SBHS) on a
  Fee-For-Service basis included in a childs
  IEP/IFSP.
• Medically Licensed Fee-For-Service Participants
• Speech/Language Pathologists
• Occupational Therapists
• Certified Occupational Therapy Assistants
• Physical Therapists
• Licensed Physical Therapy Assistants
• Nurses
• Delegated Health Care Assistants
• Clinical Psychologists
• Licensed Clinical Social Workers

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Connecting the Puzzle Pieces
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• Medicaid Administrative Claiming (MAC)
• Federal matching funds under Medicaid are
  available for the cost of administrative
  activities that directly support efforts to
  identify and enroll potential eligibles into
  Medicaid and that directly support the provision
  of medical services covered under the state
  Medicaid plan. To the extent that school
  employees perform administrative activities that
  are in support of the state Medicaid plan,
  federal reimbursement may be claimable through
  the MAC program.
• MAC Participants may include
• Administrators
• Principals
• Teachers
• Assistants
• Secretaries
• School Counselors (TSPC licensed)

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DIRECT COVEREDMEDICAID/OHP SERVICES
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• Health Services
• Well-child exams
• Immunizations (May not be during exclusion or for
  education enrollment requirements)
• Routine physicals
• Maternity and newborn care
• Medical Services
• Preventive services such as well-child check ups
• Laboratory or x-rays
• Treatment for most major diseases
• Hospital stay
• Substance abuse
• Vision care, routine screenings, and glasses
• Hearing services, hearing aids, batteries
• Home health care
• Specialists care referrals
• Physical, occupational, and speech therapy
• Medical equipment and supplies

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DIRECT COVEREDMEDICAID/OHP SERVICES
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• Dental Services
• Preventive services (cleaning, fluoride
  treatments, sealants for children)
• Routine services (fillings, x-rays)
• Dental check ups
• Tooth removal
• Dentures
• 24-hour emergency care
• Specialist care and referrals
• Mental Health Services
• Evaluations
• Therapy
• Consultations
• Medication management
• Programs for daily and community living

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NOT Covered Direct Services
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• Treatment for minor acute health conditions, such
  as scratches, bruises, headaches, colds,
  application of Band-aids or administration of
  non-prescriptive medications
• Conditions that have no useful treatment
• Treatments that are not generally effective

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NOT CoveredServices Integral to Direct Services
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• Administrative activities such as coordinating,
  follow-up, or monitoring performed in support of
  direct medical/health services that are NOT
  covered or reimbursable under the Medicaid FFS
  program are NOT reimbursable under the Medicaid
  Administrative Claiming Program.

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POINTS OF CLARIFICATION
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• Handouts
• Medicaid Provider Participation
• How to Report Activities Provided by Direct
  Service Providers
• Referral, Coordination and Monitoring of
  Medicaid-Covered Services Code C1

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Medicaid Provider Participation
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• Administrative activities performed in support of
  direct medical/health services that are not
  covered or reimbursable under the Medicaid
  program are NOT reimbursable under the Medicaid
  Administrative Claiming Program.
• In order for a medical/health service to be
  reimbursable, the provider furnishing such
  services must be an enrolled or participating
  Medicaid provider and bill Medicaid for the
  service.
• If the provider is not an enrolled or
  participating Medicaid provider or chooses not to
  bill Medicaid for the services rendered, then the
  service cannot be reimbursed and the
  administrative expenditures related to the
  service are also not allowable.
• An education agency does not have to be an
  enrolled or participating Medicaid provider in
  order to claim referrals of students to
  Medicaid-covered medical/health services provided
  in the community, as long as the provider
  rendering the services is an enrolled or
  participating Medicaid provider.

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Helpful Resources
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• For Assistance in Finding Local Medicaid
  Providers contact information is available by
  county at the following websites
• To assist in choosing Local Medicaid Providers
  click on the comparison chart in your county
• http//www.oregon.gov/DHS/healthplan/data_pubs/pla
  nlist/main.shtml
• Local DHS Offices for Children, Adults and
  Families (CAF)
• http//www.oregon.gov/DHS/localoffices/localoffice
  s.pdf
• Oregon County Health Department Directory
• http//egov.oregon.gov/DHS/ph/lhd/lhd.shtml
• Community Mental Health Programs list by County
• http//egov.oregon.gov/DHS/mentalhealth/cmh-progra
  ms.shtml

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Helpful Resources
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• For assistance in linking students and or their
  families to the Oregon Health Plan and Medicaid
  covered Health services try using either of the
  following interactive websites
• Oregon Helps!
• http//www.oregonhelps.org/
• Oregon DHS How Do I?
• http//www.oregon.gov/DHS/how_do_i.shtml

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Referrals to Claimable Medicaid Providers
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• Referrals made for Medicaid covered health
  services provided by Licensed Health Care
  Professionals who work for actively enrolled
  Medicaid providers and who are billing Medicaid
  may be claimed under code C1. These include
• Some ESDs
• Some School Districts
• Public Health Agencies
• Hospitals
• Mental Health Agencies and
• Some Clinics and Private Practices

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Direct Service Providers
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• Reporting Medicaid Administrative Claiming
  Activities which are integral to or an extension
  of direct or consultative services are not
  claimable
• An Oregon Board Licensed Health Professional
  cannot claim Code C1 activities, such as
  referrals, monitoring, gathering history or
  background information in advance of a referral,
  the coordination of Medicaid covered services, OR
  Code D1 activities, such as scheduling or
  arranging transportation to Medicaid covered
  services and scheduling, arranging or providing
  translation for Medicaid covered services which
  are integral or related to consultation or direct
  treatment services provided for a child by that
  individual.
• Registered Nurse
• Occupational Therapist
• Certified Occupational Therapy Assistant
• Physical Therapist
• Licensed Physical Therapy Assistant
• Speech/Language Pathologist
• Licensed Psychologist
• Licensed Clinical Social Worker
• Delegated Health Care Assistant

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Direct Service Providers
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• Activities that meet the descriptions of Code C1
  and D1 (ie coordination, referral, gathering
  history in advance of a referral, scheduling,
  arranging, or providing translation services
  necessary to understand treatment of a health
  condition or scheduling or arranging of
  transportation services to a Medicaid covered
  service), which are integral or related to
  consultation or direct treatment services
  provided for a child by a Direct Service Provider
  are considered direct services and must be coded
  F. This is true regardless of whether or not the
  education agency the direct service provider
  works for is an active participating Medicaid
  Provider.
• Clear and concise supporting documentation must
  be maintained by all direct service providers who
  report Code C1 or D1.
• Direct Service Providers may claim B1 and E1
  activities without this same concern.

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IN-DISTRICT REFERRALS
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• The linkage between Fee-For-Service and MAC
• In-district referrals are only claimable when
• the school is enrolled with the Division of
  Medical Assistance programs as a School Medical
  (SM) Medicaid provider and actively billing SBHS
  specified on a childs IEP or IFSP for
  reimbursement under the Fee-For-Service program
  (NOTE If the referral is provided by an ESD
  employee who works in the district and the ESD is
  an active participating Medicaid provider, then
  the referral may be claimed under code C1.1) and
• the referral is made to a staff member who holds
  a license from an Oregon Medical Licensing board

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Some Referrals are NOT Claimable
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• Referrals made to staff licensed/credentialed
  through TSPC (only) for the purpose of a health
  evaluation, diagnostic testing, and behavior
  counseling services are not claimable under code
  C1 (i.e., school psychologist, school counselor,
  teacher with a speech endorsement).
• Referrals for state-mandated health services are
  NOT claimable.
• For example, state laws may require that
  immunizations be provided to all school children,
  regardless of the childs income status or
  whether the child is Medicaid eligible. In such
  a case the administrative activities related to
  assisting the child to obtain such immunizations
  in the school would not be reimbursable as a
  Medicaid administrative cost.
• Notifying parents regarding immunizations during
  exclusions as required by education would not be
  a claimable activity under MAC.)
• Referrals to NON-Medicaid health care providers,
  such as
• School Districts or ESDs not enrolled as a
  Medicaid provider or not actively participating
  in Medicaid billing.
• Some Kaizer Health
• Some Kaizer Permanente

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TSPC School Counselor
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• OAR 584-017-0441
• Knowledge, Skills and Abilities for Initial
  School Counselor
• A TSPC Licensed School Counselor may provide the
  following within the scope of their license
• 1(b) Develop, design, implement, monitor, and
  evaluate a comprehensive developmental and
  inclusive school counseling program that
  integrates Oregon's four developmental domains
  academic (learn to learn), personal/social (learn
  to live), career (learn to work), and community
  involvement (learn to contribute)
• According to Oregon Administrative Rules a TSPC
  Licensed School Counselor does not provide direct
  health services to students such as, diagnostic
  evaluations, health assessment and behavior
  counseling for an identified health condition.
  Therefore, referrals and coordination activities
  made to Medicaid providers for Medicaid covered
  services by a TSPC Licensed School Counselor are
  claimable activities, as they are not providing
  direct health or medical services.
• If a referral is made to a TSPC Licensed School
  Counselor for a diagnostic health evaluation, the
  referral is not claimable as Medicaid does not
  recognize TSPC licensure as meeting the criteria
  for Medically Qualified Staff who may bill
  Medicaid for Medicaid covered services.

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TSPC Licensed School Psychologist
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• OAR 584-017-0351
• Knowledge, Skills and Abilities for Initial
  School Psychologist License
• A TSPC Licensed School Psychologist may provide
  the following within the scope of their license
• 2a) Candidates demonstrate skill in assessing or
  providing for assessments in the following areas
  academic knowledge and achievement, intelligence
  and cognitive functioning, scholastic aptitude,
  personality, emotional status, social skills and
  adjustment, adaptive behavior, language and
  communication skills, sensory and neurological
  functioning, educational setting, and
  family/environmental influences.
• (3) Consultation and Collaboration Candidates
  have knowledge of behavioral, mental health,
  collaborative, and/or other consultation models
  and methods and of their application to
  particular situations.
• (8) Prevention, Crisis Intervention, and Mental
  Health Candidates have knowledge of human
  development and psychopathology and of associated
  biological, cultural, and social influences on
  human behavior. Candidates provide or contribute
  to prevention and intervention programs that
  promote the mental health and physical well-being
  of students. Candidates have knowledge of crisis
  intervention and collaborate with school
  personnel, parents, and the community in the
  aftermath of crises.

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TSPC Licensed School Psychologist

• According to Oregon Administrative Rules a TSPC
  Licensed School Psychologist may provide direct
  health services to students such as, diagnostic
  evaluations and assessment and behavior
  counseling for an identified health condition.
  Referrals and coordination of Medicaid covered
  services made by a TSPC Licensed School
  Psychologist to Medicaid providers for a child in
  which they provide direct health services are
  considered integral to or an extension of a
  direct service and must be coded F.
• If a referral is made to a TSPC Licensed School
  Psychologist for a diagnostic health evaluation,
  the referral is not claimable as Medicaid does
  not recognize TSPC licensure as meeting the
  criteria for Medically Qualified Staff who may
  bill Medicaid for Medicaid covered services.

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MAC CODING GUIDE
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• Handout
• MAC Claiming Coding Guide

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Non Claimable Codes
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• A School Related and Educational Activities
• B2 Non Medicaid OHP/Outreach
• C2 - Referral, Coordination, Monitoring and
  Training on Non Medicaid /OHP Services
• D2 Non Medicaid/OHP Transportation/Translation
• E2 Program Planning, Policy Development and
  Interagency Coordination Related to Non-Medical
  Services
• F Direct Medical Services

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Non-Claimable School Related Educational
Activities
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• Code A
• This code should be used for any school-related
  activities that are not health related.
• Includes the development, coordination and
  monitoring of a students IEP or other education
  plan.

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MAC Claimable Activities
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• Claimable Categories
• B1 Medicaid OHP/Outreach
• C1 OHP Referral, Coordination, Monitoring and
  Training
• D1 OHP Transportation/Translation
• E1 Medical Program Planning, Policy
  Development, and Interagency Coordination

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Medicaid Outreach
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• Medicaid outreach activities are those performed
  to inform eligible or potentially eligible
  individuals about Medicaid and how to access the
  Medicaid program.
• Oregon Medicaid
• Oregon Health Plan (OHP)
• State Childrens Health Insurance Program (SCHIP)

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B1 Medicaid Outreach
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• B1.1
• Informing children and their families on how to
  effectively access, use, and maintain
  participation in Medicaid/OHP.
• Includes describing the range of services, and
  distributing OHP literature.
• B1.2
• Assisting the student/family to access, apply
  for, and/or complete the Medicaid/OHP
  application.
• Includes coordinating transportation and
  providing and coordinating translation related to
  OHP application, and gathering appropriate
  information.

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B1 Medicaid Outreach
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• B1.3
• Checking a student and/or family's OHP status.
• May be done by reviewing the families medical
  card, contacting the local DHS agency, working
  with in-district staff who have access to
  Medicaid eligibility.
• B1.4
• Contacting pregnant and parenting teenagers about
  the availability of Medicaid/OHP for prenatal and
  well baby care programs.

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C1 - Referral, Coordination, Monitoring
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• C1.1
• Referring students for medical, mental health,
  dental health and substance abuse evaluations and
  services covered by Medicaid/OHP (includes
  gathering information in advance of referrals).
• Referrals made to staff licensed/credentialed
  through TSPC only for the purpose of a health
  evaluation, diagnostic testing, and behavior
  counseling services are not claimable under MAC
  code C1 (i.e., school psychologist, school
  counselor, teacher with a speech endorsement).
  Such activities are not reimbursable by Medicaid,
  yet are still considered a direct service and
  must be coded F.

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C1 - Referral, Coordination, Monitoring
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• C1.2
• Coordinating the delivery of medical health,
  mental health, dental health and substance abuse
  services covered by Medicaid/OHP. (Includes Youth
  Services Team and CARE team meetings).
• Coordinated the delivery of a community based
  medical service for a child with severe health
  care needs.
• Assisted family with scheduling a dental
  appointment with a Medicaid provider.
• Participated in a scheduled meeting with staff to
  coordinate access to necessary Medicaid covered
  health related services for a student.

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C1 - Referral, Coordination, Monitoring
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• C1.3
• Monitoring the delivery of medical (Medicaid/OHP)
  covered services. (Includes monitoring and
  evaluating the medical services component of the
  IEP).
• The following activities are NOT claimable
• Activities performed in the initial development
  of the IEP and/or formal IEP meetings (i.e.,
  annual, 3-yr)
• Monitoring minor acute health conditions, such as
  scratches, bruises, headaches, colds, application
  of Band-aids or administration of
  non-prescriptive medications
• Monitoring Conditions that have no useful
  treatment
• Monitoring required by Delegation from a
  Registered Nurse, such as seizure monitoring.

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C1 - Referral, Coordination, Monitoring
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• C1.3
• The 2003 CMS Medicaid Administrative Claiming
  guide indicates the following are covered under
  code C1
• Providing follow-up contact to ensure that a
  child has received the prescribed
  medical/dental/mental health services covered by
  Medicaid.
• Monitoring and evaluating the Medicaid service
  components of the IEP as appropriate.
• When necessary and appropriate claimable
  scenarios may include
• A classroom teacher who works closely with a
  student receiving Medicaid-covered services on an
  IEP is involved in a scheduled meeting necessary
  to monitor and evaluate the medical service
  components of the IEP (this excludes the actual
  IEP meetings).
• A classroom teacher who works closely with a
  student makes follow-up contact with a qualified
  Medicaid Health Services provider to ensure
  services previously prescribed or referred for
  were received.

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C1 - Referral, Coordination, Monitoring
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• C1.4
• Training Coordinating, conducting or
  participating in training events or seminars for
  outreach staff regarding the benefits of
  medical/Medicaid related services.
• Participating in a MAC training.
• Attending a seminar on how to effectively provide
  OHP outreach.
• The portion of a training where the content
  focuses on recognition of signs and symptoms of
  specific medical conditions.

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D1 Transportation/Translation
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• D1.1
• Scheduling and arranging transportation to OHP
  covered services.
• Does NOT include the provision of the actual
  transportation service or the direct costs of the
  transportation (bus fare, taxi fare, etc, but
  rather the administrative activities (related
  paperwork, clerical activities, staff travel
  time, etc.) involved in providing the
  transportation.
• D1.2
• Scheduling, arranging or providing translation
  for OHP covered services.
• Arranging for or providing translation services
  (oral and signing) that assist the individual to
  access and understand necessary care or treatment
  covered by Medicaid.
• Developing translation materials that assist
  individuals to access and understand necessary
  care or treatment covered by Medicaid.

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E1 Program Planning, Policy Development
Interagency Coordination
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• E1.1
• Developing strategies and policies to assess or
  increase the capacity of school
  medical/dental/mental health programs (includes
  workgroups)
• Identifying gaps or duplication of
  medical/dental/mental services and developing
  strategies to improve the delivery and
  coordination of these services.
• Developing procedures for tracking families
  requests for assistance with medical/dental/mental
  health services and providers, including
  Medicaid.
• This does not include the actual tracking of
  requests for Medicaid services.
• Developing Medicaid provider list to assist staff
  in referring families to Medicaid providers.

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E1 Program Planning, Policy Development
Interagency Coordination
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• E1.2
• Working with other agencies and/or providers to
  improve the coordination and collaboration and
  delivery of medical, mental health and substance
  abuse services.
• Working with other agencies to evaluate the need
  for medical/dental/mental services in relation to
  specific populations or geographic areas.
• Working with other agencies and/or providers to
  improve collaboration around the early
  identification of medical/dental/mental problems.
• El.3
• Monitoring the medical/mental health/dental
  health delivery system in schools.

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Code F Direct Services
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• Providing Direct Services vs. Administrative
  Activities
• The Centers for Medicare Medicaid Services
  (CMS) rule states Activities that are
  considered integral to, or an extension of direct
  medical services, are NOT CLAIMABLE as an
  Administrative expense (e.g., patient follow-up,
  patient assessment, patient counseling, patient
  education, patient consultation, billing
  activities). These activities must be reported
  under Code F, Direct Medical Services.

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Claims Over 10
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• Section V(A) of the 2003 CMS Medicaid
  Administrative Claiming Guide states (pg 37)
• Documentation maintained in support of
  administrative claims must be sufficiently
  detailed to permit CMS to determine whether the
  activities are necessary for the proper and
  efficient administration of the state plan.
  Simply checking a box on a time study form
  doesnt not facilitate independent validation of
  the sample results. It is critically important
  for additional documentation to be maintained, in
  order to verify the appropriateness of the claims
  in terms of allowability and allocability and to
  limit the risk of the federal government.
• For survey claims where 10 or more of the total
  time reported is claimable under MAC, supporting
  documentation is required. Supporting
  documentation must
• Be clear and concise
• Use actions verbs as identified under each
  claimable code in the MAC coding guide (ie
  referred, gathered information, coordinated,
  arranged, scheduled, etc) to accurately describe
  claimable activities reported in the MAC survey.
• Supporting documentation must be maintained for a
  period of seven years.

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CMS Action
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• CMS-2287-Final
• CMS made rule 2287 final, eliminating Medicaid
  Administrative Claiming and severely limiting
  Medicaid claiming for school based special
  transportation claims, effective February 2008.
• However, recently passed legislation placed a
  moratorium on implementing the final rule until
  April 1, 2009, by placing a delay on the
  implementation of these changes.

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Children are one third of our population and all
of our future
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