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 Jeff Olson NC Department of Health and Human Services Local Support Team Manager Division of Social Services/Child Welfare Section

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

4 New opportunities More adults and children can receive services More adults and children can receive services More than a replacement for ARCM More than a replacement for ARCM Allows other qualified staff to serve Allows other qualified staff to serve

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) (b)(7). 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) (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 ). Medicaid Administrative Claiming (MAC) activities must be “in some way connected with administering services covered under the state plan” (Medicaid State Plan Manual section ). 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) 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)

Administrative Memo Excerpt

10 Medicaid “admin” claiming identifies expenditures related to activities They include: 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.

11 What you need to know Medicaid Administrative Claiming Basics

12 MAC Basics for Workers Allows Allows –Coordination of Medicaid services when an individual is receiving other services –Activities has 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

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 is not required CM credential or experience* 13

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

“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 Eligible who needs assistance in accessing Medicaid services under the NC Medicaid State Plan (including Health Choice) Adults and Children who are Medicaid Eligible who needs 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 requires 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 Categories for Activity Coding 1. Referral, Coordination and Monitoring of Medicaid Services (SIS code 340) 2. Arranging Transportation Services for Client to Access Medicaid Services (SIS code 343) 3. Outreach for Medicaid Services (SIS code 342) 4. 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: 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 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) Care coordination of needed Medicaid covered medical, mental health or substance abuse services (1 of 3)

20 Referral, Coordination and Monitoring of Medicaid Services (SIS Code 340) Monitoring and evaluating the Medicaid covered medical components of the individual’s service plan for effectiveness in addressing needs 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. Preparing documentation for interdisciplinary planning meetings, case planning meetings, etc. Participating in treatment plan meetings 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 Gathering information for facilitating prior authorizations In-home training of parents or family to improve the coordination/delivery of Medicaid services 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 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 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 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: 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)

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: 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: 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. Includes all related paperwork, clerical activities, or staff travel required to perform these activities. Both written and oral methods may be used. Both written and oral methods may be used. (2 of 4)

27 Outreach for Medicaid Services (SIS Code 342) Specific activities include: 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 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: 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 Assuring that health/mental health problems are diagnosed and treated early (4 of 4)

Outreach for Medicaid Services MAC 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: 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. 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: 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)

Facilitating an Application for the Medicaid Program MAC 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.

You can only bill that portion of time that is connected to accessing Medicaid services under 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 meets requirements for MAC 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 meets 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 meets requirements for MAC 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 meets requirements for MAC

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

38 More on MAC for Children

39 Child Welfare In Child Welfare, the identified federal and state benchmarks associated with CFSR’s are Safety, Permanence and Well Being for children 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. 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.

40 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 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. 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.

41 Child Welfare Agencies may also want to consider this claiming for activities involving prevention. 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 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

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

43 Adult and Children Case Studies In this corner……. Adult workers Children workers Adult workers Children workers

44 So, Now What? (MAC Activities Flow chart)

45 DSS-5027 for MAC codes 340 & 343 Document beneficiary’s request on the 5027 Document beneficiary’s request on the 5027 Open/update a service information record Open/update a service information record A signature is not required when individual is opened on the DSS-5027 for MAC A signature is not required when individual is opened on the DSS-5027 for MAC If MAC and another service is opened on DSS a signature is not required for MAC but would be for the other service If MAC and another service is opened on DSS a signature is not required for MAC but would be for the other service If MAC is added to the DSS-5027 where there is already an existing service, a signature is not required for MAC If MAC is added to the DSS-5027 where there is already an existing service, a signature is not required for MAC

46 Medicaid Administrative Claiming that DOES NOT require a 5027 Medicaid Outreach (SIS code 342) Medicaid Outreach (SIS code 342) Facilitating an Application for the Medicaid Program (SIS code 341) Facilitating an Application for the Medicaid Program (SIS code 341)

47 Assess the Client’s Environment and Functional Status Assess needs for medical, educational, social or other services Assess needs for medical, educational, social or other services Determine the need for accessing Medicaid service under the State Plan Determine the need for accessing Medicaid service under the State Plan For Adult Services, use the Adult Services Functional Assessment(DSS- 6220) For Adult Services, use the Adult Services Functional Assessment(DSS- 6220) Children’s Services will complete the Strengths and Needs Assessment DSS-5229 and the DSS-5010 Children’s Services will complete the Strengths and Needs Assessment DSS-5229 and the DSS-5010

Claiming MAC Reimbursement for the Assessment (carving out) Only those items related to accessing Medicaid services can be billed as a MAC activity Conduct the entire assessment and then make a determination of how much is related to accessing Medicaid Services

49 Service Plan DSS-6221 for Adult Services Service Plan should include: The service needs identified during the assessment The service needs identified during the assessment Strategies for locating and referring the recipient to programs and providers that will meet the recipient needs Strategies for locating and referring the recipient to programs and providers that will meet the recipient needs Goals for the outcome of case management Goals for the outcome of case management The service needs, strategies, goals and dates must be supported by the assessment information The service needs, strategies, goals and dates must be supported by the assessment information

50 Service Plan DSS-5239 or 5240 for Child Welfare Service Plan should include: Specific health and or behavioral health needs of the child identified during the assessments Specific health and or behavioral health needs of the child identified during the assessments Strategies for locating and referring the child to programs and providers that will meet the child’s needs Strategies for locating and referring the child to programs and providers that will meet the child’s needs Name(s) of the person(s) responsible for accomplishing these activities Name(s) of the person(s) responsible for accomplishing these activities

Claiming MAC Reimbursement for Service Plan Goals (carving out) Regardless of whether a goal can be billed to MAC, all identified needs should be addressed!! Goals that can be billed to MAC are those that assists in accessing Medicaid Services under the NC Medicaid State Plan

52 MAC Activities during the CPS Assessment The child’s specific needs must be identified and documented through the SDM tools The child’s specific needs must be identified and documented through the SDM tools Documentation must include identifying strategies and activities to address the health and behavioral health needs Documentation must include identifying strategies and activities to address the health and behavioral health needs A description of the activities A description of the activities

53 Monitoring/Follow up by the Worker The expectation is that adult and children services will follow their normal procedures for case planning including monitoring and follow up. Theses will be discussed in the breakout groups (adults and children services do not use the same forms)

54 Find your Groups Again Adults Children

55 Day Sheet (DSS-4263) All social workers must follow the documentation guidelines, and correctly fill out the day sheet to ensure that activities are being properly documented All social workers must follow the documentation guidelines, and correctly fill out the day sheet to ensure that activities are being properly documented (Day sheet training guide)

56 Monitoring MAC activities will be monitored periodically according to the DHHS Monitoring Plan MAC activities will be monitored periodically according to the DHHS Monitoring Plan

The Monitoring Tool Day Sheet Entries/Claims, NOT Records/Cases

58 What have we learned today? Test your Knowledge

59 QUESTIONS? Certificates Homework Class evals Case Study answers Frequently Asked Questions (FAQs) see handout WRAP UP

60 Who Gonna Contact? Charles Williams - Jeff Olson - Adult Program Representatives Children Program Representatives - Charles Jackson(DMA) -

Medicaid Administrative Claiming for Adults and Children Medicaid Administrative Claiming for Adults and Children Last modified on: October 27, 2014