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Medicaid Administrative Claiming For Adults and

Children

Rethinking Cost Claiming Service Activities

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PresentersCharles WilliamsNC Department of Health and Human Services Social Service Program CoordinatorDivision of Aging and Adult Servicescharles.williams@dhhs.nc.gov

Evan FriedelN.C. Department of Health and Human ServicesDivision of Social Services/Child Welfare SectionChildren’s Program RepresentativeEvan.Friedel@dhhs.nc.gov

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Purpose of this Training• Introduce Medicaid Administrative

Claiming opportunities• Outline parameters for use of MAC• Provide examples of allowable

activities

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New opportunities

• More adults and children can receive services

• More than a replacement for ARCM• Allows other qualified staff to serve• Maybe the best thing since

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Overview• Under Title XIX of the Social Security

Act, section 1903(a)(7), federal payment is available at a rate of 50 percent for amounts expended by a state “as found necessary by the Secretary for the proper and efficient administration of the state plan,” per 42 Code of Federal Regulations (CFR) 433.15(b)(7).

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Overview• Medicaid Administrative Claiming (MAC)

activities must be “in some way connected with administering services covered under the state plan” (Medicaid State Plan Manual section 4302.2).

• Time billed to MAC must be directly related to medical assistance to Medicaid covered services under North Carolina’s Medicaid State Plan. (see Administrative Memo)

Administrative Memo Excerpt

Administrative Memo Excerpt

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Medicaid “admin” claiming identifies expenditures related to

activities• They include:

– Medicaid Outreach;– Medicaid Eligibility Determinations;– Referral to Medicaid Services;– Medicaid Case Planning, Review, and

Management;– Development of an Individual Plan of

Care for Medicaid Services; – Coordinating transportation needed to

access Medicaid services.

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What you need to know

Medicaid Administrative Claiming Basics

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MAC Basics for Workers• Allows

– Coordination of Medicaid services when an individual is receiving other services

– Activities have to be connected to accessing Medicaid services covered under Medicaid State Plan

– Claiming of travel and documentation time when it is connected to Medicaid services

MAC Basics for Workers (continued)

– Can be provided in any setting, including facilities*

– Only county staff or contracted worker(not an contracted agency) can bill for MAC activities

– Day sheets must be completed by DSS staff or contracted worker for ALL MAC codes

– There are no required CM credential or experience*

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MAC Basics for Fiscal Staff• FFP is Federal 50% County 50%• Uncapped federal funding• Activities recorded on day sheets and

reported on the DSS-1571 rather than NCTracks billing

• Claims are billed only on Part I of the fiscal note/SIS (No part II or Part IV)

• No cost settlement required• Only one cost center for both adult

and children

What’s the Point? (example)

• ADMINISTRATIVE TIME FOR COUNTY STAFF TO ASSIST INDIVIDUALS TO ACCESS MEDICAID SERVICES UNDER THE NC STATE MEDICAID PLAN!!! 15

“With great power, comes great responsibility!”

• Just about everybody who walks in your door can receive MAC activities (uncapped funds)

• It’s not how much can I bill, but what does my client need

• Got to have an agency plan (Internal)

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NC Medicaid Eligible Population Adults and Children who are Medicaid

beneficiaries who need assistance in accessing Medicaid services under the NC

Medicaid State Plan (including Health Choice) And/Or

Adults and Children who are served through Medicaid Outreach and/or require

assistance in completing a Medicaid application in order to access Medicaid

services

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4 Coding Categories(see MAC Desk Guide)

Categories of Activities

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Categories for Activity Coding1.Referral, Coordination and

Monitoring of Medicaid Services (SIS code 340)

2.Arranging Transportation Services for Client to Access Medicaid Services (SIS code 343)

3.Outreach for Medicaid Services (SIS code 342)

4.Facilitating an Application for the Medicaid Program (SIS code 341)

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Referral, Coordination and Monitoring of Medicaid Services (SIS code 340)• Referring and/or coordinating

Medicaid covered services for individuals that have:– functional impairments or mental

health disabilities, and/or – substance abuse/addiction disorders

• Performing assessments to identify health and mental health needs in advance of referrals or evaluations

• Care coordination of needed Medicaid covered medical, mental health or substance abuse services (1 of 3)

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Referral, Coordination and Monitoring of Medicaid Services (SIS Code 340)• Monitoring and evaluating the

Medicaid covered medical components of the individual’s service plan for effectiveness in addressing needs

• Preparing documentation for interdisciplinary planning meetings, case planning meetings, etc.

• Participating in treatment plan meetings

(2 of 3)

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Referral, Coordination and Monitoring of Medicaid Services (SIS Code 340)• Gathering information for facilitating

prior authorizations • In-home training of parents or family

to improve the coordination/delivery of Medicaid services

• Follow-up contact to ensure that an individual has received the prescribed Medicaid services

(3 of 3)

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Arranging Transportation Services for Client to Access Medicaid Services

(SIS Code 343)• Scheduling or arranging

transportation services that assist the individual or family to access necessary care or treatment by health/mental health care providers

• Includes activities such as related paperwork, clerical activities, or staff travel required to arrange transportation

(1 of 3)

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Arranging Transportation Services for Client to Access Medicaid Services

(SIS Code 343)• It does not include:

– provision of the actual transportation service as a direct service

– activities that contribute to the actual billing of transportation

– accompanying an individual to Medicaid services as an administrative activity

(2 of 3)

Staff Travel and Transportation Services for

Client to Access Medicaid Services

• See example (Staff Travel and Transportation)

(3 of 3)

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Outreach for Medicaid Services (SIS Code 342)

• Used when performing activities that inform individuals about:– available Medicaid services, – how to access Medicaid services, – the importance of accessing medical,

mental health, aging, functional/developmental disability, and alcohol and drug services and

– the importance of maintaining a routine place for health care

(1 of 4)

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Outreach for Medicaid Services

(SIS Code 342)• General activities include: – bringing persons into the Medicaid system

for the purpose of determining eligibility and

– arranging for the provision of Medicaid services.

• Includes all related paperwork, clerical activities, or staff travel required to perform these activities.

• Both written and oral methods may be used.

(2 of 4)

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Outreach for Medicaid Services (SIS Code 342)

• Specific activities include:– Developing, disseminating or presenting

materials to inform individuals about Medicaid services and where to obtain services

– Informing individuals and families about the benefits and availability of services provided by Medicaid

– Informing individuals and their families on effectively accessing, using, and maintaining participation in all health and mental health resources under the federal Medicaid Program

(3 of 4)

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Outreach for Medicaid Services

(SIS Code 342)• Assisting in early identification of

individuals who could benefit from the health/mental health services provided by Medicaid

• Assisting the Medicaid agency to fulfill objectives of the Medicaid program by:– Informing individuals of the benefits of

prevention – Helping individuals and families use

health/mental health resources• Assuring that health/mental health

problems are diagnosed and treated early (4 of 4)

Outreach for Medicaid ServicesMAC SIS Code 342 activties

(note, this is typically used for individuals/families that are not part of an open case)

• You create a brochure to explain where Medicaid services can be obtained in your county

• You work a booth at a health fair and talk to people in the community about the benefits they could receive from Medicaid

• You talk with a family about available Medicaid services and how it will help make them all healthier

• You coordinate the printing of informational packets about Medicaid services and where they can be obtained

NOT Outreach for Medicaid Services• You provide information on food stamps to a

family that is applying for Medicaid at your office (This is not MAC. Providing information on food stamps is not a Medicaid activity)

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Facilitating an Application for the Medicaid Program (SIS code 341)

• Used when: – assisting an individual or family to make

application for Medicaid or – assisting an individual to maintain

Medicaid eligibility• Includes all related paperwork, clerical

activities or staff travel required to perform these activities.

(1 of 2)

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Facilitating an Application for the Medicaid Program (SIS code 341)

• Includes: – Verifying an individual’s current

Medicaid eligibility status – Explaining Medicaid eligibility rules and

the Medicaid eligibility process – Assisting individuals or families to

complete a Medicaid eligibility application

– Assisting individuals or families to gather information and documents for the Medicaid application (2 of 2)

Facilitating an Application for the Medicaid Program

MAC SIS Code 341 activities• You write down a list of the Medicaid eligibility rules and explain each one to a family interested in Medicaid services

• You help a gentleman collect the various documents he needs to complete a Medicaid application

• You help a client renew his Medicaid coverage• You refer a woman to her local assistance office to

complete an application for Medicaid• You complete a disability determination application

in order for the individual to obtain Medicaid NOT Facilitating an Application for the Medicaid

Program• You help a client complete an application to work at

the local grocery store, so that he can have a job with health care coverage (This is not MAC. Completing a job application, or doing anything for private insurance is not a Medicaid activity.

• You can only bill that portion of time that is connected to accessing Medicaid services under the State Medicaid Plan

• If you make a visit or transport a client, your travel and documentation must reflect the percentage of Medicaid time that you billed

• This above is true for all MAC activities including assessment and service plans

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More on MAC for Adults

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Adult Wards of the DSS• The county department of social

services (DSS) can bill MAC activities for a beneficiary for whom the DSS has been appointed legal guardian and if the activities meet the requirements for MAC

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Adult Payees of the DSS• The county department of social

services (DSS) can bill MAC activities for a beneficiary for whom the DSS has been appointed the Payee if the beneficiary is Medicaid eligible and if the activities meet the requirements for MAC

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Special Assistance In Home (SA-IH)

• The county department of social services (DSS) can bill MAC activities in conjunction with case management for SA-IH participants

• You MUST document how these activities are assisting an individual in accessing Medicaid services

CAP (Community Alternatives

Program)26 A) Can CAP staff claim MAC activities while providing case management activities under a waiver service? (CAP case management time is still available).No. To avoid duplicate claiming, allowable administrative activities that are reimbursed through another program such as CAP cannot also be claimed under MAC. Staff members providing CAP services may be able to claim reimbursable administrative activities under MAC when the coordination of Medicaid services are not reimbursed under CAP or CAP case management time is no longer available.

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CAPExamples of activities that should be claimed as CAP (when available) include: Assessing Care Planning Referral and Linkage Monitoring and Follow-upCAP staffs often provide both direct services and administrative activities. The activities listed on the previous page are direct services/activities related to CAP. These services are integral to case management and would be considered duplication of payment if claimed under MAC when allowed under CAP or when CAP case management time is still available because activities are properly paid for as part CAP services and reimbursed at the federal medical assistance percentage (FMAP). 40

CAP 26 B) If activities provided to a waiver beneficiary is not billable to the waiver, can CAP staff bill their time to MAC? Yes. A few examples of activities (not a comprehensive list) that could be potentially claimable under MAC by a CAP staff: Completing the Service Request Form (SRF) Preparing documents and participating in discussion meetings

with supervisor and staff Documenting case management activities Outreach to Board Members/auxiliary about CAP (Advisory

meeting attendance) Outreach to community about CAP services, how to apply,

eligibility criteria, referral In-home training to families to improve coordination/delivery

of Medicaid services (CAP does not provide training to families, just coordinate the referral, link and monitor)

Staff travel to arrange transportation 41

CAP  

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26 C) If the allotted case management time has been exhausted for billable waiver case management activities, could MAC be used once a CAP beneficiary has exhausted all of their CAP funds? Yes. MAC activities can be selected only after time has been exhausted under CAP. The case management agency must have supporting documentation that proves case management time was exhausted as a result of efficient resourcing. Assisting a CAP beneficiary to access a Medicaid service to remain safely in their community could be claimed as MAC activities given that documentation supports exhaustion of case management time and the need for the participant to have access to a Medicaid service.

CAP/DA Waiver Services Adult day health Personal care aide Home accessibility and adaptation Meal preparation and delivery Institutional respite services Non-institutional respite services Personal Emergency Response Services Specialized medical equipment and supplies Participant goods and services Community transition services Training, education and consultative services Assistive technology Case management Care advisor (CAP/Choice only) Personal assistant (CAP/Choice only) Financial management services (CAP/Choice only) An annual calendar allotment of case management is set at 42hours/168units from January1st -December 31st.

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CAP52. Can any other worker, such as APS, Guardianship, Payee, SAIH, etc., bill allowable MAC activities for a client that is a current CAP beneficiary, since they are not the CAP worker? Yes. Multiple workers can bill time to MAC for working with a CAP beneficiary when APS, Guardianship, and Special Assistance is provided.

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More on MAC for Children

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Child Welfare• In Child Welfare, the identified federal

and state benchmarks associated with CFSR’s are Safety, Permanence and Well Being for children

• MAC coding can be used for time spent on activities to meet health and mental health well being needs of children open for CWS who are Medicaid beneficiaries.

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Child Welfare• MAC cannot be used for any activities

focused solely on Safety and Permanency. Other funding sources must be used for those activities.

• MAC can also be used for In Home cases in which children are not at serious risk of foster care placement, but health and behavioral health needs exist that if appropriately addressed, could prevent future maltreatment.

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Child Welfare• Agencies may also want to consider this

claiming for activities involving prevention.

• MAC can be used for “third track” situations in which a CPS report is received and not accepted for assessment, but there are needs identified that could be addressed to prevent future reports or assist the family to overcome a health/behavioral health crisis

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Applying MAC Activities in Case Work

Are you ready to do the

MAC-arena?!

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Adult and Children Case StudiesIn this corner…….

Adult workers Children workers

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So, Now What?(MAC Activities Flow chart)

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DSS-5027 for MAC codes 340 & 343

• Document the beneficiary’s request on the 5027

• Open/update a service information record• A signature is not required when an

individual is opened on the DSS-5027 for MAC

• If MAC and another service are opened on the DSS-5027 a signature is not required for MAC but would be for the other service

• If MAC is added to a DSS-5027 where there is already an existing service opened, a signature is not required for MAC

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Medicaid Administrative Claiming that DOES NOT require a 5027• Medicaid Outreach (SIS code 342) • Facilitating an Application for the

Medicaid Program (SIS code 341)

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Assess the Client’s Environment

and Functional Status • Assess needs for medical, educational, social or other services

• Determine the need for accessing Medicaid services under the State Plan

• For Adult Services, use the Adult Services Functional Assessment(DSS-6220)

• Children’s Services will complete the Strengths and Needs Assessment DSS-5229 and the DSS-5010

Claiming MAC Reimbursement for the Assessment (carving

out) • Only those items

related to accessing Medicaid services can be billed as a MAC activity

• Conduct the entire assessment and then make a determination of how much time is related to accessing Medicaid Services

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Service Plan DSS-6221 for Adult ServicesService Plan should include:• The service needs identified during the

assessment• Strategies for locating and referring the

recipient to programs and providers that will meet the recipient needs

• Goals for the outcome of case management

• The service needs, strategies, goals and dates must be supported by the assessment information

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Service Plan DSS-5239 or 5240 for Child WelfareService Plan should include:• Specific health and or behavioral

health needs of the child identified during the assessments

• Strategies for locating and referring the child to programs and providers that will meet the child’s needs

• Name(s) of the person(s) responsible for accomplishing these activities

Claiming MAC Reimbursement for Service Plan Goals (carving

out)• Regardless of whether

a goal can be billed to MAC, all identified needs should be addressed!!

• Goals that can be billed to MAC are those that assist in accessing Medicaid Services under the NC Medicaid State Plan

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MAC Activities during the CPS Assessment

• The child’s specific needs must be identified and documented through the SDM tools

• Documentation must include identifying strategies and activities to address the health and behavioral health needs

• A description of the activities

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Monitoring/Follow up by the Worker

The expectation is that adult and child services will follow their normal procedures for case planning including monitoring and follow up. These will be discussed in the breakout groups

(adult and child services do not use the same forms)

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Find your Groups Again

Adults NARRATIVES Children DOCUMENTATION

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Day Sheet (DSS-4263)• All social workers must follow the

documentation guidelines, and correctly fill out the day sheet to ensure that activities are being properly documented

(Day sheet training guide)

Documentation

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DON’T mix notes!!!

Your notes should clearly define which activities are MAC and which activities should be billed to another code (examples)

Documentation (continued)

A mixed noteI took Jeff to the doctor to have a check up and have his medicines refilled. Afterwards I took Jeff to visit his sister since he has been alone a lot and he needs to get out more. When we got back to Jeff’s house, I went over the instructions that the doctor had given him. MAC code 340 – 120 minutes

A good noteI took Jeff to the doctor to have a check up and have his medicine refilled. I discussed with Jeff the instructions that the doctor had given him MAC code 340 – 90 minutesI took Jeff to visit with his sister since he has been alone a lot and needs to get out more. Code 330 – 30 minutes 64

PayBack (Disallowed cost)

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• You bill 340 and/or 343 and the individual is not Medicaid

• You bill 340 and/or 343 and the individual is not opened on the DSS-5027

• You bill any MAC code for an activity that is not allowed

• You bill any MAC code and there is no documentation

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Monitoring• MAC activities will be monitored

periodically according to the DHHS Monitoring Plan

How often will we be monitored for MAC?

Adult servicesEvery Four years(25 counties per year)

Adult services follow the SSBG schedule of monitoring

Children servicesEvery Three years (about 33 counties per year)

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MAC Sample Size Kelly Ripa and Shaquille O'Neal

• Level III Counties 5 claims each SIS code (20)

• Level II Counties4 claims each SIS code (16)

• Level I Counties 3 claims each SIS code (12)

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The Monitoring Tool

• Day Sheet Entries/Claims, NOT Records/Cases

Frequently Asked Questions

You got questions…..We got answers (we hope)

https://dma.ncdhhs.gov/document/medicaid-administrative-claiming-mac-adults-and-children

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What have we learned today? Test your Knowledge

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QUESTIONS?

CertificatesHomeworkClass evals

Case Study answersFrequently Asked Questions

(FAQs) see handout

WRAP UP

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Who You Gonna Contact?

Charles Williams - charles.williams@dhhs.nc.gov

Evan Friedel – evan.Friedel@dhhs.nc.govAdult Program Representatives -

http://www.ncdhhs.gov/aging/adultsvcs/aprlist.htmChildren Program Representatives -http://www.ncdhhs.gov/dss/team/CPRList.htmlChildren Services website - https://nccwta.org

Medicaid Administrative Claiming for Adults and

Children• Last modified on:

December 08, 2015