Transcript Medicaid Administrative Claiming

Medicaid Administrative Claiming
“MAC”
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
students and their families!
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.
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Important Facts
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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?
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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 Activity Codes
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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
MAC Activity Codes
Non-Claimable Codes
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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
School Related and Educational Activities
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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 & Oregon Healthy Kids
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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.
What does it cover?
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Healthy Kids covers all of the health care kids need
including:
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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.
Who is eligible?
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.
Medicaid/OHP Services
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Health Services
 Well-child exams
 Immunizations (May not be during exclusion or for education enrollment
requirements)
 Routine physicals
 Maternity and newborn care
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Medical Services
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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
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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.
Medicaid/OHP Services
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Dental Services
 Preventive services (cleaning, fluoride treatments, sealants for
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children)
Routine services (fillings, x-rays)
Dental check ups
Tooth removal
Dentures
24-hour emergency care
Specialist care and referrals
Mental Health Services
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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 – Medicaid Outreach
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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 – Medicaid Outreach
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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 – Medicaid Outreach
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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 – Medicaid Outreach
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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 - Referral, Coordination, Monitoring & Training
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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.
C1 - Referral, Coordination, Monitoring &
Training
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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
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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.
C1 - Referral, Coordination, Monitoring &
Training
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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 - Referral, Coordination, Monitoring & Training
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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 - Referral, Coordination, Monitoring & Training
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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 - Referral, Coordination, Monitoring & Training
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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 - Referral, Coordination, Monitoring & Training
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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 - Referral, Coordination, Monitoring & Training
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C1.4
○ The following State Mandated
trainings are not covered:
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First Aid Training
CPR Training
EPI Training
Blood-borne Pathogens Training
D1 – Transportation/Translation
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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.
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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 – Program Planning, Policy Development & Interagency
Coordination
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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 – Program Planning, Policy
Development & Interagency Coordination
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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
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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).
Code F – Direct Services
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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.
Non Covered Services – CODE F
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.)
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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
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Place yourself in the following scenarios
and attempt to answer the questions
correctly.
 YOU’RE GOING TO TEST WELL. GOOD
LUCK!!
Providing Appropriate Supporting Documentation
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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
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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 Reminders
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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
Completing the MAC Survey
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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?
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1) The MAC Coordinator for your district:
_______________________________
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2) Building Level Trainer:
_______________________________
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3) The ESD Medicaid Facilitator:
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________________________________
Helpful Resources
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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
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