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Medicaid Administrative Claiming
 2008-2009 Train-The-Trainers Workshop
Oregon DHS Support

The Oregon Department of Human Services
      Medicaid Administrative Claiming
  Division of Medical Assistance Programs

              Linda Williams
SBHS Medicaid Operations and Policy Analyst
             (503) 945-6730

              Lasa Baxter
 DHS Contracted SBHS Medicaid Specialist
            (541) 975-5614
       Presentation Materials

 2008-2009 MAC Power Point Presentation
  - white
 School-Based Medicaid/OHP
  Administrative Claiming Coding Guide -
 Approved Medicaid/OHP Services -
 Audit Support Document – white
         Presentation Overview
   Medicaid in Schools
   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
             Medicaid in Schools

   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.
         Medicaid in Schools

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
 MAC Jointly Funded
             Federal Government:
              Center for Medicare
              and Medicaid Services
CMS 50%       (CMS)

             State Government:
DHS 50%       Oregon Department of
              Human Services (DHS)
Connecting the Puzzle Pieces
        Connecting the Puzzle Pieces
   Fee-For-Service:
   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) included in a child’s 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
    Connecting the Puzzle Pieces
   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
            Administrators
            Principals
            Teachers
            Assistants
            Secretaries
            School Counselors (TSPC licensed)
            School Psychologists (TSPC licensed)
             DIRECT COVERED
   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
              DIRECT COVERED
   Dental Services
       Preventive services (cleaning, fluoride treatments, sealants for
       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
 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
 Treatments that are not generally
               NOT Covered
    Services Integral to Direct Services
   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.
     Trainer Responsibilities

 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.
       Trainer Responsibilities

 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

   Handouts
     Medicaid Provider Participation
     Medicaid Outreach and Eligibility
      Determination – Code B1
     Referral, Coordination and Monitoring of
      Medicaid-Covered Services – Code C1
              Medicaid Provider
   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
   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.

   Handout:
       MAC Claiming Coding Guide
       Non – Claimable Codes
   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
   E2 – Program Planning, Policy Development
    and Interagency Coordination Related to
    Non-Medical Services
   F – Direct Medical Services
              School Related &
            Educational Activities
   Code A
       This code should be used for any school-
        related activities that are not health
          Includesthe development, coordination and
          monitoring of a student’s IEP or other
          education plan.
        MAC Claimable Activities

   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
            Medicaid Outreach

   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 Children’s Health Insurance Program
           B1 – Medicaid Outreach

   B1.1
       Informing children and their families on how to
        effectively access, use, and maintain participation in
          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.
        B1 – Medicaid Outreach
   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
   B1.4
       Contacting pregnant and parenting teenagers
        about the availability of Medicaid/OHP for
        prenatal and well baby care programs.
   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 Medicaid provider and actively
           billing 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
               Direct Service Providers
   Reporting Medicaid Administrative Claiming Activities which are
    integral to or an extension of direct of consultative services:

        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
           Direct Service Providers
   Code C1 activities and D1 activities as before mentioned
    which are integral or related to consultation or direct
    treatment services provided for a child by a Direct Service
    Provider are considered such regardless of whether or not
    the education agency they work 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.
C1 - Referral, Coordination, Monitoring

   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 are not claimable under code C1
             (i.e., school psychologist, school counselor,
             teacher with a speech endorsement).
              Some Referrals are NOT
   Referrals made to staff licensed/credentialed through TSPC (only) for the
    purpose of a health evaluation 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 child’s 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 ESD’s not enrolled as a Medicaid provider or not actively
        participating in Medicaid billing.
      Kaiser Permanente
     Referrals to Claimable Medicaid
   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:
       ESDs;
       School Districts;
       Public Health Agencies;
       Hospitals;
       Mental Health Agencies; and
       Some Clinics and Private Practices
    C1 - Referral, Coordination, Monitoring

   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.
        C1 - Referral, Coordination, Monitoring

   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.
C1 - Referral, Coordination, Monitoring

   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
           Oregon Health Plan (OHP) outreach.
          The portion of a training where the content focuses
           on recognition of signs and symptoms of specific
           medical conditions.
    D1 – Transportation/Translation

   D1.1
        Scheduling and arranging transportation to OHP covered
             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
   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.
    E1   –     Program Planning, Policy Development &
                   Interagency Coordination

   E1.1
       Developing strategies and policies to assess or
        increase the capacity of school
        medical/dental/mental health programs (includes
            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.
E1      –       Program Planning, Policy Development &
                    Interagency Coordination

   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.
          Code F – Direct Services
   Providing Direct Services vs. Administrative
       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
                   CMS Action
   CMS-2287-F:
       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, placing a delay on the
        implementation of these changes.
 Children are one
   third of our
population and all
 of our future…

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