Transcript Title Page - Multnomah Education Service District

Medicaid Administrative Claiming
“MAC”
2016-2017
Train-The-Trainers
Oregon Health Authority Support
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
Agenda
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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
Medicaid In Schools
• 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 in Schools
• 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
MAC Match Leveraging
• Reimbursement authority
– Pursuant to 42 CFR 433.50, 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.
MAC Match Leveraging
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.
MAC Eligibility Report
• 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 non-federal 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.
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 personby-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.
Audit Requirements - District
• 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
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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 5 business days prior to the
assigned date.
The school district(s) will accomplish the survey on the date
assigned.
Trainer Responsibilities
• Trainers must attend a MAC train-the-trainers
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 period
– Staff must sign the training sign in sheet
• Records training date
• Provides access into the MESD web based system
Trainer Responsibilities
• 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.
Trainer Responsibilities
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
Trainer Responsibilities
• 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 (no less than 5 business
days) after completing the survey. The documentation should:
– 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
Trainer Responsibilities
• 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
Medicaid in Schools
Personnel Reporting MAC Activities
Administrative Service
Providers
Claimable Categories
• B1 – Medicaid/OHP
Outreach and Facilitating
– Administrators
Medicaid/OHP Eligibility
– Principals
• C1 – Referral, Coordination,
– Teachers
Monitoring and Training of
– Educational Assistants Medicaid OHP Services
• D1 – Medicaid/OHP
– Secretaries
Transportation and
– Counselors
Translation
– TSPC School
• E1 Program Planning,
Psychologists
Policy Development, and
Interagency Coordination
related to Medical Services
Medicaid in Schools
Personnel Reporting MAC Activities
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
Medicaid in Schools
Personnel Reporting MAC Activities
• 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.
Medicaid in Schools
Personnel Reporting MAC Activities
• 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.
Medicaid in Schools
Personnel Reporting MAC Activities
• 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:
○ Provided 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)
– 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
• Other Non-Claimable scenarios may include:
– As mandated by state law, a secretary generates a county
immunization status report during exclusion.
• Link to exclusion information:
– http://public.health.oregon.gov/PreventionWellness/VaccinesIm
munization/GettingImmunized/Documents/SchLawHandbook.pd
f
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.
Medicaid Outreach & The Oregon Health
Plan
• Medicaid outreach activities are those performed to
inform eligible or potentially eligible individuals about
Medicaid and how to access the Oregon Health Plan.
• Oregon Health Plan
– 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?
 The Oregon Health Plan covers all health care needs
for kids 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
○ For free coverage, household income cannot be more than 300% of federal
poverty level and may be up to $74,115 for a family of 4.
Oregon Health Plan Application Assistance
• OHP Application/Information
– http://healthcare.oregon.gov/Pages/index.aspx
• General Information
• On-Line Application
Referring Students for Medical Services
 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
Referring Students for Medical Services
 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
Non Claimable Referrals
• 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.
• 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
Helpful Resources
• 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/ProviderPartnerResourc
es/LocalHealthDepartmentResources/Pages/lhd.aspx
– Oregon Healthcare.gov- Finding Health Insurance
http://healthcare.oregon.gov/Pages/index.aspx
– Find a Local DHS Office Near You
○ http://www.oregon.gov/DHS/Offices/Pages/index.aspx
Medicaid Administrative Claiming
“MAC”
2016-17
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.
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 Activity Codes
 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
• 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
• 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 & The Oregon Health
Plan
• Medicaid outreach activities are those performed to
inform eligible or potentially eligible individuals about
Medicaid and how to access the Oregon Health Plan.
• Oregon Health Plan
– 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?
 The Oregon Health Plan covers all health care needs
for kids 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.
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
○ For free coverage, household income cannot be more than 300% of federal
poverty level and may be up to $74,115 for a family of 4.
Oregon Health Plan Application Assistance
• OHP Application/Information
– http://healthcare.oregon.gov/Pages/index.aspx
• General Information
• On-Line Application
Medicaid/OHP Services
 Health Services
 Well-child exams
 Immunizations (May not be during exclusion or for education
enrollment requirements)
 Routine physicals
 Maternity and newborn care
 Medical Services
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








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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
Medicaid/OHP Services
• Dental Services
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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
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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 sub-codes.
B1 – Medicaid Outreach
• 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
 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
 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 in-district 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
• 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
 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
• 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.
C1 - Referral, Coordination, Monitoring &
Training
 Immunizations Continued
Non Claimable – C2
 Non-claimable 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
• 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
 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
• 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
 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
 C1.4
○The following State Mandated
trainings are not covered:
– First Aid Training
– CPR Training
– EPI Training
– Blood-borne Pathogens Training
D1 – Transportation/Translation
 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 – Program Planning, Policy Development & Interagency
Coordination
• 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
 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).
Code F – Direct Services
• 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.)
 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!!
Providing Appropriate Supporting Documentation
• 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 Reminders
• 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
 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?
 1) The MAC Coordinator for your district:
________________________________
 2) Building Level Trainer:
________________________________
 3) The ESD Medicaid Facilitator:

________________________________
Helpful Resources
• 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/ProviderPartnerResourc
es/LocalHealthDepartmentResources/Pages/lhd.aspx
– Oregon Healthcare.gov- Finding Health Insurance
http://healthcare.oregon.gov/Pages/index.aspx
– Find a Local DHS Office Near You
○ http://www.oregon.gov/DHS/Offices/Pages/index.aspx