WHAT IS MEDICAID ADMINISTRATIVE CLAIMING?

MEDICAID ADMINISTRATIVE CLAIMINGin OregonCenter for Prevention & Health Promotion, Oregon Health Authority11/21/2017

WHAT IS MEDICAID ADMINISTRATIVE CLAIMING?

Medicaid Administrative Claiming Is: …a method of identifying and accounting for the time spent by staff of health departments on activities that generally connect clients eligible for Medicaid with Medicaid-covered services. The time study—done on “MAC survey days” is the primary mechanism for identifying and categorizing Medicaid administrative activities performed by eligible employees. The time study also serves as the basis for developing claims for the costs of administrative activities that may be properly reimbursed under Medicaid.

Four survey days occur randomly each quarter. The local MAC coordinator receives notification a week prior to each survey date. On the survey date, or within the four working days after the date, each individual in the cost pool logs into the MESD website and completes an on-line survey accounting for all activities done by that person during paid time on the survey date. Paid time at work is surveyed in 15-minute increments. Staff time falls into any one of ten activity codes. Predominant portion of a 15-minute increment is what’s recorded Example: Between 8:00 to 8:15 AM, a worker spends 8 minutes giving information to a client about OHP. The rest of the time within that period the worker spends in general office activities. Because the majority of the time within the 15-minute increment was devoted to a claimable activity (i.e. giving info about OHP), the worker will click on the radio button for “A1”—one of the claimable codes that is specifically about “Outreach”—for the 8-8:15 period. Logging a MAC Survey Day

Developing The Claim Formula for Reimbursement Non-federal salary & benefits paid to all staff in MAC Cost Pool (provided locally) X % of allowable time (time study) X % of Medicaid eligible (local estimate) = Total Claim X 50% non-federal match = Net revenue

MAC: How it works 1. Local health dept identifies appropriate staff to be in cost pool. 2. Cost pool members are trained in MAC. 3. Certification of trainees sent to MESD. 4. Before start of a quarter, list of those trained cost pool members who will be in that quarter’s cost pool is sent to MESD. 5. During quarter, all cost pool members participate in four random MAC survey dates.

$ 120,000 • 20,000 7. Fiscal manager subtracts portion of this figure that is paid out of federal sources. • At end of quarter, fiscal manager calculates total salary & benefits paid to cost pool during quarter. $ 100,000 8. Total non-fed salary & benefits for cost pool is reported to MESD, along with % of LHD’s clientele that is Medicaid-eligible (50-70%). X 25% = $25,000 9. MESD calculates average amount of time spent by cost pool in claimable activities during quarter (from survey data), applies to total cost pool pay, then times M/E %. X 86% = $ 21,500 • Resulting dollar figure is LHD’s claim • for the quarter.

The three factors determining the size of your MAC claim: • Composition and number of staff in your cost pool: This will determine the dollar amount representing total salary and benefits paid to all in the cost pool during the entire quarter. • Average percentage of MAC-claimable time (as compared to all paid hours) documented by all cost pool members (average of the four survey days). • Average percentage of Medicaid-eligible clients (as compared to all clients) served on all survey days. The second factor is the one that LHDs have the most control over, and will be determined largely by how accurately staff account for their time, and how division of work is managed.

Cost Pool • Those having routine contact with children and families • Nurses, community health workers, interpreters, eligibility specialists, front office staff, health educators / promotoras • Does not include federally funded WIC staff, sanitarians, janitorial, or volunteers • Supervisors of these staff (if appropriate, i.e. significant time spent on case coordination, providing back up) • Department administrators (if appropriate, i.e. significant time spent on systems coordination)

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

Code E: Direct Medical Services • 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

Code F: Other Work Activities, orAny Other Paid Time • 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

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 availablility 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.

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

Code A2: Outreach and Application Assistance for Non-OHP Programs • Providing information about health-related services not covered by OHP (wellness/fitness classes, weight-loss programs, nutrition workshops, etc.) • Helping someone enroll in above, or in a non-health-related program such as SNAP, TANF, etc.

Q: In what situations would I code time serving a client as A2? • Informing about classes, workshops, other instruction that are generally aimed at low-income clients but not covered by OHP. • Helping people to enroll/register for such services.

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. • 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.

Code B-1: Referral, Coordination, Monitoring and Training of Medicaid Services • This code should be used for: • Making referrals / appointments for medical, mental, dental health or substance abuse services covered by Medicaid/OHP • Coordinating supportive documentation / tasks to help connect clients to services covered by Medicaid/OHP • MAC trainings

Code B-2: Referral, Coordination, Monitoring and Training of Non-Medicaid Services • 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

Q: During a home visit to follow up on a child’s situation, his mother announces that she is pregnant. The nurse making the visit asks questions about the pregnancy, then makes a referral for that person. Is the referral claimable, and can the nurse claim the travel time to and from the home? A: Yes to both. Because the referral is made for one who is not the recipient of the service that was the reason for the home visit, the time given by the nurse for the referral is properly claimed as a B1.1 activity. And, since a B1 activity took place during the course of the visit, the nurse can also claim travel time as B1.5.

Q: If assisting staff take blood pressure, measure height and weight, and assist with lab work, is it considered 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.”

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

Delegating activities for MAC credit Nurse determines a date to see her patient Jane: 2. OS Betty schedules appt for Jane. Code “B1.1: Referral” Code “E : Direct service” 1. Nurse asks Office Spec Betty to call Jane and schedule appt. • Nurse examines Jane, gives • her an immunization. 3. On day of appt, Betty does intake of Jane, updating her file. Code “E” Code “B1.2: Coordination” 5. Nurse refers Jane to WIC services. Code “E” 6. Two days later, nurse tells OS Betty to call Jane and ask if any adverse reaction to immi. 7. Betty calls Jane w/question. Code “E” Code “B1.3: Monitoring” 8. Nurse discusses Jane’s case w/Supervisor John. 9. John advises nurse re Jane. Code “E” Code “B1.2: Coordination”

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.

Q: Today’s meeting attended by several cost pool participants lasted all morning. Medicaid health services were discussed. What portion of their time during this AM can these staff claim? A: Only those times during the meeting devoted to discussing system coordination related to Medicaid services. If the total amount of claimed staff time is significant, it is requested that at least one—and preferably both—of the following documents be available on file: • A written agenda for the mtg clearly outlining Medicaid-related topics; • Official notes kept of the mtg that would document the claimable portion(s).

Q: At a multi-disciplinary team meeting, a cost pool member coordinates care for several clients who are not his patients; what code is used? If the same employee then attends a meeting where improvements to the way that care is coordinated for all low-income clients, would he code it the same? A: When the activity aims to connect specific individuals with specific OHP-covered services, it will be coded as B1; in this case, since it’s coordination, it will be B1.2. When the activity aims to improve, enhance, or extend the whole system of health- care delivery, it will be coded with a “systems change” (D1) code.

Code D2: System Coordination Related to Non-OHP Services • 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

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 claim time spent attending meetings or trainings lasting for several hours, a record of the session should be on file which will document that the agenda item(s) during claimed time were claim-eligible.

OHA Public Health Services MAC Contracts Administrator • Dave Anderson david.v.anderson@state.or.us 971-276-0412

WHAT IS MEDICAID ADMINISTRATIVE CLAIMING?