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Medicaid Administrative Claiming For Adults and Children

Medicaid Administrative Claiming For Adults and Children. Rethinking Cost Claiming Service Activities. Presenters. Charles Williams NC Department of Health and Human Services Social Service Program Coordinator Division of Aging and Adult Services charles.williams@dhhs.nc.gov Evan Friedel

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Medicaid Administrative Claiming For Adults and Children

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  1. Medicaid Administrative Claiming For Adults and Children Rethinking Cost Claiming Service Activities

  2. Presenters Charles Williams NC Department of Health and Human Services Social Service Program Coordinator Division of Aging and Adult Services charles.williams@dhhs.nc.gov Evan Friedel N.C. Department of Health and Human Services Division of Social Services/Child Welfare Section Children’s Program Representative Evan.Friedel@dhhs.nc.gov

  3. Purpose of this Training Introduce Medicaid Administrative Claiming opportunities Outline parameters for use of MAC Provide examples of allowable activities

  4. New opportunities • More adults and children can receive services • More than a replacement for ARCM • Allows other qualified staff to serve • Maybe the best thing since

  5. Overview Under Title XIX of the Social Security Act, section 1903(a)(7), federal payment is available at a rate of 50 percent for amounts expended by a state “as found necessary by the Secretary for the proper and efficient administration of the state plan,” per 42 Code of Federal Regulations (CFR) 433.15(b)(7).

  6. Overview Medicaid Administrative Claiming (MAC) activities must be “in some way connected with administering services covered under the state plan” (Medicaid State Plan Manual section 4302.2). Time billed to MAC must be directly related to medical assistance to Medicaid covered services under North Carolina’s Medicaid State Plan. (see Administrative Memo)

  7. Administrative Memo Excerpt

  8. Administrative Memo Excerpt

  9. Medicaid “admin” claiming identifies expenditures related to activities • They include: • Medicaid Outreach; • Medicaid Eligibility Determinations; • Referral to Medicaid Services; • Medicaid Case Planning, Review, and Management; • Development of an Individual Plan of Care for Medicaid Services; • Coordinating transportation needed to access Medicaid services.

  10. What you need to know Medicaid Administrative Claiming Basics

  11. MAC Basics for Workers • Allows • Coordination of Medicaid services when an individual is receiving other services • Activities have to be connected to accessing Medicaid services covered under Medicaid State Plan • Claiming of travel and documentation time when it is connected to Medicaid services

  12. MAC Basics for Workers (continued) • Can be provided in any setting, including facilities* • Only county staff or contracted worker(not an contracted agency) can bill for MAC activities • Day sheets must be completed by DSS staff or contracted worker for ALL MAC codes • There are no required CM credential or experience*

  13. MAC Basics for Fiscal Staff FFP is Federal 50% County 50% Uncapped federal funding Activities recorded on day sheets and reported on the DSS-1571 rather than NCTracksbilling Claims are billed only on Part I of the fiscal note/SIS (No part II or Part IV) No cost settlement required Only one cost center for both adult and children

  14. What’s the Point? (example) • ADMINISTRATIVE TIME FOR COUNTY STAFF TO ASSIST INDIVIDUALS TO ACCESS MEDICAID SERVICES UNDER THE NC STATE MEDICAID PLAN!!!

  15. “With great power, comes great responsibility!” • Just about everybody who walks in your door can receive MAC activities (uncapped funds) • It’s not how much can I bill, but what does my client need • Got to have an agency plan (Internal)

  16. NC Medicaid Eligible Population Adults and Children who are Medicaid beneficiaries who need assistance in accessing Medicaid services under the NC Medicaid State Plan (including Health Choice) And/Or Adults and Children who are served through Medicaid Outreach and/or require assistance in completing a Medicaid application in order to access Medicaid services

  17. 4 Coding Categories(see MAC Desk Guide) Categories of Activities

  18. Categories for Activity Coding Referral, Coordination and Monitoring of Medicaid Services (SIS code 340) Arranging Transportation Services for Client to Access Medicaid Services (SIS code 343) Outreach for Medicaid Services (SIS code 342) Facilitating an Application for the Medicaid Program (SIS code 341)

  19. Referral, Coordination and Monitoring of Medicaid Services (SIS code 340) • Referring and/or coordinating Medicaid covered services for individuals that have: • functional impairments or mental health disabilities, and/or • substance abuse/addiction disorders • Performing assessments to identify health and mental health needs in advance of referrals or evaluations • Care coordination of needed Medicaid covered medical, mental health or substance abuse services (1 of 3)

  20. Referral, Coordination and Monitoring of MedicaidServices (SIS Code 340) • Monitoring and evaluating the Medicaid covered medical components of the individual’s service plan for effectiveness in addressing needs • Preparing documentation for interdisciplinary planning meetings, case planning meetings, etc. • Participating in treatment plan meetings (2 of 3)

  21. Referral, Coordination and Monitoring of Medicaid Services (SIS Code 340) • Gathering information for facilitating prior authorizations • In-home training of parents or family to improve the coordination/delivery of Medicaid services • Follow-up contact to ensure that an individual has received the prescribed Medicaid services (3 of 3)

  22. Arranging Transportation Services for Client to Access Medicaid Services (SIS Code 343) • Scheduling or arranging transportation services that assist the individual or family to access necessary care or treatment by health/mental health care providers • Includes activities such as related paperwork, clerical activities, or staff travel required to arrange transportation (1 of 3)

  23. Arranging Transportation Services for Client to Access Medicaid Services (SIS Code 343) • It does not include: • provision of the actual transportation service as a direct service • activities that contribute to the actual billing of transportation • accompanying an individual to Medicaid services as an administrative activity (2 of 3)

  24. Staff Travel and Transportation Services for Client to Access Medicaid Services • See example (Staff Travel and Transportation) (3 of 3)

  25. Outreach for Medicaid Services (SIS Code 342) • Used when performing activities that inform individuals about: • available Medicaid services, • how to access Medicaid services, • the importance of accessing medical, mental health, aging, functional/developmental disability, and alcohol and drug services and • the importance of maintaining a routine place for health care (1 of 4)

  26. Outreach for Medicaid Services (SIS Code 342) • General activities include: • bringing persons into the Medicaid system for the purpose of determining eligibility and • arranging for the provision of Medicaid services. • Includes all related paperwork, clerical activities, or staff travel required to perform these activities. • Both written and oral methods may be used. (2 of 4)

  27. Outreach for Medicaid Services (SIS Code 342) • Specific activities include: • Developing, disseminating or presenting materials to inform individuals about Medicaid services and where to obtain services • Informing individuals and families about the benefits and availability of services provided by Medicaid • Informing individuals and their families on effectively accessing, using, and maintaining participation in all health and mental health resources under the federal Medicaid Program (3 of 4)

  28. Outreach for Medicaid Services (SIS Code 342) • Assisting in early identification of individuals who could benefit from the health/mental health services provided by Medicaid • Assisting the Medicaid agency to fulfill objectives of the Medicaid program by: • Informing individuals of the benefits of prevention • Helping individuals and families use health/mental health resources • Assuring that health/mental health problems are diagnosed and treated early (4 of 4)

  29. Outreach for Medicaid ServicesMAC SIS Code 342 activties(note, this is typically used for individuals/families that are not part of an open case) • You create a brochure to explain where Medicaid services can be obtained in your county • You work a booth at a health fair and talk to people in the community about the benefits they could receive from Medicaid • You talk with a family about available Medicaid services and how it will help make them all healthier • You coordinate the printing of informational packets about Medicaid services and where they can be obtained NOT Outreach for Medicaid Services • You provide information on food stamps to a family that is applying for Medicaid at your office (This is not MAC. Providing information on food stamps is not a Medicaid activity)

  30. Facilitating an Application for the Medicaid Program (SIS code 341) • Used when: • assisting an individual or family to make application for Medicaid or • assisting an individual to maintain Medicaid eligibility • Includes all related paperwork, clerical activities or staff travel required to perform these activities. (1 of 2)

  31. Facilitating an Application for the Medicaid Program (SIS code 341) • Includes: • Verifying an individual’s current Medicaid eligibility status • Explaining Medicaid eligibility rules and the Medicaid eligibility process • Assisting individuals or families to complete a Medicaid eligibility application • Assisting individuals or families to gather information and documents for the Medicaid application (2 of 2)

  32. Facilitating an Application for the Medicaid ProgramMAC SIS Code 341 activities • You write down a list of the Medicaid eligibility rules and explain each one to a family interested in Medicaid services • You help a gentleman collect the various documents he needs to complete a Medicaid application • You help a client renew his Medicaid coverage • You refer a woman to her local assistance office to complete an application for Medicaid • You complete a disability determination application in order for the individual to obtain Medicaid NOT Facilitating an Application for the Medicaid Program • You help a client complete an application to work at the local grocery store, so that he can have a job with health care coverage (This is not MAC. Completing a job application, or doing anything for private insurance is not a Medicaid activity.

  33. You can only bill that portion of time that is connected to accessing Medicaid services under the State Medicaid Plan • If you make a visit or transport a client, your travel and documentation must reflect the percentage of Medicaid time that you billed • This above is true for all MAC activities including assessment and service plans

  34. More on MAC for Adults

  35. Adult Wards of the DSS The county department of social services (DSS) can bill MAC activities for a beneficiary for whom the DSS has been appointed legal guardian and if the activities meet the requirements for MAC

  36. Adult Payees of the DSS The county department of social services (DSS) can bill MAC activities for a beneficiary for whom the DSS has been appointed the Payee if the beneficiary is Medicaid eligible and if the activities meet the requirements for MAC

  37. Special Assistance In Home (SA-IH) The county department of social services (DSS) can bill MAC activities in conjunction with case management for SA-IH participants You MUST document how these activities are assisting an individual in accessing Medicaid services

  38. CAP (Community Alternatives Program) 26 A) Can CAP staff claim MAC activities while providing case management activities under a waiver service? (CAP case management time is still available). No. To avoid duplicate claiming, allowable administrative activities that are reimbursed through another program such as CAP cannot also be claimed under MAC. Staff members providing CAP services may be able to claim reimbursable administrative activities under MAC when the coordination of Medicaid services are not reimbursed under CAP or CAP case management time is no longer available.

  39. CAP Examples of activities that should be claimed as CAP (when available) include: • Assessing • Care Planning • Referral and Linkage • Monitoring and Follow-up CAP staffs often provide both direct services and administrative activities. The activities listed on the previous page are direct services/activities related to CAP. These services are integral to case management and would be considered duplication of payment if claimed under MAC when allowed under CAP or when CAP case management time is still available because activities are properly paid for as part CAP services and reimbursed at the federal medical assistance percentage (FMAP).  

  40. CAP 26 B) If activities provided to a waiver beneficiary is not billable to the waiver, can CAP staff bill their time to MAC? Yes. A few examples of activities (not a comprehensive list) that could be potentially claimable under MAC by a CAP staff: • Completing the Service Request Form (SRF) • Preparing documents and participating in discussion meetings with supervisor and staff • Documenting case management activities • Outreach to Board Members/auxiliary about CAP (Advisory meeting attendance) • Outreach to community about CAP services, how to apply, eligibility criteria, referral • In-home training to families to improve coordination/delivery of Medicaid services (CAP does not provide training to families, just coordinate the referral, link and monitor) • Staff travel to arrange transportation

  41. CAP • 26 C) If the allotted case management time has been exhausted for billable waiver case management activities, could MAC be used once a CAP beneficiary has exhausted all of their CAP funds? • Yes. MAC activities can be selected only after time has been exhausted under CAP. The case management agency must have supporting documentation that proves case management time was exhausted as a result of efficient resourcing. Assisting a CAP beneficiary to access a Medicaid service to remain safely in their community could be claimed as MAC activities given that documentation supports exhaustion of case management time and the need for the participant to have access to a Medicaid service.

  42. CAP/DA Waiver Services • Adult day health • Personal care aide • Home accessibility and adaptation • Meal preparation and delivery • Institutional respite services • Non-institutional respite services • Personal Emergency Response Services • Specialized medical equipment and supplies • Participant goods and services • Community transition services • Training, education and consultative services • Assistive technology • Case management • Care advisor (CAP/Choice only) • Personal assistant (CAP/Choice only) • Financial management services (CAP/Choice only) An annual calendar allotment of case management is set at 42hours/168units from January1st -December 31st.

  43. CAP 52. Can any other worker, such as APS, Guardianship, Payee, SAIH, etc., bill allowable MAC activities for a client that is a current CAP beneficiary, since they are not the CAP worker? Yes. Multiple workers can bill time to MAC for working with a CAP beneficiary when APS, Guardianship, and Special Assistance is provided.

  44. More on MAC for Children

  45. Child Welfare In Child Welfare, the identified federal and state benchmarks associated with CFSR’s are Safety, Permanence and Well Being for children MAC coding can be used for time spent on activities to meet health and mental health well being needs of children open for CWS who are Medicaid beneficiaries.

  46. Child Welfare MAC cannot be used for any activities focused solely on Safety and Permanency. Other funding sources must be used for those activities. MAC can also be used for In Home cases in which children are not at serious risk of foster care placement, but health and behavioral health needs exist that if appropriately addressed, could prevent future maltreatment.

  47. Child Welfare Agencies may also want to consider this claiming for activities involving prevention. MAC can be used for “third track” situations in which a CPS report is received and not accepted for assessment, but there are needs identified that could be addressed to prevent future reports or assist the family to overcome a health/behavioral health crisis

  48. Applying MAC Activities in Case Work Are you ready to do the MAC-arena?!

  49. Adult and Children Case StudiesIn this corner……. Adult workers Children workers

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