2011-2012 Train-The-Trainers Annual workshop Host Site: Multnomah ESD August 9, 2011
This presentation was provided by: Oregon Health Authority 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 Operations (541) 975-5614
2011-2012 Power Point Presentation • Medicaid in Schools • Participation of Charter Schools in MAC • Cost Pool Development • MAC Audit Requirements • MAC & Oregon Healthy Kids • Immunizations • Monitoring • Referral Resources • 10% Audit Support Document • Approved Medicaid OHP Services • School-Based Medicaid/OHP MAC Claiming Coding Guide
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 the primary payer for reimbursement of health-related services provided under IDEA. CMS 2003 Administrative Claiming Guide
Medicaid Administrative Claiming (MAC) • MAC is a Medicaid reimbursement program which allows school districts to be reimbursed for some of the costs associated with providing administrative activities that directly support the provision of medical services covered under the state Medicaid plan. • Federal/State partnership • Kindergarten -21 • Including but not limited to children in special education • Outreach – Assistance with Medicaid eligibility determination • Referral, Coordination and Monitoring of health services • Interagency Coordination
Participation of Charter Schools in MAC • Charter Schools may participate in the MAC program under an ESD that holds a MAC agreement with OHA. • A charter school will be considered a separate school participating under the MAC contract between the associated ESD and the Oregon Health Authority when a charter school: • has its own institutionalized number approved by ODE; • is responsible as a separate school from its sponsored school district to conduct an annual audit and reports findings annually to ODE; • has applied for and has been granted status as a 501 c3 non-profit organization; • possesses its own federal tax id number; • and hires and employs its own employees (As per Barbara Gates, ODE)
Participation of Charter Schools in MAC • Please consider the following internal processes need to be address if a charter school participates under your ESD. • A MAC sub-agreement with the charter school must be obtained in order to participate. • If this is an additional sub-agreement, estimate additional MAC revenue and ensure this will not exceed the cap established in the ESDs MAC agreement with OHA • The charter school will report to the associated ESD their own cost pool, conduct a random survey assigned to them quarterly, and have their own component claim as part of the compiled total MAC claim. • The charter school may desire to have its own MAC site coordinator and trainer to provide trainings, follow-up on the survey process, notify staff of survey days, report supporting documentation, etc.
Cost Pool Development • Of critical importance is the development of an accurate cost pool. Cost pool is defined as the actual (not estimated) total salary and benefits (including OPE) paid for staff that are eligible to participate in the MAC survey. • Staff supported entirely by federal funds, may NOT be included in the cost pool or survey. Staff partially paid through federal funds may be included in the cost pool as long as only the non-federal fund portion of employee cost is reported. However, the employee must report their entire paid work time in the survey.
Cost Pool Development STEP ONE: • IDENTIFY APPROPRIATE STAFF • Include either certified or classified staff who routinely have contact with students and/or families creating opportunities to provide Medicaid outreach and related activities as outlined in the MAC coding guide or who have direct supervision of employees who do. • Exclude maintenance and food services staff, bus drivers, and volunteers (non-paid staff). These groups have limited contact with students to provide MAC services or are not paid employees. • Staff must participate under the District or ESD they are paid by and on the corresponding survey date assigned to that agency.
Cost Pool Development STEP TWO: • IDENTIFY ACTUAL SALARY AND BENEFITS PAID • After identifying appropriate staff for the cost pool, report the actual salary, benefits and Other Personnel Expenses (OPE) paid for each individual for the survey period, removing all federal funds. • (For a definition of OPE reference OMB circular A-87)
Cost Pool Development STEP THREE: • REMOVE FEDERAL FUNDS FROM COST POOL • Only general fund and other fund sources may make up the cost pool calculations. Any federal funds applied to the salary, benefits and OPE package of an individual employee must be removed on a FTE person-by-person basis. • Federal funds the ESD/district expends may include IDEA, ARRA, Title I, federal grants, etc. These funds must be removed from the cost pool to comply with federal regulations. Federal funds expended for services and supplies (S & S) costs, indirect or other non-personnel (non-salary and benefits) costs may not be included in the cost pool. NOTE: • Documentation must be maintained detailing how the federal funds applicable to salary, benefits and OPE have been removed from the cost pool.
Pruning the Cost Pool • The ESD/district will want to set up a process to evaluate the cost pool on a systematic basis, assessing classifications and individuals as to their impact on the claim. • Pruning the cost pool is an acceptable practice in order to present a more effective claim and reduce administrative burdens.
Methods for Pruning the Cost Pool • Methods for Pruning • Remove any staff, who over the course of a determined period, have never reported a claimable MAC activity. • Blindly survey staff utilizing scenarios for providing MAC activities to determine whether staff may potentially engage in MAC activities over the course of time. • Remove staff employed for .02 FTE or less, as they may have limited contact with students and/or their families to provide MAC activities.
Maintain all supporting documentation for the MAC claim for a period of seven years. • ESD (under MAC Agreement w/OHA) • District (MAC Coordinator) • Business Office (All supporting financial documents) • Provide contact information and be available to OHA for review of MAC claims.
Trainers must attend a MAC train-the-trainers workshop annually. • Trainers must schedule and provide training to staff which covers all aspects of the reporting process. • Training must occur no less than once annually • Prior to the survey day • Staff must sign the training sign in sheet • Records training date • Provides access into the MESD web based system
Complete a review of the survey results and obtain necessary supporting documentation from staff. • 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 and to limit the risk of audit findings.
Training should provide staff with: • copies of training materials , a referral list, and documentation forms • a description of the survey process • three survey periods Fall, Winter, Spring • random survey day • selection of survey participants (random or 100%) • an understanding of what is claimable as an administrative activity in the school setting • an understanding of the activity codes and how to report them in the MESD web based reporting system • an understanding of when and how to complete the 10% documentation form • access to technical assistance
Individualsurveys reporting more than 10% of recorded FTE require additional documentation • Request staff complete a MAC Support form for each claimable time frame and activity code recorded. The documentation should: • be recorded soon after completing the survey (no less than 5 business days); • be brief and concise; • use descriptive words (best practice is to use the key words from the activity guide such as referred, coordinated, monitored, etc.); • only provide information pertinent to the claimable activity performed; and • do not identify the individual student or family by name. • Review the MAC Support form to ensure documentation is for allowable MAC activities • Submit MAC Support form to your district’s MAC Coordinator
Coding Accuracy Reminders for Staff • Over/Under Reporting of Time • Do not report claimable time only • Do not report more time than paid for • Using Correct Login (name on paycheck) • Saving the Survey • Reporting unpaid lunch • time frame should be left blank on survey • Reporting Paid Absences • code A
Administrative Service Providers • Administrators • Principals • Teachers • Assistants • Instructional • Secretaries • Counselors • Psychologists • Limited participation Claimable Categories • B1 – Medicaid/OHP Outreach and Facilitating Medicaid/OHP Eligibility • C1 – Referral, Coordination, Monitoring and Training of Medicaid OHP Services • D1 – Medicaid/OHP Transportation and Translation • E1 Program Planning, Policy Development, and Interagency Coordination related to Medical Services
Oregon Licensed Health Care Professionals • Speech Language Therapist • Occupational Therapist • Certified Occupational Therapist Assistant (COTA) • Physical Therapist • Licensed Physical Therapy Assistant (LPTA) • Nurse • Delegated Health Care Aide • Clinical Psychologist • Licensed Clinical Social Worker Claimable Categories • B1 – Medicaid/OHP Outreach and Facilitating Medicaid/OHP Eligibility • C1.4 - Training • E1 - Program Planning, Policy Development, and Interagency Coordination related to Medical Services
Oregon Board Licensed Health Professionals • Licensed Health Care Professionals employed by school districts or ESD’s cannotclaim C1 and D1 activities that are considered integral to, or an extension of, direct or consultative medical services. • C1.1 – Referral • C1.2 – Coordination • C1.3 – Monitoring • D1.1 – Transportation • D1.2 – Translation • This applies regardless as to whether or not the district is an enrolled Medicaid provider accessing reimbursement.
If the school psychologist makes a referral to a community Medicaid provider for a student who he/she does not provide direct service to, the referral and coordination would be claimable under C1. • TSPC Licensed Psychologist • 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 student in which they provide direct “health” services are considered integral to or an extension of a direct service and are NOT claimable. The service would be reported on the survey as Code F – Direct Service.
These monitoring activities are considered Direct Medical Services and may not be reported under code C1.3. • Delegated Health Care Aide – Educational Assistant • An educational /instructional assistant providing delegated nursing tasks under the supervision of a Nurse pursuant to the services identified on an IEP are “Direct MedicalServices”. Such activities must be reported as “F” on the survey.
Activity vs. Outcome • It is important staff report the claimable MAC activity performed on the survey date even when the outcome may be unknown. • Claimable example: • A school counselor reports C1.1 on their MAC survey, when on the MAC survey day they refer a child for a mental health evaluation to the local county mental health department. The staff at this time may not know the outcome of the referral, which is acceptable and does not change the reporting the Medicaid-covered referral activity.
Points of Clarification • Claimable vs. Non-Claimable Immunizations • Code C1.3: • Physical Monitoring of Direct Services vs. Follow-up to ensure Direct Services were provided
Immunizations • Claimable referrals for Immunizations: (C1.1) • Referrals to assist families in accessing immunizations from enrolled Medicaid providers are claimable as C1.1 as long as they are: • Not Free of Charge (Billed to Medicaid) • Provided outside the school setting • Claimable scenarios may include: • An office secretary, at the request of a parent, referred a student in need of immunizations to the local County Health Department for covered immunizations.
Immunizations • Non-Claimable referrals for Immunizations: (C2) • Activities performed in association with a free immunization clinic offered in school or other settings • 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 • Non-Claimable scenarios may include: • As mandated by state law, a secretary generates a county immunization status report during exclusion. • An office secretary refers a child for immunizations to a free immunization clinic offered in the community.
C1.3 Monitoring & Follow-up Activities • Use of code C1.3 is used for reporting claimable monitoring or follow-up activities, which includes providing follow-up contact to ensure that a child has received prescribed medical/dental/mental health services covered by Medicaid or that they were arranged/coordinated as planned. • NOTE: • Physical monitoring of a child’s health condition regardless of the severity or type is not a claimable C1.3 monitoring activity.
C1.3 Monitoring & Follow-up Activities • Claimable scenarios may include: • A classroom teacher who works closely with a student receiving Medicaid-covered services on an IEP is involved in a team conference or meets individually with a therapist to evaluate the medical component(s) of an IEP (this excludes the actual IEP meeting). • 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.
Non-Claimable Monitoring & Follow-up Activities • Non-Claimable Monitoring or Follow-up Activities: (F) • Monitoring minor acute health conditions, such as scratches, bruises, headaches, colds, application of Band-Aids or administration of non-prescriptive medications • Monitoring required by Delegation from a Registered Nurse, such as seizure, catheterization, g-tube feeding & blood sugar monitoring. • Monitoring of a diagnosed health condition (regardless of the severity or type of health condition) • Activities performed in the initial development of the IEP and/or formal IEP meetings (i.e., annual, 3-yr)
Non-Claimable Monitoring & Follow-up Activities • Non-Claimable scenarios may include: • An educational/instructional assistant trained by and under the supervision of a registered nurse monitors a student’s seizures as outlined in the Nursing plan of care pursuant to the IEP. • An office secretary monitors a student in the office or a sick room who has been complaining of a headache and/or nausea. • A classroom teacher monitoring a child for adverse reactions after an insulin injection was self-administered by the child. • A secretary monitoring a child with a bee allergy for adverse reactions to a bee sting.
MAC & Oregon Healthy Kids • Participation in MAC & Oregon Healthy Kids Application Assistor • Currently, In Oregon all Healthy Kids contracted ESDs are considered “Volunteer Organizations”, meaning they process Healthy Kids applications for free and are not paid the $75 assistor fee for applications that result in eligibility. • This was accomplished to avoid any duplication in payment for outreach activities provided by ESDs who participate in the MAC program. This action was not intended to exclude ESDs from participating as Healthy Kids application assistors.
Medicaid outreach activities are those performed to inform eligible or potentially eligible individuals about Medicaid and how to access the Medicaid program. • Healthy Kids • A State sponsored program providing all of Oregon’s uninsured children under the age of 19 access to no cost or affordable, comprehensive, health insurance coverage.
Healthy Kids covers all of the health care kids need including: • Medical, dental and vision care • Regular checkups and preventive care • Prescription medicines and medical equipment • Mental health and chemical dependency services Coverage lasts for a least one full year.
Three key qualifiers for no-cost or low-cost coverage 1.) Age • Must be under the age of 19 (19th birthday) 2.) Residency • Must live in Oregon and be a legal resident 3.) Income • Must have been without health insurance for two months (exceptions: parent’s job loss or a child’s serious medical need). • For free or low-cost coverage, household income cannot be more than 300% of federal poverty level ($67,200.00 for a family of four).
A family of 4 that makes $44,900 or less annually may qualify for no cost coverage. = $0.00 Monthly Premium • A family of four that earns between $44,900 to $67,200 a year may qualify for a low-cost option. This is determined on a sliding scale. On average, low cost coverage for a family of four = $50.00 Monthly Premium
Healthy Kids • http://www.oregonhealthykids.gov/index.html • General Information • On-Line Application
Medicaid Provider – Referral List • OHA will be providing a quarterly Medicaid provider list via the MESD MAC web-site by county.
Referrals made for Medicaid covered health services provided by Licensed Health Care Professionals who work for enrolled Medicaid providers and who are billing Medicaid are claimable. These include, but are not limited to: • Some ESD’s • Some School Districts • Public Health Agencies • Hospitals • Mental Health Agencies • Medical Clinics • Private Practices
As per the Federal 2003 MAC guide: • 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. • Referrals made to medically Qualified direct service providers employed by a school district or ESD that is not a participating Medicaid provider are NOTclaimable. • Medicaid does NOT recognize TSPC licensure; therefore, referrals made to staff licensed/credentialed through TSPC only (i.e., school counselor, school psychologist, teacher with a Speech endorsement) for the purpose of a health evaluation, diagnostic test and behavior counseling are NOT a claimable MAC activity
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 (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
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://public.health.oregon.gov/ProviderPartnerResources/LocalHealthDepartmentResources/Pages/lhd.aspx • Community Mental Health Programs list by County • http://egov.oregon.gov/DHS/mentalhealth/cmh-programs.shtml
2011-2012 Annual Staff Training
Training Introduction • Thank youfor participating in this important training. As teachers and professionals who work daily with students, your jobs involve much more than instruction. Your efforts to link students and their families to Medicaid-covered health services that can impact a child’s ability to learn provides structure and support in developing successful learners.
Training Introduction Your participation in Medicaid Administrative Claiming (MAC) is a way in which you can help your District to receive reimbursement for Medicaid outreach and associated health related activities you provide. This reimbursement helps schools to continue to provide vital health services. Thank you again for your participation in this training and your work with Oregon students and their families!
2011-2012 Power Point Presentation • School-Based Medicaid/OHP MAC Claiming Coding Guide • Claimable Codes • Non-Claimable Codes • Referral Resources • 10% Audit Support Document • Approved Medicaid OHP Services