Medicaid Administrative Claiming for Schoolbased Services MACSS in Iowa

1
Medicaid Administrative Claiming for School-based
Services (MACSS) in Iowa

• ICN Session
• Fiscal
• September 16, 2003

2
Agenda

• Background - EPSDT
• Agency Participation - Organizational Structure
• Working with Billing Agents
• Staff Participation
• RMS Time Study
• Activity Codes
• The Quarterly Claim
• Required Matching Funds
• 10 Reserve Funds
• Contingency Fees

• Training
• DHS Reviews
• Annual Report
• Audit File
• Getting Started
• Responsibilities of Lead Agency
• Accountability for all Schools
• On-line Resources
• State Level Contacts
• Process for Questions and Answers

3
Background

• MACSS is a process by which Federal Financial
  Participation may be claimed for administrative
  case management activities carried out in a
  school setting that are necessary for the proper
  and efficient administration of Iowas Medicaid
  State Plan for children ages 0-21 (through age
  20).
• MACSS supports Iowas EPSDT Care for Kids program.

4
Iowas EPSDT (Care for Kids) Program

• Early Children should receive quality
  health care beginning at birth
  and continuing through childhood including
  identification, diagnosis, and
  treatment of medical conditions as early as
  possible.
• Periodic Children should receive screening
  and preventive care at regular
  intervals throughout childhood (age 0
  through 20) according to standards set by
  responsible professional groups.
• Screening Children should be screened for
  conditions, diseases, or
  abnormalities to initiate further
  diagnosis and receive early and continuing
  treatment of these conditions.
  Services shall include
  vision, hearing, medical, dental, and
  mental health screenings.

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Iowas EPSDT (Care for Kids) Program

• Diagnosis Children should receive further
  evaluation for conditions or signs
  identified in the periodic
  screens that indicate further
  treatment may be required.
• Treatment Children should receive
  treatment that involves the
  correction of health problems
  identified in the screening and diagnosis
  components of EPSDT.

6
Agency Participation

• Agreements will be established with school
  districts only.
• Time studies include only school district
  employees.
• No contracted staff may be included in time
  studies.
• Must have sufficient public unrestricted funds
  derived from state, county, or local generated
  revenues to match federal reimbursements.
• May not be used as match for other programs.

7
Agency Participation

• Organizational structure
• Lead agency status will be limited to one school
  district per county.
• Lead school district must participate in MACSS.
• Other school districts may participate under the
  lead agency.
• Annual agreements established
• Lead agency agreement with DHS
• Sub-agency agreement(s) with lead agency
• Fiscal year July 1 through June 30

8
MACSS Organizational Structure
Centers for Medicare and Medicaid Services (CMS)
Iowa Dept. of Human Services
Iowa Dept. of Public Health
Interagency Agreement
Technical Assistance
Lead School District
Billing Agents (if applicable)
Sub-agreement
Other School Districts
Billing Agents (if applicable)
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Working with Billing Agents

• Contracting with billing agents is the
  prerogative of local participating school
  districts.
• Role for billing agents
• Assist schools in compiling the Quarterly Claim
• Provide technical assistance
• Provide additional trainings following the state
  required trainings
• Assist schools in gathering information for
  response to the Medicaid State Agency regarding
  inquiries, audit findings, claim resolution, etc.

10
Staff Participation

• Staff participating in time studies may include
  employees serving in schools who...
• Facilitate Medicaid outreach / enrollment /
  eligibility determination.
• Provide administrative support for Medicaid
  related activities.
• Do not include staff who
• Provide ONLY direct care or educational services.
• Have positions that are 100 supported by grant
  funds.
• Bill service coordination under the Medicaid LEA
  program.

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Staff Participation

• Appropriate staff may include
• Nurses
• Counselors
• At-risk Coordinators
• Health Care Associates
• Interpreters / Translators for medical services
• Other paraprofessionals
• Psychologists
• Social Workers

12
RMS Time Study

• Time studies will be conducted through a process
  known as Random Moment Sampling (RMS).
• Computer generated random worker - moments are
  selected for the quarter (3,000 statewide /
  quarter).
• For a given sample moment, the worker completes
  the RMS Observation Form.
• Who were you with?/ What were you doing?/ Why
  were you performing this activity?
• Signature and Date
• Certified time coder from Lead Agency codes the
  activity.
• Time code percentages included in an agencys
  claim are based upon statewide coding percentages.

13
RMS Time Study

• Process for Implementation
• One month before start of quarter, Lead Agency
  sends DHS a list of staff to be included in the
  time study for each participating agency (lead
  and subs).
• DHS generates the worker-moments for the upcoming
  quarter.
• Two weeks prior to start of quarter, DHS sends
  RMS Observation Forms and sample control lists to
  lead agency.
• Lead agency distributes RMS Observation Forms and
  instructions to their own staff and sub-agency.
• Completed RMS Observation Forms are returned to
  lead agency weekly.
• Certified coder at lead agency assigns activity
  codes.
• Completed forms are returned to DHS MACSS Auditor
  weekly.

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Activity Codes

• Code 1.a. Outreach and Facilitating Eligibility
  for Non-Medicaid Programs
• Code 1.b. Outreach and Facilitating Eligibility
  for Medicaid hawk-i
• Code 2. School Related Educational Activities
• Code 3. Direct Medical Services

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Activity Codes

• Code 4. a. Coordination of Transportation for
  Non-Medicaid Services
• Code 4. b. Coordination of Transportation for
  Medicaid Services
• Code 5. a. Non-Medicaid Translation
• Code 5. b. Translation Related to Medicaid
  Services

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Activity Codes

• Code 6. a. Program Planning, Policy Development,
  and Interagency Coordination Related to
  Non-Medical Services
• Code 6. b. Program Planning, Policy Development,
  and Interagency Coordination Related to Medical
  Services
• Code 7. a. Non-Medicaid Related Training
• Code 7. b. Medicaid Related Training

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Activity Codes

• Code 8. a. Referral, Coordination, and Monitoring
  of Non-Medicaid Services
• Code 8. b. Referral, Coordination, and Monitoring
  of Medicaid Services
• Code 9. General Administration
• Code 10. Not Scheduled to Work

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The Quarterly Claim

• Links staff costs associated with the time
  invested in Medicaid related activities to
  determine the claim
• Incorporates the Medicaid eligible percentage of
  children
• Applies the appropriate Medicaid provider
  percentage to Code 8.b.
• Provides for removal of revenue to be offset from
  the claim
• Applies the 50 Federal Financial Participation
  Rate

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The Quarterly Claim

• Consists of 3 components
• Salaries and Benefits Report
• Revenues Worksheet
• Invoice
• Use of DHS Excel format is required.
• Red triangle in cell Information is provided as
  to what should be entered into that cell.
• Print feature is included for each page.

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The Quarterly Claim

• Salaries and Benefits Report
• Enter agency name.
• Enter total quarterly salaries as reported in
  payroll journal.
• Enter total quarterly benefits as reported in
  payroll journal.
• Under Cost Pool 1, enter employees that
  participate in the RMS Time Study by name and
  position. Enter corresponding salary and
  benefits for the quarter.
• Under Cost Pool 3, enter superintendents,
  principals, assistant principals, and their
  supporting clerical staff (if clerical are in
  Source Codes 2320 2400) by name and position.
  Enter corresponding salary and benefits for the
  quarter.

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The Quarterly Claim

• Revenues Worksheet
• Enter agency name.
• Total Quarterly Revenues
• Report all revenues for the quarter except the
  entire 1100, 1200, 2100, and 3100 series source
  codes.
• MACSS Reimbursements
• Report under Cost Pool 1 the gross MACSS
  reimbursements received in the quarter (before
  10 reserve and lead agency / other fees are
  deducted).
• Medicaid LEA reimbursements
• Report under Cost Pool 1 all Medicaid LEA
  reimbursements received in the quarter except
  those for service coordination.

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The Quarterly Claim

• Revenues Worksheet
• Federal Revenue
• Report all revenues for the quarter in the 4000
  series source codes that apply to staff in Cost
  Pools 1 3.
• State and Intermediate Revenue
• Report restricted revenues for the quarter in
  source codes 2000 and 3000 that apply to staff in
  Cost Pools 1 3.
• Other Revenue Sources
• Report other revenue sources for the quarter such
  as contracted costs from other agencies, fees
  paid by clients, insurance payments, and other
  3rd party reimbursements that apply to staff in
  Cost Pools 1 3.

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The Quarterly Claim

• Invoice
• Enter agency name.
• Enter travel and training costs for the quarter
  for staff in each of the three cost pools.
• Cost Pool 1 Includes costs for staff in the
  RMS time study.
• Cost Pool 2 Includes costs for all staff other
  than those included in Cost Pools 1 and 3.
• Cost Pool 3 Includes costs associated with
  Superintendents, Principals, and Assistant
  Principals, and their supporting clerical staff
  (if clerical are in Source Codes 2320 2400).

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The Quarterly Claim

• Invoice
• Enter RMS Time Study results for each time code.
• Use statewide RMS Time Study results.
• Enter units of time (not percentages).
• Enter the Department of Educations unrestricted
  indirect cost rate for the school district
  (established annually).
• Can be found at http//www.state.ia.us/educate/fis
  /sft/car/index.html

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The Quarterly Claim

• Invoice
• Enter percentage of Medicaid recipients.
• Free reduced lunch percentages are no longer
  allowed.
• CMS requires tracking of actual Medicaid enrolled
  children.
• The Iowa Department of Education will be
  conducting a sample survey of children enrolled
  in Iowa schools to determine a statewide rate of
  Medicaid eligible children.
• All participating school districts will be
  provided information as to the statewide rate to
  be included in the claim.
• Maintain documentation of the percentage of
  Medicaid eligibles for the audit file.

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The Quarterly Claim

• Invoice
• Enter Medicaid provider percentage.
• CMS requires tracking of providers to whom
  students are referred or with whom services are
  coordinated or monitored.
• These providers may include physicians, dentists,
  psychologists, psychiatrists, opticians, and
  other providers such as pharmacies.
• To determine the Medicaid provider percentage,
  divide the number of Medicaid providers by the
  total number of providers to whom students are
  referred or with whom services are coordinated or
  monitored. (Percentage is applied to Code 8.b.)

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The Quarterly Claim

• Invoice
• Medicaid provider percentage
• Website link to list of Medicaid providers will
  be provided by the Department of Education.
• Tracking form will be completed by each coder.
• Submit tracking document with initial claim.
• Maintain documentation of the Medicaid provider
  percentage for the audit file.

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The Quarterly Claim

• One Purchase Order/Payment Voucher is due to
  Sally Nadolsky within 180 days of the end of each
  quarter (September 30, December 31, March 31,
  June 30)
• Include all 3 pages (Salaries and Benefits
  Report, Revenues Worksheet, and Invoice) for the
  lead agency and each sub-holder.
• Include the tracking document for providers and
  determination of Medicaid provider percentage.

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Required Matching Funds

• Each school district must certify required
  non-federal matching funds.
• For every federal dollar received, a equal amount
  of match is required.
• Federal Financial Participation is 50
• Agency certifies the other 50 as match
• Source must be public unrestricted funds.
• Designated matching funds must not be used as
  match for another grant / program.
• Signed certification is required on each invoice.

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10 Reserve Funds

• Agreement requires a minimum of 10 of the
  federal reimbursement to be held in reserve.
• Are used to offset any disallowance identified in
  an audit. If disallowance exceeds the amount in
  reserve, the agency is responsible for total
  disallowance.
• Must be in a separate line item or separate
  account.
• Must be held for a rolling 5 year time period.

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Contingency Fees

• DHS withholds up to 5 of claim to support the
  RMS time study, review of claim, and technical
  assistance.
• Lead agency may retain percentage of the
  sub-holder claim for administering the program.
• Must have supporting documentation for amount
  withheld (update annually).
• Must cover costs without profit-making.
• Billing agencies
• Fees must be related to the cost of processing.
• May not assess percentage dependent upon federal
  reimbursements collected per CFR and OMB
  regulations.

32
Training

• Certification of fiscal training is required for
  the staff person preparing the claim for each
  participating agency.
• Contact Janet Beaman for training needs.

33
DHS Reviews

• Oversight will occur on a regular basis.
• Desk reviews of both coding and quarterly claim
• Review of 10 of coding each quarter
• Review of quarterly claim and supporting
  documentation each quarter
• At a minimum, biennial in-depth desk reviews
• Periodic on-site reviews

34
Annual Report

• Lead agency submits to Sally Nadolsky at DHS each
  year
• Due by September 30
• Includes summary of fiscal elements for the
  claiming year for both lead and sub-agencies
• Includes narrative report on use of funds for
  both lead and sub-agencies
• Per contract must be used to expand or enhance
  health related services for children.

35
Audit File

• Audit file must be retained for 5 years
• Components
• Coding policies
• Job descriptions reflecting activities claimed
• Table of organization
• Documentation of the Medicaid eligible percentage
• Documentation supporting the determination of the
  Medicaid provider percentage
• Accounting information for cost pools and revenues

36
Audit File

• Components
• Computations and calculations for preparation of
  quarterly claim
• Documentation of DE unrestricted indirect cost
  rate for the school
• Documentation of matching funds
• Use of reimbursed funds
• Documentation of 10 held in reserve
• Documentation of analysis of administrative fees
  assessed to sub-agencies (for Lead Agencies)
• Documentation of technical assistance training

37
Getting Started

• Determine whether participating as lead agency or
  sub-agency.
• Establish MACSS agreement (lead or sub) each
  year.
• New contracts to begin October 1, 2003 June 30,
  2004.
• New coding structure and RMS time study
  anticipated to begin January 1, 2004.
• School districts that have no previous experience
  with the program may begin when RMS time study is
  implemented.

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Getting Started

• Identify key contact personnel for MACSS.
• Certified coder from lead agency and certified
  back-up coder
• Contact persons for RMS Time Study and Fiscal
  components
• Determine appropriate staff for inclusion in the
  RMS time study.
• Provide list of participating staff by name and
  position to Lead Agency and then DHS.
• Update job descriptions and Table of
  Organization.
• Establish process for tracking providers.

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Responsibilities of Lead Agencies

• Submits Lead Agency agreement to DHS
• Enters into sub-agreements with other appropriate
  entities as sub-holders
• Provides technical assistance to sub-holders
• Provides pertinent communications to sub-holders
• Provides list of coders by name position to DHS
  for lead agency and sub-holders each quarter
• Provides Observation Forms and worker-moments to
  lead agency staff and sub-holders for each
  quarter
• Designates certified coder and back-up who code
  lead agency and sub-holder activities

40
Responsibilities of Lead Agencies

• Submits coded Observation Forms to DHS auditor
  weekly
• Develops lead agency Quarterly Claim and receives
  those of sub-holders
• Provides quality assurance review of sub-holder
  claims
• Submits one PO/PV to DHS for both lead and subs
  quarterly (with required supporting documents)
• Maintains Lead Agency audit file
• Coordinates on-site reviews of lead and sub
  agencies
• Responsible to DHS for all disallowances
  identified in state and federal audits

41
Accountability for all Schools

• Recognize the authority of the State Medicaid
  Agency regarding policies, rules, regulations
• Assure proper and efficient administration of the
  Medicaid State Plan through compliance with
• CMS Medicaid School-based Administrative Claiming
  Guide, May 2003
• OMB Circular A-87
• 45CFR Parts 74 and 95
• 42 CFR 447.10(f) and
• State requirement to participate in RMS time study

42
Accountability for all Schools

• Provide responses to Medicaid State Agency
  regarding inquiries, audit findings, claims
  resolution, etc.
• Certify sufficient public unrestricted funds for
  match (those not used as match for other
  programs)

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On-line Resources

• CMS Medicaid School-Based Administrative Claiming
  Guide, May 2003
• http//cms.hhs.gov/medicaid/schools/clmguide.asp
• OMB Circulars A-87 and A-133
• http//www.whitehouse.gov/omb/circulars/index.html
  
• Iowa Department of Education Uniform Financial
  Accounting for Iowa LEAs and AEAs
• http//www.state.ia.us/educate/fis/sft/ufa/index.h
  tml

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State Level Contacts
45
State Level Contacts

• For the Medicaid Local Education Agency (LEA)
  program
• Dann Stevens, Consultant
• Iowa Department of Education
• Grimes State Office Building
• 400 East 14th Street
• Des Moines, IA 50319
• Phone [phone]
• FAX [phone]
• e-mail Dann.Stevens_at_ed.state.ia.us

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Process for Questions and Answers

• Questions may be submitted at anytime.
• Written responses will be developed for those
  questions submitted by Wednesday, October 15th.
• Submit to Janet Beaman at jbeaman_at_idph.state.ia.us
  
• Written responses will be sent to all
  participants.