MEDICAID

1. MEDICAID

2. Medicaid Administrative Claiming--MAC vs. Targeted Case Management and Maternity Case Management

3. MAC • MAC is for the proper and efficient administration of the State’s Medicaid Plan – aka – the Oregon Health Plan. • Public Health Departments are reimbursed for specific activities that they are already doing. • Only additional work is taking a survey that takes about 10 minutes to complete.

4. Administrative Claiming IS NOT: • Targeted Case Management (Babies First!, CaCoon) • This is the process by which public health bills for health services provided to Medicaid/OHP eligible children pursuant to a case management plan. • Maternity Case Management • This is part of the OMAP benefit and not a leveraging program.

5. Medicaid Administrative Claiming Is: • A method of identifying and accounting for the time spent by public health programs staff on administrative activities such as referral and outreach. Reimbursement is then claimed for the time spent performing these activities. • Other than taking the survey and preparing the claim, no new work is required. • Staff do not need to know who is Medicaid/OHP eligible.

6. MAC and TCM • MAC is population based; TCM is individual Medicaid eligible based • MAC is total time accounting; TCM is billing for specific service; it is a Code E Direct Service • MAC provided to all by all staff in cost pool; TCM is provided only to Medicaid eligibles through the State Medicaid Plan amendment • MAC not dependent on a TCM plan • Public Health staff can do TCM and MAC- guidance is provided by DHS Multiple Leveraging Program Participation Guidance

7. TCMs in Oregon • DD • Children Adults and Families – Medicaid Eligible Parents 14 and Over Who Receive AFDC • SCF/OYA • Babies First/CaCoon • HIV (Multnomah only) • Substance Abusing Parents

8. MAC Claiming Formula • 1. Cost Pool • X • 2. Medicaid eligible percentage • X • 3. Percent of allowable time (survey) • = • Public Health total claim • 50% Match Required= Net claim

9. Developing the Cost Pool • Identify appropriate staff: routine contact with child and family(s) • Nurses, date stampers, interpreters, health educators, program development, etc. • Do not include janitorial, food service, accounting, lab techs, etc. • Identify actual salary, benefits and other personnel expenses • Remove federal funds from the cost pool • Cost pool established quarterly

10. Medicaid Eligible Percentage • Public health programs will use program data to establish • Unduplicated count of individuals in service • Formula: All individuals in service on Medicaid/OHP divided by all individuals in service • Percentage is established quarterly

11. Random Moment Survey Survey 4 days/qtr Ten activity codes 15-minute blocks of time Predominant activity Random Day Survey dates and participants are randomly selected Survey from 8am-6pm Training Everyone must be trained before taking survey MAC Survey How it Works

14. Ten Activity Codes • A1. Outreach and application assistance for Medicaid/OHP Program. • A2. Outreach and Application assistance for non- Medicaid/OHP Outreach. • B1. OHP Referral , Coordination, Monitoring, Training • B2. Non-OHP Referral, Coordination, Monitoring Training • 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.

15. 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

16. Code A1 Examples • Informing clients and others about the OHP/Medicaid program and referring them to DHS; • Date stamping and handing out OHP applications to clients. • Providing information regarding Medicaid managed care programs and health plans to individuals and families and how to access that system. • Confirming or verifying with DHS an individual's current Medicaid eligibility status; • Contacting pregnant and parenting teenagers about the availability of Medicaid prenatal and well baby care programs

17. Code A-2: Outreach and Application Assistance for Non-OHP Programs This code should be used for: • Non-OHP outreach; social, educational, legal or other services not covered by OHP • Informing parents/guardians about non-OHP programs: TANF; food stamps; WIC; etc. • Translation of or assisting to comprehend applications to these programs; • Scheduling/promoting activities which educate individuals about the benefits of healthy lifestyles; tobacco cessation, or general nutrition

18. Code A2 Examples • üOutreach campaigns directed toward encouraging persons to access social, educational, legal or other services not covered by Medicaid. • üInforming an individual or family about programs such as Temporary Assistance for Needy Families (TANF), food stamps, Women’s Infant & Children Program (WIC), day care, legal aid, and other social or educational programs and referring them to the appropriate agency to make application

19. B-1: OHP Referral, Coordination, Monitoring and Training This code should be used for: • Making referrals for and/or coordinating the medical/developmental health/dental health/mental health and substance abuse services covered by OHP • Providing any information that may be required in advance of these referrals • Providing follow up contact to ensure that a child has received the prescribed health services

20. Code B1 Examples • üMaking referrals for and/or coordinating medical health, dental health, mental health or substance abuse services covered by Medicaid, including medical or physical examinations and necessary medical evaluations • üProviding information and making referrals for and/or scheduling Medical screenings. • üArranging for any diagnostic or treatment services, which may be required as a result of a condition identified during an evaluation or screening. • üGathering information that may be required in advance of these referrals or evaluations.

21. More Code B1 Examples • Working with individuals, their families, other staff, and providers to identify, arrange for, and coordinate services covered under Medicaid that may be required as a result of screens, evaluations, or examinations. • The actual referral of an individual to a medical program for Medicaid-covered services. • Trainingwhich improves the delivery of Medicaid-covered services, including TCM training • Participating in or coordinating training which enhances early identification, intervention, screening and referral of clients with special health needs to medical services.

22. B-2: Non-OHP Referral,Coordination,Monitoring, and Training This code should be used if not TCM/MCM for: • Making referrals for social services, community wellness, etc. programs • Gathering any information that may be required in advance of these referrals • Making referrals for educational or vocational programs.

23. B2 Examples • Making referrals for and/or coordinating WIC services. • Working with individuals, their families, other staff, and providers to identify, arrange for, and coordinate social services including housing, food bank, etc. • Assist family in accessing parenting support group to empower parents with optimal parenting skills

24. Code C-1: Medicaid/OHP Transportation and Translation • This code should be used for: • scheduling, arranging or providing transportation to Medicaid/OHP covered services • If destination time is positive, can include the staff travel time back and forth! • scheduling, arranging or providing translation services to assist individual to access and understand necessary care and treatment

25. C-2: Non-Medicaid/OHP Transportation and Translation • This code should be used for: • scheduling, arranging or providing transportation to social, vocational and/or other educational programs and activities • scheduling, arranging or providing translation services to assist individual to access and understand necessary non-Medicaid/OHP services

26. 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

27. D1 Examples • Working internally or with other agencies providing Medicaid services to improve the coordination and delivery of services, to expand access to specific populations of Medicaid eligibles, and to improve collaboration around the early identification of medical problems. • Reducing overlap and duplication in Medicaid-covered services and closing gaps in the availability of services. • Planning and developing strategies to increase Medicaid system capacity and close Medicaid service gaps; includes analyzing Medicaid data related to a specific program or specific group.

28. Code D-2: Referral, Coordination and Monitoring of Non-Medicaid 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 • improve coordination, expand access or delivery of non-Medicaid/OHP services • develop strategies to assess or increase the capacity of non-medical, dental and mental health programs

29. D2 Examples • Working internally or with other agencies to improve the coordination and delivery of social services such as housing, food banks, etc. • Coordinating bioterrorism preparedness. • Meeting with community groups to address issues with environmental health systems (water systems, restaurant inspections, etc). • Provide health expertise to a community group on writing a juvenile offender grant, which proposes a new system to respond to juvenile offenders and their parents.

30. CODE E - DIRECT SERVICE • An activity that is done to correct or ameliorate a condition • Any activity that is considered integral to, or an extension of a specified covered service • Does not have to be a billable service • May not have to be performed by a practitioner – administering first aid

31. Code E ExamplesCode E Examples • Give immunizations at public immunization clinic • TCM/MCM • Providing health/dental/mental health services • Conducting health/dental/mental health assessments/evaluations and diagnostic testing • Administering first aid or prescribed injection or medication to an individual

32. 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, paid lunch, jury duty or any other paid time away from work • Budget development; general supervision

33. Multiple Leveraging Guidance • Individuals can participate in two leveraging programs-direct and administrative • The time survey is a tool to cost allocated between programs

34. Staff do not need to know who is Medicaid/OHP eligible It is the activity of staff that is being measured, not the outcome of the activity Staff do not need to know all about Medicaid/OHP Time study determines staff time spent on eligible and non-eligible activities Good Information to Know

35. Contacts • Fritz Jenkins, DHS fritz.jenkins@state.or.us • Gary Williams, DHS gary.r.williams@state.or.us