MEDICAID ADMINISTRATIVE CLAIMING REFRESHER Training for LHDs (rev 3/27/06)

1. MEDICAID ADMINISTRATIVE CLAIMINGREFRESHERTraining for LHDs(rev 3/27/06)

2. Status of Medicaid Administrative Claiming in Oregon (2/06) • Currently 22 counties participating. • About half of LHDs are claiming in range of 25-40%. Most of the rest are 10-24%

3. Cost Pool Issues • Appropriate staff for inclusion in cost pool: • Those with routine contact with children and families: community health workers, interpreters, eligibility specialists, health educators / promotoras, nurses • Those who directly supervise nurses, NPs, other direct care providers • Department administrators IF they frequently work on strategic planning around service-delivery issues and policies • Do not include staff that are mostly or totally federally funded

4. Cost Pool Issues • LHDs are responsible for maintaining quarterly documentation showing how federal funds are removed from the salary, benefits and OPE of each member of the cost pool. • There is no single, preferred method for accomplishing this. What’s important: a way to clearly trace “cost pool $” to non-fed sources.

5. Cost Pool Issues: Pre-Quarter At least one week prior to start of a new quarter, you must send to MESD—in electronic form—all cost pool data for that quarter; for each member: • Name • ID number • Title • FTE DO NOT FAX THIS INFO! To be faxed: Sign-in sheet for cost pool members newly trained or re-trained.

6. Training Requirements • Trainers must receive DHS training at least once a year • All staff who are to be surveyed must be trained prior to taking the survey • All staff in cost pool must be trained face to face by LHD’s designated Trainer at a minimum of once per year • Staff must sign in at training (see sign-in sheet on next slide) • Trainers ensure adequate time for training and are the first line for technical assistance for staff

8. Q: When should an LHD send multiple staff to a DHS training? If there is a good chance that the LHD’s designated Trainer will be unable to carry out training duties within the next 9-12 months, the LHD should have another member of the cost pool also attend a DHS training, in case that person may need to be designated as the new Trainer.

9. Post-Quarter Cost Pool Issues Within 30 days after the end of a quarter, respective salary and benefits for each member of the cost pool who participated in that quarter’s survey (actual salary and benefits) must be sent to MESD on an electronic spreadsheet, to include: • Name • ID number • Title • FTE DO NOT FAX THIS INFO!

10. The Time StudyPercent of Allowable Time • Strategy of random moment sampling using time study done quarterly • Random day selection • 4 days selected by DHS using random number table • Individual staff surveyed on all of the 4 days • All 4 days are used by each LHD • All public health staff in cost pool are surveyed

11. Q: Why do survey dates seem to come in clusters? It’s hard for LHDs to monitor surveys when they are only a few days apart. Survey dates are selected at random by DHS using a method that selects the dates one at a time from all days in a year, screening out only those that are on weekends or government holidays. If a date were to be rejected according to any other criteria (e.g. it’s too close to another survey date), it would not be a random date.

12. Ten Activity Codes • A1. Outreach and application assistance for Medicaid/OHP Program • A2. Outreach and Application assistance for non- Medicaid/OHP Outreach • B1. Referral, Coordination, Monitoring and Training of Medicaid services • B2. Referral, Coordination, Monitoring and Training of Non-Medicaid Services • C1. Medicaid/OHP Transportation and Translation • C2. Non-Medicaid/OHP Transportation and Translation • D1. System Coordination related to OHP services. • D2. System Coordination related to Non-OHP services. • E. Direct Health Care Services. • F. Other work activities

13. Code A1: Outreach and Application Assistance for OHP Program • This code should be used for: • Informing individuals on how to access, use and maintain OHP • Assisting in early identification of individuals who could benefit from OHP health services • Explaining OHP eligibility rules and process • Assisting individuals to complete OHP application including translation and comprehension activities

14. Documentation for Positive MAC codes A1: Outreach and Application Assistance for the Medicaid Program • A1.1 Conducted individual or group session to inform potentially Medicaid eligible individuals about the benefits and availability of services provided by the Medicaid program. • A1.2 Informed a person on how to effectively access, use, and maintain participation in Medicaid/OHP-covered health care resources . (Includes describing the range of services, and distributing OHP literature) A1.3 Created and/or disseminated materials to inform individuals or families about Medicaid • A1.4 Assisted a person on how to access, apply for and/or complete the Medicaid/OHP application (includes transportation and translation related to the application and gathering appropriate information) A1.5 Checked a person’s OHP status • A1.6 Contacted a pregnant woman or parent about the availability of Medicaid/OHP for prenatal and well baby care programs • A1.7 Staff travel or paperwork related to outreach and application assistance for the Medicaid program.

15. Q: My front-office person claimed most of her day as positive “A”-type activities. What explanatory notes should I enter into her file for that survey? You should note: • How many total clients she dealt with for the positive activities • Which other employees in your cost pool were ensuring that other front-office functions were being covered (their surveys should reflect this) • Other circumstances that help to explain why demand for outreach and application assistance was unusually high that day

16. Code B-1: Referral, Coordination, Monitoring and Training of Medicaid Services • This code should be used for: • Case planning activities for OHP covered services (not TCM/MCM) • Monitoring the delivery of the OHP covered services • Making referrals for and/or coordinating medical, mental, dental health or substance abuse services covered by Medicaid/OHP • Agency staffing and consultation on health and developmental issues • Gathering background information that may be required in advance of referrals

17. Documentation for Positive MAC codes B1: Referral, Coordination, Monitoring and Training of Medicaid Services • B1.1 Referred a person for medical, mental health, dental health and substance abuse evaluations and services covered by Medicaid/OHP. (Includes gathering information in advance of referrals) • B1.2 Coordinated the delivery of medical health, mental health, dental health and substance abuse services covered by Medicaid/OHP. (Includes participation in multidisciplinary team meetings, conferencing on health, developmental issues, consultations, and preparing or presenting materials for case review) • B1.3 Monitored the delivery of medical (Medicaid/OHP) covered services. • B1.4 Participated in, coordinated or conducted a training on Medicaid Administrative Claiming. • B1.5 Staff travel or paperwork related to Referral, Coordination, Monitoring and Training of Medicaid Services.

18. Code B-2: Referral, Coordination, Monitoring and Training of Non-Medicaid Services • This code should be used if not TCM/MCM for: • Case planning for non-Medicaid/OHP services • Coordinating and monitoring educational, vocational, and social services of family plan • General health, weight loss • Training on these type programs • Referral to WIC, food banks, TANF, energy assistance

19. Difference between B1.5: “Paperwork related to referral, coordination, monitoring and training of Medicaid services” and all other positive “B” codes: Usually, paperwork is directly supporting a “B” activity: • Writing down an appointment and/or entering it into a schedule is intrinsic to referring a client to a specific service: code it “B1.1: Referred a person…” • Preparing a presentation for a meeting with an MDT, or taking notes from (1) an MDT meeting or (2) a meeting with a nurse that is under your supervision re her case load: code it “B1.2: Coordinated the delivery of…” • Entering the results of a followup call in the file of a patient that has been treated by someone else (i.e. the service provider): code it “B1:3 Monitored the delivery…”

20. Difference between B1.5: “Paperwork related to referral, coordination, monitoring and training of Medicaid services” and all other positive “B” codes: • Taking notes during a MAC training provided by the LHD MAC coordinator: code it “B1.4: Participated in…a training on MAC.” • Rule of thumb: “B1.5” should be used rarely, for activities that don’t quite qualify as directly supportive of the ones noted above, yet still related. Example: writing a required report on one or more of these activities.

21. Q1: If flow staff take blood pressure, measure height and weight, and assist with lab work, is it considered direct service?Q2: If clerical staff enter this information into a patient’s record, is it also direct service? A: All these activities are considered part of the medical assessment and evaluation of clients and as such are classified as “E”, “Direct Health Care Services.”

22. C-1: Medicaid/OHP Transportation and Translation • This code should be used for: • Scheduling, arranging or providing transportation to Medicaid/OHP covered service • Arranging for or providing translation services that assist the individual to access and understand necessary care and treatment

23. Documentation for Positive MAC codes C1: Medicaid/OHP Transportation and Translation • C1.1 Scheduled, arranged or provided transportation to OHP covered services (not as part of the direct services billing for transportation) • C1.2 Scheduled, arranged or provided translation for OHP covered services (translation for access to or understanding necessary care and treatment) • C1.3 Staff travel or paperwork related to Medicaid/OHP transportation and translation

24. Code D-1: System Coordination Related to OHP Services • This code should be used for: • Working internally and with other agencies to improve OHP services • Identifying gaps, duplications, overlaps of medical services • Developing strategies to access or increase the capacity of medical, developmental, dental, mental health programs • Interagency coordination to improve delivery of OHP services

25. Documentation for Positive MAC codes D1: System Coordination Related to Medicaid Services • D1.1Developed strategies and policies to assess or increase the capacity, access and utilization of community medical/dental/mental health programs (Includes workgroups) • D1.2 Worked internally or with other agencies and/or providers to improve the coordination and collaboration and delivery of medical, mental health and substance abuse services. • D1.3 Staff travel or paperwork related to System Coordination for Medicaid Services

26. Q: The Department Administrator has entered a significant amount of time as “D1” for meetings that he attended. Since no one else in the cost pool went to these meetings, is there still a need for the LHD Coordinator to have documentation on those meetings? A: Yes. As LHD Coordinator, you are responsible for having documentation that will back up significant claims under the “D” code. Make sure that the Administrator is aware of your need for: • a written agenda for the mtg clearly outlining Medicaid-related topics • notes kept of the mtg that record the time spent on these topics • Evidence of action(s) taken / decision(s) made as a result of mtg

27. Code D2: System Coordination Related to Non-OHP Services • This code should be used for: • working collaboratively with other agencies to identify gaps, overlaps or duplication of non-medical/health services, such as vocational, social or educational services • improving coordination and expanding access or delivery of non-Medicaid/OHP services • developing strategies to assess or increase the capacity of non-medical, dental and mental health programs

28. Code E: Direct Medical Services • This code should be used for: • Targeted Case Management or Maternity Case Management Services • providing direct health/dental/mental health care services • conducting health/dental/mental health assessments/evaluations and diagnostic testing • administering first aid or prescribed injection or medication to an individual

29. Code F: Other Work Activities • This code should be used for: • All other job related activities that do not fall under one of the above categories • Paid time off; vacation leave, sick leave; or any other paid time away from work

30. Using Code B1 versus Code E • Administering first aid, or administering an insulin injection – who does it, and then who “monitors” it--is the question to ask • Providing direct mental health treatment following DSM IV protocols – Code E • Coordinating with a community-based mental health provider for monitoring follow-up of the provider’s services – Code B1

31. Survey Documentation Protocols • In most cases, it is not necessary for staff to provide a written narrative account of an activity; documentation is in the form of a numeric system that associates an activity narrative with a number. • MESD web survey system has the method for documenting built in to the survey • Exceptions: • When an employee claims 50%+ of time worked as MAC, the Coordinator should note the reason for this and keep in a file. • When employees attend meetings or trainings lasting for several hours, a record of the session should be on file.

32. Coding Details and Guidelines • Code only paid time and actual work hours • Paid leave including absences, vacation, etc. are Code F (supervisor may need to complete survey) • Blank increments on survey are only used for unpaid time—otherwise will default to Code F: other • Part-time employees survey only paid time worked on the day of survey

33. Activities to be completed each quarter

34. Activities to be completed each quarter

35. Activities to be completed each quarter

36. Activities to be completed each quarter

37. Activities to be completed each quarter

38. THIS IS YOUR INVOICE PRO FORMA, NOT A BILL FOR YOU TO PAY! 3. Assign it a number for your own tracking purposes. This is the amount of your claim for the qtr. By sending this signed invoice, you are asking DHS to pay you this amount. 4. Fax it to this number. 1. Make sure all information on the form is correct. This is the match that you will pay AFTER you have received an OMAP invoice, which will come with the claim check from DHS. You will also receive a bill for this IGA charge AFTER you have been paid your claim. 2. If correct, have it signed. DO NOT PAY ANYTHING UNTILYOU’VE RECEIVED AN INVOICE FROM DHS! 5. Fax cc to these numbers.

39. Activities to be completed each quarter

40. 1. The approved methods for calculating Medicaid eligible percentage include which of the following? Method #1: Use an MIS system to generate an unduplicated list of all clients seen during the quarter, and their Medicaid status. Method #2: Take the unduplicated number of Medicaid clients who are served by each program which has staff in the cost pool and divide it by the total number of clients in those same programs. Method #3: Take the unduplicated number of Medicaid clients seen on survey days and divide it by the total unduplicated number of all clients seen on those days. MAC Quiz • Methods 1 and 2 • Method 3 only • Any of Methods 1-3 Correct answer: (c)

41. 2. True or False: The list of cost pool members for a new quarter can be submitted after the quarter has started, as long as it is done prior to the first survey of that quarter. False. The list must be submitted at least one week before the start of the quarter.

42. 3. A nurse conducts a pregnancy test,then does a home visit depending on the outcome of the test. Which activity is MAC claimable? A: Both activities are MAC claimable.B: Conducting the pregnancy test is not, but the home visit is.C: Neither activity is MAC claimable. Answer: C. Both are coded “E,” Direct Service, regardless of the outcome.

43. True or False: Jane Doe takes a break for 10 minutes in the middle of activities that are MAC claimable. Because she didn’t use the whole 15-minute period as a break, she can claim that period as MAC time. False. The code for any 15-minute increment must be the one that reflects the activity that is predominant during that 15-minute increment.

44. Q: Is attendance at an MDT meeting coded “B” or “D”? A: MDT meetings aim to coordinate services around a specific client or clients, and so attendance at such a meeting will normally be coded “B1.2: Coordinated the delivery of medical/mental/dental health and substance abuse issues covered by OHP.” 6. Q: Will I need to keep agenda and/or notes as evidence of attendance at an MDT meeting? A: Unless the meeting lasts for an unusually long time, there is no need to maintain extra documentation for meetings re specific clients/cases.

45. Health Services MAC Coordinator • Dave Anderson david.v.anderson@state.or.us 971-673-0334

46. QUESTIONS