Transcript Medicaid Administrative Claiming “MAC”

2014-2015
Train-The-Trainers
Annual workshop
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 and Policy Analyst
(541) 975-5614













Medicaid in Schools
MAC Match Leveraging
Participation of Charter Schools in MAC
Cost Pool Development
MAC Audit Requirements
Procedures for Assigning Survey Dates
MAC & Oregon Healthy Kids
Immunizations
Monitoring
Referrals
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
 Reimbursement
authority
 Pursuant to 42 CFR 433.51, only a unit of
government is authorized to participate in Federal
Financial Participation (FFP) by providing the nonfederal share of public funds for Medicaid
reimbursement for covered services.
 The ESD certifies by its signature on the MAC
intergovernmental agreement (IGA) that the nonfederal matching funds it transfers to DHS are not
federal funds, or are federal funds authorized by
federal law to be used to match other federal funds
and that all sources of funds are allowable.
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 nonprofit 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.

Cumulative Report – 2012 Statewide MAC %
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 nonfederal 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.
Procedure for Assigning
Survey Dates

DHS will provide ESDs with random survey dates prior to start
of the school year.

The ESD will assign the dates to school districts without influence
or input from any school district.

The ESD will inform the school district(s) of the week (not the
specific date) of their assigned random date prior to the first
day of the applicable survey period. This will allow the ESD
and school district(s) ample time for scheduling and providing
training.

The ESD will inform the school district(s) of the specific random
date no greater than 10 business days prior to the assigned date.

The school district(s) will accomplish the survey on the date
assigned.
Trainers must attend a MAC train-thetrainers 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

Any claimable time reported on a survey may be
reviewed by OHA and a request for supporting
documentation issued.
○ 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
Claimable Categories








Administrators
Principals
Teachers
Educational Assistants
Secretaries
Counselors
TSPC School
Psychologists



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 cannot claim 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.

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.
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.

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 Medical Services”. Such activities must be
reported as “F” on the survey.
These monitoring activities are considered Direct Medical Services
and may not be reported under code C1.3.
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 with an enrolled
Medicaid provider

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.

Link to exclusion information:
 http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/Gettin
gImmunized/Documents/SchLawHandbook.pdf
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.
 A referral was made by the school counselor for mental health
services to an enrolled provider, the school counselor follows up
with the parent following the appointment to coordinate care and
changes in medication.
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.
Oregon Health Plan/Healthy Kids Programs
 A State sponsored Medicaid 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 coverage, household income cannot be
more than 300% of federal poverty level ($46,300 for
a family of 4).
A family of 4 that makes $46,300 or less annually
may qualify for no cost coverage. = $0.00 Monthly
Premium
A family of four that earns between $46,330 to
$69,380 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/
 General Information
○ On-Line Application

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 NOT claimable.
 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 and in
applying for Medicaid insurance the following websites are
useful:
 Oregon Health Policy Board – What’s Happening With
Health Care in Oregon
○ http://www.oregon.gov/oha/OHPB/Pages/index.aspx
 Oregon County Health Department Directory
○ http://public.health.oregon.gov/ProviderPartnerResource
s/LocalHealthDepartmentResources/Pages/lhd.aspx
 Cover Oregon - Finding Health Insurance For You
○ https://www.coveroregon.com//
 Find a Local DHS Office Near You
○ http://www.oregon.gov/DHS/localoffices/localoffices.p
df
2014-2015
Annual Staff Training
Training Introduction

Thank you for 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 and
social services.
Thank you again for your participation in
this training and your work with Oregon
What is Medicaid Administrative
Claiming (MAC)
MAC is a survey method of identifying and
accounting for the time spent by public school staff
on medically related activities, that otherwise
would be the financial responsibility of the State.
 Participation in School-Based MAC allows for the
administrative activities associated with the
coordination, referral, outreach, and program
planning of Medicaid covered health services to be
reimbursed for education agencies.
 The MAC program strengthens local relationships
between service providers and public agencies.

Important Facts





You do not need to know who is Medicaid/OHP
eligible
It is the activity you are doing that is being
measured, not the outcome of the activity
The time study determines your time spent on
eligible and non-eligible activities
When you report claimable MAC activities during
your day you must complete a supporting
documentation form in support of the activities
being reported
Submit the support document to your local building
coordinator or designee
How is MAC time reported?

The web-based survey is utilized to record
activities staff perform during the paid hours of a
school day. This is accomplished by reporting
the activities in a code category that best fits the
activity performed. There are three survey
periods per school year. Each survey period
DHS/OHA will select random survey dates of
which your District/ESD will be assigned one.
○ September – December
○ January – March
○ April – June

MAC Claimable Categories
 B1 – Medicaid Outreach – Healthy Kids/Healthy KidsConnect
 C1 – OHP Referral, Coordination, Monitoring and Training
 C1 = Child Specific
 D1 – OHP Transportation/Translation
 E1 – Medical Program Planning, Policy Development, and
Interagency Coordination
 E1 = Everyone Benefits
Non-Claimable Codes






A – School Related and Educational Activities
B2 – Non Medicaid OHP/Outreach
C2 - Referral, Coordination, Monitoring and Training on Non
Medicaid /OHP Services
D2 – Non Medicaid/OHP Transportation/Translation
E2 – Program Planning, Policy Development and Interagency
Coordination Related to Non-Medical Services
F – Direct Medical Services
 Non-claimable codes represent non-health related and/or
educational activities that DO NOT generate reimbursement

Code A
 This code should be used for
any school-related activities that
are not health related.
○ Including but not limited to
classroom instruction, grading
papers, supervision of staff,
recess duty, student discipline,
and developing curriculum.
 Note: Participating in an IEP
meeting must also be reported
as code A. (This includes the
development, coordination and
monitoring of a student’s IEP or
other education plan.)


Medicaid outreach activities are those performed to
inform eligible or potentially eligible individuals about
Medicaid and how to access the Medicaid program.
Oregon Health Plan/Healthy Kids Programs
 A State sponsored Medicaid 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.

Health Services
 Well-child exams
 Immunizations (May not be during exclusion or for education enrollment
requirements)
 Routine physicals
 Maternity and newborn care

Medical Services











Preventive services such as well-child check ups
Laboratory or x-rays
Treatment for most major diseases
Hospital stay
Substance abuse
Vision care, routine screenings, and glasses
Hearing services, hearing aids, & batteries
Home health care
Specialists care & referrals
Physical, occupational, and speech therapy
Medical equipment and supplies

NOTE: If any of these activities are provided as “free care” or free to all students,
they must be coded as C2. Activities performed free of charge are not MAC
claimable.

Dental Services
 Preventive services (cleaning, fluoride treatments, sealants for







children)
Routine services (fillings, x-rays)
Dental check ups
Tooth removal
Dentures
24-hour emergency care
Specialist care and referrals
Mental Health Services





Evaluations
Therapy
Consultations
Medication management
Programs for daily and community living
The following section is an introduction to the
MAC coding categories for claimable activities
codes B1, C1, D1, and E1.
Each code category provides a general
description of the claimable activities, including
examples of those activities and their subcodes.

B1.1
 Informing children and their family’s on how to
effectively access, use, and maintain participation in
Medicaid/OHP.
○ Includes describing the range of services, and
distributing OHP literature.
 Gave a family the details about qualifying for OHP, application
process and whom to contact.
 Through a Spanish speaking interpreter I identified how to
apply for OHP.
 Worked with school counselor to answer a family’s questions
about OHP and how to apply. What benefits are covered,
eligibility requirements, etc.
 Informed the Grandmother of a student who needs extensive
surgery on his arm about OHP. The family is uninsured.

B1.2
 Assisting the student/family to access, apply for,
and/or complete the Medicaid/OHP application.
○ Includes coordinating transportation and providing
and coordinating translation related to OHP
application, and gathering appropriate information.
 Referred a family for OHP application assistance and
helped get an application for Medicaid/OHP through our
Family Support Center.
 Phone call with a parent regarding documentation
requirements for the OHP application. Explained time
frame and importance of providing all documentation.
 Assisted a family with resources necessary for them to
apply for OHP.

B1.3
 Checking a student and/or family's OHP status.
 May be done by reviewing the family’s medical card,
contacting the local DHS agency, working with indistrict staff who have access to Medicaid eligibility.
 Informed a parent of a child with dental needs how to check
the status of their OHP eligibility.
 Checked on the OHP eligibility status of a student returning
from foster care to her immediate family. She was covered
while in foster care but will need to reapply.
 Verified a student who attempted suicide the previous day
was not insured and discussed access to OHP. Followed up
with school counselor and County Mental Health crisis unit.

B1.4
 Contacting pregnant and parenting
teenagers about the availability of
Medicaid/OHP for prenatal and well baby
care programs.
 Spoke with student regarding Medicaid/OHP for
prenatal care.
 Reviewed availability of services covered under
Medicaid/OHP prenatal and well baby
programs.

C1.1 - Referral
 Referring students for medical, mental health, dental health and
substance abuse evaluation and services covered by Medicaid/OHP.
 Includes gathering information in advance of referrals.
Gathered information on a student identified during a vision screening as
needing further evaluation for an eye exam, student has trouble reading
instructions at a distance.
Discussion with team regarding the health needs of a student who just
returned from an out of state school. Parent reports regression, team
discussed referral to County Mental Health agency.
Met with student and mother. Student has substance abuse issues.
Referral to County Health Department for UA.
Referral of a student with Mental Health needs to County Mental Health.
Gathered information in advance of a referral for a student with dental
health needs from the parents and school nurse.

Immunizations
 Claimable – C1.1 Referral
 Administrative activities related to referrals to assist families in accessing
immunizations from enrolled Medicaid providers are claimable as C1.1 Referral.
 To be claimable the immunization may Not be Free of Charge (An
exception is that the service is billed to Medicaid insurance by the
service provider, but may be free of charge to parent/child)
 To be claimable, immunizations must be provided outside the school

Free Care Principal – Federal Guidance
 Precludes Medicaid from paying for the costs of Medicaid-covered
services and activities which are generally available to all students
without charge.

Immunizations Continued
 Non Claimable – C2
 Administrative activities related to assisting children and
families to access “FREE” immunizations
 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
- Performing a primary review summary
- Mailing exclusion orders
- Completing a county immunization status report

C1.2
 Coordinating the delivery of medical health, mental health, dental
health and substance abuse services covered by Medicaid/OHP.
○ Includes Youth Services Team and CARE team meetings
 Discussion with School Counselor regarding student who is in
need of health and mental health services and how to best
assist the family in gaining access to services through OHP.
 Contacted local OHP provider to determine resources
available for a student needing glasses.
 Coordinating the delivery of medical services for a student with
depression with administration, student, family and DHS.

C1.3 - The 2003 CMS Medicaid Administrative Claiming
guide indicates the following are covered under code C1:
 Providing follow-up contact to ensure that a child has received the
prescribed medical/dental/mental health services covered by
Medicaid.
 Monitoring and evaluating the Medicaid service components of the IEP
as appropriate.
 When necessary and appropriate 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.

C1.3
 The following monitoring activities are NOT claimable:
○ Activities performed in the initial development of the IEP and/or
formal IEP meetings (i.e., annual, 3-yr)
○ 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)

C1.4
 Training: Coordinating, conducting or
participating in training events or seminars for
outreach staff regarding the benefits of
medical/Medicaid related services.
○ Participating in a MAC training.
 Excludes the amount of time spent learning how to fill
out the actual survey.
○ Attending a seminar on how to effectively provide
OHP outreach.
○ The portion of a training where the content
focuses on recognition of signs and symptoms of
specific medical conditions.
 Suicide
 Autism
 Drug and Alcohol Abuse

C1.4
○ The following State Mandated trainings
are not covered:




First Aid Training
CPR Training
EPI Training
Blood-borne Pathogens Training

D1.1
 Scheduling and arranging transportation to OHP covered
services.
○ Does NOT include the provision of the actual transportation
service or the direct costs of the transportation (bus fare, taxi
fare, personal transport, etc, but rather the administrative
activities (related paperwork, clerical activities, staff travel
time, etc.) involved in providing the transportation.

D1.2
 Scheduling, arranging or providing translation for OHP
covered services.
○ Arranging for or providing translation services (oral and
signing) that assist the individual to access and understand
necessary care or treatment covered by Medicaid.
○ Developing translation materials that assist individuals to
access and understand necessary care or treatment covered
by Medicaid.

E1.1
 Developing strategies and policies to assess or
increase the capacity of school
medical/dental/mental health programs (includes
workgroups)
 Worked with nurses and local dentists
regarding increasing access to dental
services for students.
 Review with school team current Mental
Health support system effectiveness.
 Reviewed strategies on how to better identify
and provide access to treatment for students
with asthma.

E1.2
 Working with other agencies and/or providers to
improve the coordination and collaboration and
delivery of medical, mental health and substance
abuse services.
 Attended a community meeting in which access to Mental
Health services for students was discussed. Brainstormed
ways to improve access/delivery of Mental health services
to OHP eligible students.
 Attended a community health resource meeting. We
identified gaps in existing support systems and collaborated
w/various agencies about district wide health needs.
 Collaborating with other agencies/providers on available
OHP options/programs to better serve students in school
with Mental Health needs.
E1 – Program Planning, Policy
Development & Interagency Coordination

El.3
 Monitoring the medical/mental health/dental
health delivery system in schools.
○ Developing advisory or work groups of health
professionals to provide consultation, advice
and monitoring of the delivery of health care
services to school populations.
○ Evaluating the need and/or effectiveness of
medical services provided in the school
setting (such as a school based health
center).

Providing Direct Services vs. Administrative
Activities
 The Centers for Medicare & Medicaid Services
(CMS) rule states: Activities that are considered
integral to, or an extension of direct medical
services, are NOT CLAIMABLE as an
Administrative expense (e.g., patient follow-up,
patient assessment, patient counseling, patient
education, patient consultation, billing activities).
These activities must be reported under
Code F, Direct Medical Services.
EXAMPLES
 Treatment or monitoring activities related to minor
acute health conditions such as, scratches, bruises,
headaches, colds, application of bandages or
distribution of non-prescriptive medications.
 Physical monitoring of health/medical services on a
child’s IEP.
 (NOTE: Follow-up to ensure the activities on an IEP
(prescribed) are covered under C1.3.)

Monitoring a child’s health condition regardless of the
severity or type of condition.
 School secretary monitoring a child in the health room for
adverse reaction to a bee sting
 Teacher monitoring a child after an insulin injection
 Educational assistant monitoring a child following a seizure
Test Your Knowledge

Place yourself in the following scenarios
and attempt to answer the questions
correctly.
 YOU’RE GOING TO TEST WELL. GOOD
LUCK!!

Individual surveys reporting claimable MAC activities
○ 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
 Reporting of Time:
○ Report only PAID work time
○ Report time in 15 minute blocks
○ Report all activities performed during the paid work
day
 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

Steps required to complete the MAC survey:
 Access the MESD website through the following link
http://mac.mesd.k12.or.us
 From the MESD screen choose Survey Login for the ESD under
which you participate
 Indicate your first name and last name as it appears on your
paycheck
 Document the activities performed for your PAID work day from the
list of Activity codes.
 7:30 – 8:30 Code A
 8:30 – 9:00 Code B1.1
 9:00 – 2:30 Code A
 2:30 – 3:30 Code E1.2
 Save the survey
Note: Paid absences are reported as
Code A. Unpaid lunch is left blank
Who do I contact if I need technical assistance?

For assistance in finding local Medicaid providers and in
applying for Medicaid insurance the following websites are
useful:
 Oregon Health Policy Board – What’s Happening With
Health Care in Oregon
○ http://www.oregon.gov/oha/OHPB/Pages/index.aspx
 Oregon County Health Department Directory
○ http://public.health.oregon.gov/ProviderPartnerResource
s/LocalHealthDepartmentResources/Pages/lhd.aspx
 Cover Oregon - Finding Health Insurance For You
○ https://www.coveroregon.com//
 Find a Local DHS Office Near You
○ http://www.oregon.gov/DHS/localoffices/localoffices.p
df