Medicaid Administrative Claiming for School-based Services (MACSS) in Iowa

1. Medicaid Administrative Claiming for School-based Services (MACSS) in Iowa ICN Session Fiscal September 16, 2003

2. Background - EPSDT Agency Participation - Organizational Structure Working with Billing Agents Staff Participation RMS Time Study Activity Codes The Quarterly Claim Required Matching Funds 10% Reserve Funds Contingency Fees Training DHS Reviews Annual Report Audit File Getting Started Responsibilities of Lead Agency Accountability for all Schools On-line Resources State Level Contacts Process for Questions and Answers Agenda

3. Background • MACSS is a process by which Federal Financial Participation may be claimed for administrative case management activities carried out in a school setting that are necessary for the proper and efficient administration of Iowa’s Medicaid State Plan for children ages 0-21 (through age 20). • MACSS supports Iowa’s EPSDT Care for Kids program.

4. Iowa’s EPSDT (Care for Kids) Program • Early =Children should receive quality health care beginning at birth and continuing through childhood including identification, diagnosis, and treatment of medical conditions as early as possible. • Periodic =Children should receive screening and preventive care at regular intervals throughout childhood (age 0 through 20) according to standards set by responsible professional groups. • Screening =Children should be screened for conditions, diseases, or abnormalities to initiate further diagnosis and receive early and continuing treatment of these conditions. Services shall include vision, hearing, medical, dental, and mental health screenings.

5. Iowa’s EPSDT (Care for Kids) Program • Diagnosis =Children should receive further evaluation for conditions or signs identified in the periodic screens that indicate further treatment may be required. • Treatment =Children should receive treatment that involves the correction of health problems identified in the screening and diagnosis components of EPSDT.

6. Agency Participation • Agreements will be established with school districts only. • Time studies include only school district employees. • No contracted staff may be included in time studies. • Must have sufficient public unrestricted funds derived from state, county, or local generated revenues to match federal reimbursements. • May not be used as match for other programs.

7. Agency Participation • Organizational structure • Lead agency status will be limited to one school district per county. • Lead school district must participate in MACSS. • Other school districts may participate under the lead agency. • Annual agreements established • Lead agency agreement with DHS • Sub-agency agreement(s) with lead agency • Fiscal year = July 1 through June 30

8. MACSS Organizational Structure Centers for Medicare and Medicaid Services (CMS) Iowa Dept. of Human Services Iowa Dept. of Public Health Interagency Agreement Technical Assistance Lead School District Billing Agents (if applicable) Sub-agreement Other School Districts Billing Agents (if applicable)

9. Working with Billing Agents • Contracting with billing agents is the prerogative of local participating school districts. • Role for billing agents: • Assist schools in compiling the Quarterly Claim • Provide technical assistance • Provide additional trainings following the state required trainings • Assist schools in gathering information for response to the Medicaid State Agency regarding inquiries, audit findings, claim resolution, etc.

10. Staff Participation • Staff participating in time studies may include employees serving in schools who……... • Facilitate Medicaid outreach / enrollment / eligibility determination. • Provide administrative support for Medicaid related activities. • Do not include staff who……… • Provide ONLY direct care or educational services. • Have positions that are 100% supported by grant funds. • Bill service coordination under the Medicaid LEA program.

11. Staff Participation • Appropriate staff may include: • Nurses • Counselors • At-risk Coordinators • Health Care Associates • Interpreters / Translators for medical services • Other paraprofessionals • Psychologists • Social Workers

12. RMS Time Study • Time studies will be conducted through a process known as Random Moment Sampling (RMS). • Computer generated random worker - moments are selected for the quarter (3,000 statewide / quarter). • For a given sample moment, the worker completes the RMS Observation Form. • Who were you with?/ What were you doing?/ Why were you performing this activity? • Signature and Date • Certified time coder from Lead Agency codes the activity. • Time code percentages included in an agency’s claim are based upon statewide coding percentages.

13. RMS Time Study • Process for Implementation • One month before start of quarter, Lead Agency sends DHS a list of staff to be included in the time study for each participating agency (lead and subs). • DHS generates the worker-moments for the upcoming quarter. • Two weeks prior to start of quarter, DHS sends RMS Observation Forms and sample control lists to lead agency. • Lead agency distributes RMS Observation Forms and instructions to their own staff and sub-agency. • Completed RMS Observation Forms are returned to lead agency weekly. • Certified coder at lead agency assigns activity codes. • Completed forms are returned to DHS MACSS Auditor weekly.

14. Activity Codes • Code 1.a. Outreach and Facilitating Eligibility for Non-Medicaid Programs • Code 1.b. Outreach and Facilitating Eligibility for Medicaid & hawk-i • Code 2. School Related Educational Activities • Code 3. Direct Medical Services

15. Activity Codes • Code 4. a. Coordination of Transportation for Non-Medicaid Services • Code 4. b. Coordination of Transportation for Medicaid Services • Code 5. a. Non-Medicaid Translation • Code 5. b. Translation Related to Medicaid Services

16. Activity Codes • Code 6. a. Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services • Code 6. b. Program Planning, Policy Development, and Interagency Coordination Related to Medical Services • Code 7. a. Non-Medicaid Related Training • Code 7. b. Medicaid Related Training

17. Activity Codes • Code 8. a. Referral, Coordination, and Monitoring of Non-Medicaid Services • Code 8. b. Referral, Coordination, and Monitoring of Medicaid Services • Code 9. General Administration • Code 10. Not Scheduled to Work

18. The Quarterly Claim • Links staff costs associated with the time invested in Medicaid related activities to determine the claim • Incorporates the Medicaid eligible percentage of children • Applies the appropriate Medicaid provider percentage to Code 8.b. • Provides for removal of revenue to be offset from the claim • Applies the 50% Federal Financial Participation Rate

19. The Quarterly Claim • Consists of 3 components • Salaries and Benefits Report • Revenues Worksheet • Invoice • Use of DHS Excel format is required. • Red triangle in cell: Information is provided as to what should be entered into that cell. • Print feature is included for each page.

20. The Quarterly Claim • Salaries and Benefits Report • Enter agency name. • Enter total quarterly salaries as reported in payroll journal. • Enter total quarterly benefits as reported in payroll journal. • Under Cost Pool #1, enter employees that participate in the RMS Time Study by name and position. Enter corresponding salary and benefits for the quarter. • Under Cost Pool #3, enter superintendents, principals, assistant principals, and their supporting clerical staff (if clerical are in Source Codes 2320 & 2400) by name and position. Enter corresponding salary and benefits for the quarter.

21. The Quarterly Claim • Revenues Worksheet • Enter agency name. • Total Quarterly Revenues • Report all revenues for the quarter except the entire 1100, 1200, 2100, and 3100 series source codes. • MACSS Reimbursements • Report under Cost Pool #1 the gross MACSS reimbursements received in the quarter (before 10% reserve and lead agency / other fees are deducted). • Medicaid LEA reimbursements • Report under Cost Pool #1 all Medicaid LEA reimbursements received in the quarter except those for service coordination.

22. The Quarterly Claim • Revenues Worksheet • Federal Revenue • Report all revenues for the quarter in the 4000 series source codes that apply to staff in Cost Pools 1 & 3. • State and Intermediate Revenue • Report restricted revenues for the quarter in source codes 2000 and 3000 that apply to staff in Cost Pools 1 & 3. • Other Revenue Sources • Report other revenue sources for the quarter such as contracted costs from other agencies, fees paid by clients, insurance payments, and other 3rd party reimbursements that apply to staff in Cost Pools 1 & 3.

23. The Quarterly Claim • Invoice • Enter agency name. • Enter travel and training costs for the quarter for staff in each of the three cost pools. • Cost Pool #1: Includes costs for staff in the RMS time study. • Cost Pool #2: Includes costs for all staff other than those included in Cost Pools #1 and #3. • Cost Pool #3: Includes costs associated with Superintendents, Principals, and Assistant Principals, and their supporting clerical staff (if clerical are in Source Codes 2320 & 2400).

24. The Quarterly Claim • Invoice • Enter RMS Time Study results for each time code. • Use statewide RMS Time Study results. • Enter units of time (not percentages). • Enter the Department of Education’s unrestricted indirect cost rate for the school district (established annually). • Can be found at http://www.state.ia.us/educate/fis/sft/car/index.html

25. The Quarterly Claim • Invoice • Enter percentage of Medicaid recipients. • Free & reduced lunch percentages are no longer allowed. • CMS requires tracking of actual Medicaid enrolled children. • The Iowa Department of Education will be conducting a sample survey of children enrolled in Iowa schools to determine a statewide rate of Medicaid eligible children. • All participating school districts will be provided information as to the statewide rate to be included in the claim. • Maintain documentation of the percentage of Medicaid eligibles for the audit file.

26. The Quarterly Claim • Invoice • Enter Medicaid provider percentage. • CMS requires tracking of providers to whom students are referred or with whom services are coordinated or monitored. • These providers may include physicians, dentists, psychologists, psychiatrists, opticians, and other providers such as pharmacies. • To determine the Medicaid provider percentage, divide the number of Medicaid providers by the total number of providers to whom students are referred or with whom services are coordinated or monitored. (Percentage is applied to Code 8.b.)

27. The Quarterly Claim • Invoice • Medicaid provider percentage • Website link to list of Medicaid providers will be provided by the Department of Education. • Tracking form will be completed by each coder. • Submit tracking document with initial claim. • Maintain documentation of the Medicaid provider percentage for the audit file.

28. The Quarterly Claim • One Purchase Order/Payment Voucher is due to Sally Nadolsky within 180 days of the end of each quarter (September 30, December 31, March 31, June 30) • Include all 3 pages (Salaries and Benefits Report, Revenues Worksheet, and Invoice) for the lead agency and each sub-holder. • Include the tracking document for providers and determination of Medicaid provider percentage.

29. Required Matching Funds • Each school district must certify required non-federal matching funds. • For every federal dollar received, a equal amount of match is required. • Federal Financial Participation is 50% • Agency certifies the other 50% as match • Source must be public unrestricted funds. • Designated matching funds must not be used as match for another grant / program. • Signed certification is required on each invoice.

30. 10% Reserve Funds • Agreement requires a minimum of 10% of the federal reimbursement to be held in reserve. • Are used to offset any disallowance identified in an audit. If disallowance exceeds the amount in reserve, the agency is responsible for total disallowance. • Must be in a separate line item or separate account. • Must be held for a rolling 5 year time period.

31. Contingency Fees • DHS withholds up to 5% of claim to support the RMS time study, review of claim, and technical assistance. • Lead agency may retain percentage of the sub-holder claim for administering the program. • Must have supporting documentation for amount withheld (update annually). • Must cover costs without profit-making. • Billing agencies • Fees must be related to the cost of processing. • May not assess percentage dependent upon federal reimbursements collected per CFR and OMB regulations.

32. Training • Certification of fiscal training is required for the staff person preparing the claim for each participating agency. • Contact Janet Beaman for training needs.

33. DHS Reviews • Oversight will occur on a regular basis. • Desk reviews of both coding and quarterly claim • Review of 10% of coding each quarter • Review of quarterly claim and supporting documentation each quarter • At a minimum, biennial in-depth desk reviews • Periodic on-site reviews

34. Annual Report • Lead agency submits to Sally Nadolsky at DHS each year • Due by September 30 • Includes summary of fiscal elements for the claiming year for both lead and sub-agencies • Includes narrative report on use of funds for both lead and sub-agencies • Per contract must be used to expand or enhance health related services for children.

35. Audit File • Audit file must be retained for 5 years • Components: • Coding policies • Job descriptions reflecting activities claimed • Table of organization • Documentation of the Medicaid eligible percentage • Documentation supporting the determination of the Medicaid provider percentage • Accounting information for cost pools and revenues

36. Audit File • Components • Computations and calculations for preparation of quarterly claim • Documentation of DE unrestricted indirect cost rate for the school • Documentation of matching funds • Use of reimbursed funds • Documentation of 10% held in reserve • Documentation of analysis of administrative fees assessed to sub-agencies (for Lead Agencies) • Documentation of technical assistance & training

37. Getting Started • Determine whether participating as lead agency or sub-agency. • Establish MACSS agreement (lead or sub) each year. • New contracts to begin October 1, 2003 – June 30, 2004. • New coding structure and RMS time study anticipated to begin January 1, 2004. • School districts that have no previous experience with the program may begin when RMS time study is implemented.

38. Getting Started • Identify key contact personnel for MACSS. • Certified coder from lead agency and certified back-up coder • Contact persons for RMS Time Study and Fiscal components • Determine appropriate staff for inclusion in the RMS time study. • Provide list of participating staff by name and position to Lead Agency and then DHS. • Update job descriptions and Table of Organization. • Establish process for tracking providers.

39. Responsibilities of Lead Agencies • Submits Lead Agency agreement to DHS • Enters into sub-agreements with other appropriate entities as sub-holders • Provides technical assistance to sub-holders • Provides pertinent communications to sub-holders • Provides list of coders by name & position to DHS for lead agency and sub-holders each quarter • Provides Observation Forms and worker-moments to lead agency staff and sub-holders for each quarter • Designates certified coder and back-up who code lead agency and sub-holder activities

40. Responsibilities of Lead Agencies • Submits coded Observation Forms to DHS auditor weekly • Develops lead agency Quarterly Claim and receives those of sub-holders • Provides quality assurance review of sub-holder claims • Submits one PO/PV to DHS for both lead and subs quarterly (with required supporting documents) • Maintains Lead Agency audit file • Coordinates on-site reviews of lead and sub agencies • Responsible to DHS for all disallowances identified in state and federal audits

41. Accountability for all Schools • Recognize the authority of the State Medicaid Agency regarding policies, rules, & regulations • Assure proper and efficient administration of the Medicaid State Plan through compliance with • CMS Medicaid School-based Administrative Claiming Guide, May 2003 • OMB Circular A-87 • 45CFR Parts 74 and 95 • 42 CFR 447.10(f) and • State requirement to participate in RMS time study

42. Accountability for all Schools • Provide responses to Medicaid State Agency regarding inquiries, audit findings, claims resolution, etc. • Certify sufficient public unrestricted funds for match (those not used as match for other programs)

43. On-line Resources • CMS Medicaid School-Based Administrative Claiming Guide, May 2003 • http://cms.hhs.gov/medicaid/schools/clmguide.asp • OMB Circulars A-87 and A-133 • http://www.whitehouse.gov/omb/circulars/index.html • Iowa Department of Education Uniform Financial Accounting for Iowa LEAs and AEAs • http://www.state.ia.us/educate/fis/sft/ufa/index.html

44. Lead Agreements & Annual Report: Sally Nadolsky IA Dept. Human Services Hoover State Office Building 1305 East Walnut Des Moines, IA 50319 Phone: 515-281-5796 FAX: 515-281-8512 e-mail: snadols@dhs.state.ia.us MACSS Auditor & Invoice Processing: Anieta O’Hair IA Dept. Human Services Hoover State Office Building 1305 East Walnut Des Moines, IA 50319 Phone: 515-281-5496 FAX: 515-281-6237 e-mail: aohair@dhs.state.ia.us Training & Technical Assistance: Janet Beaman IA Dept. Public Health Lucas State Office Building 321 East 12th Street Des Moines, IA 50319 Phone: 515-281-3052 FAX: 515-242-6384 e-mail: jbeaman@idph.state.ia.us State Level Contacts

45. For the Medicaid Local Education Agency (LEA) program Dann Stevens, Consultant Iowa Department of Education Grimes State Office Building 400 East 14th Street Des Moines, IA 50319 Phone: 515-281-8505 FAX: 515-242-6019 e-mail: Dann.Stevens@ed.state.ia.us State Level Contacts

46. Process for Questions and Answers • Questions may be submitted at anytime. • Written responses will be developed for those questions submitted by Wednesday, October 15th. • Submit to Janet Beaman at jbeaman@idph.state.ia.us • Written responses will be sent to all participants.