MEDICAID ADMINISTRATIVE CLAIMING2010-2011 Train-The-Trainers

Workshop

“MAC”

Oregon DHS Support

The Oregon Department of Human ServicesMedicaid Administrative Claiming

Division of Medical Assistance Programs

Linda WilliamsSBHS Medicaid Operations and Policy Analyst

(503) 945-6730

Lasa BaxterDHS Contracted SBHS Medicaid Specialist

(541) 975-5614

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 claims.

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 on a Fee-for-Service basis.

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)

State Government:Oregon Department of Human Services (DHS)

CMS 50%

DHS 50%

Connecting the Puzzle Pieces

Connecting the Puzzle Pieces

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 child’s 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 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 may include:

Administrators Principals Teachers Assistants Secretaries School Counselors (TSPC licensed)

DIRECT COVEREDMEDICAID/OHP SERVICES 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 COVEREDMEDICAID/OHP SERVICES 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

NOT Covered Direct Services

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

NOT CoveredServices 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 also NOT reimbursable under the Medicaid Administrative Claiming Program.

POINTS OF CLARIFICATION

Handouts Medicaid Provider Participation How to Report Activities Provided by Direct Service

Providers Referral, Coordination and Monitoring of

Medicaid-Covered Services – Code C1

Medicaid Provider Participation 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.

Helpful Resources 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/planlist/main.shtml

Local DHS Offices for Children, Adults and Families (CAF) http://www.oregon.gov/DHS/localoffices/localoffices.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-programs.shtml

Helpful Resources 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

Referrals to Claimable Medicaid Providers

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

Direct Service Providers Reporting Medicaid Administrative Claiming Activities which are integral to or an extension of

direct or consultative services are not claimable:

An Oregon Medical 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 Delegated Health Care Assistant (trained by an RN to perform delegated Nursing tasks) Occupational Therapist Certified Occupational Therapy Assistant Physical Therapist Licensed Physical Therapy Assistant Speech/Language Pathologist Licensed Psychologist Licensed Clinical Social Worker

Direct Service Providers 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, care coordination, or direct treatment services provided for a child by the 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.

IN-DISTRICT REFERRALS 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 child’s 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

Some Referrals are NOT Claimable

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 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 and ESD’s which are not enrolled as a Medicaid provider or not

actively participating in Medicaid billing and; Some private health plans

TSPC “ONLY” Licensed School Counselors

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.

(NOTE: If in doubt, always be conservative in recording claimable activities. Instead code them A or F.)

TSPC “Only” Licensed School Psychologists

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.

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.

TSPC “Only”Licensed School Psychologists

MAC CODING GUIDE MAC Claiming Coding Guide –

Provider Manual Version 3.0

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 Transportation/Translation E2 – Program Planning, Policy Development and

Interagency Coordination Related to Non-Medical Services

F – Direct Medical Services

Non-Claimable School Related & Educational Activities 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 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 Coordination

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) including Kaiser OHP State Children’s Health Insurance Program (SCHIP)

including Healthy Kids

B1 – Medicaid Outreach

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.

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 eligibility.

B1.4 Contacting pregnant and parenting teenagers about the

availability of Medicaid/OHP for prenatal and well baby care programs.

Recording Code C1 vs. E1 An easy way to keep code C1 & E1 straight when recording

MAC activities is to remember the following: C1 = Child specific E1 = Everyone Benefits

Medicaid Administrative activities that may be reported under code C1 involve work specific to a child and/or their families.

Whereas, Medicaid Administrative activities that may be reported under code E1 involve actions that benefit an entire population of children.

C1 - Referral, Coordination, MonitoringNote: C = Child 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.

C1 - Referral, Coordination, Monitoring

C1.1- Immunizations The free care provision serves to limit the ability of schools to bill Medicaid for

covered services provided to Medicaid-eligible children because schools that provide needed health services often provide them to all students free of charge. For example, state laws may require that immunizations be provided to all school children.

In such a case, administrative activities related to assisting a child to obtain such immunizations “in the school” would NOT be reimbursable as a Medicaid administrative cost (see pg. 21 CMS MAC 2003 guide). For example:

Activities performed in association with a free immunization clinic offered in the school

Administrative activities performed in association with the immunization exclusion requirements, such as:

Performing a primary review summary Mailing exclusion orders Completing a county immunization status report

See the following web-link regarding Oregon school immunization requirements in the Oregon Immunization Law Handbook: http://www.oregon.gov/DHS/ph/imm/school/

C1 - Referral, Coordination, Monitoring

C1.1- Immunizations continued:

However, making referrals for and/or scheduling appropriate immunizations outside the school setting and that are Not Free of charge and are billed to Medicaid, whether during exclusion or not are claimable under MAC code C1.1. (NOT to include the non-claimable examples noted in the previous slide or as identified in the Oregon Immunization Law Handbook. Examples of claimable referrals for immunizations include:

Referrals made for school-age children and/or their families outside the school setting that are not free of charge (ie: referral for immunizations to a an enrolled Medicaid provider.)

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. The following activities are NOT claimable: Activities performed in the initial development of the IEP and/or

formal IEP meeting itself (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, catheterization, g-tube feeding & blood sugar monitoring.

Monitoring of Physical Therapy or Occupational Therapy services provided by an educational assistant

C1 - Referral, Coordination, Monitoring

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.

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 OHP outreach. The portion of a training where the content focuses on recognition of

signs and symptoms of specific medical conditions. Training to recognize signs and symptoms of potential suicide risk Training to recognize the signs and symptoms of Autism Training to recognize the signs and symptoms of Drug and Alcohol abuse

NOTE: The following State Mandated trainings are not covered: Participating in a First Aid Training Participating in an EPI Training Attending a lecture on IDEA Reauthorization: How the changes will affect district

and health agencies in disciplining students with disabilities Bloodbourne Pathogens Training

D1 – Transportation/Translation

D1.1 Scheduling and arranging transportation to OHP covered services.

Arranging for or scheduling transportation services to a Medicaid covered service or treatment.

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. (See page 21 of CMS May 2003 Guide School Based Medicaid Administrative Claiming)

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 CoordinationNote: E = Everyone

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.

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. For example: Developing advisory or work groups of health professionals to provide

consultation, advice and monitoring of the delivery of health care services to the school populations.

Evaluating the need and/or effectiveness of medical services provided in the school setting (such as a school based health center)

Code F – Direct Services 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. (See page 27 of the CMS 2003 Medicaid School-Based Administrative Claiming guide.)

Claims Over 10% 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 does 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.

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