1. MEDICAID In Oregon, it’s called the Oregon Health Plan—OHP.
State-Federal partnership to assist low income individuals and families with health care.

2. Medicaid Administrative Claiming--MAC
vs.
Targeted Case Management and Maternity Case Management
May be most familiar with Targeted Case Management, High Risk Infant Fee For Service (FFS), and Maternity Case Management as part of the OMAP benefits which is not a leveraging program.
FFS is the process by which public health programs bill Medicaid for health services.
Whereas FFS bills, MAC is a reimbursement !
Focus is on Medicaid Administrative Claiming for this training.
Later in the training there will be further discussion on dual participation: TCM and MAC.

3. MAC
MAC is for the proper and efficient administration of the State’s Medicaid Plan – aka – the Oregon Health Plan.
Public Health Departments are reimbursed for specific activities that they are already doing.
Only additional work is taking a survey that takes about 10 minutes to complete.
The official federal definition is the first line.
The real world definition is the second line.
Generally, the time it takes staff to complete (fill out) survey is approximately 10 minutes.
The survey Public health will do is specific to public health MAC; it is not the Healthy Start MAC claiming survey that a public health department may currently be participating in.

4. Administrative Claiming IS NOT:
Targeted Case Management (Babies First!, CaCoon)
This is the process by which public health bills for health services provided to Medicaid/OHP eligible children pursuant to a case management plan.
Maternity Case Management
This is part of the OMAP benefit and not a leveraging program.
Public health may do all the programs; training will help to clearly define work.
There is clear guidance as to how to maintain integrity in all programs, potentially limiting exposure.

5. Medicaid Administrative Claiming Is:
A method of identifying and accounting for the time spent by public health programs staff on administrative activities such as referral and outreach. Reimbursement is then claimed for the time spent performing these activities.
Other than taking the survey and preparing the claim, no new work is required.
Staff do not need to know who is Medicaid/OHP eligible.
Key points
This process will not change the day to day work of the individual—it only accounts for that work.
Staff do not need to be experts on OHP or know all benefit package.
Staff do not need to know who is or who is not on OHP.
The survey process establishes a cost allocation method allowing for participation in multiple leveraging programs.
Significant point is that you receive reimbursement for work that is already being performed by staff.

6. MAC and TCM
MAC is population based; TCM is individual Medicaid eligible based
MAC is total time accounting; TCM is billing for specific service; it is a Code E Direct Service
MAC provided to all by all staff in cost pool; TCM is provided only to Medicaid eligibles through the State Medicaid Plan amendment
MAC not dependent on a TCM plan
Public Health staff can do TCM and MAC- guidance is provided by DHS Multiple Leveraging Program Participation Guidance
Discussion of guidance will be later on in this training.

7. TCMs in Oregon DD
Children Adults and Families – Medicaid Eligible Parents 14 and Over Who Receive AFDC
SCF/OYA
Babies First/CaCoon
HIV (Multnomah only)
Substance Abusing Parents
Substance Abusing Parents – Polk, Yamhill, Jackson,Lincoln, Benton, Marion are the only counties where this TCM operates

8. MAC Claiming Formula 1. Cost Pool X 2. Medicaid eligible percentage
3. Percent of allowable time (survey) =
Public Health total claim
50% Match Required= Net claim
This is the formula that is in the background of Medicaid Administrative Claiming.
One of the codes is not discounted by the Medicaid eligible percentage—which will be discussed later.

9. Developing the Cost Pool
Identify appropriate staff: routine contact with child and family(s)
Nurses, date stampers, interpreters, health educators, program development, etc.
Do not include janitorial, food service, accounting, lab techs, etc.
Identify actual salary, benefits and other personnel expenses
Remove federal funds from the cost pool
Cost pool established quarterly
Fully federally funded positions remove from cost and survey, partial, remove federal funded portion and leave in survey pool.
Use dual participation guidance with TCM staff.

10. Medicaid Eligible Percentage
Public health programs will use program data to establish
Unduplicated count of individuals in service
Formula: All individuals in service on Medicaid/OHP divided by all individuals in service
Percentage is established quarterly
Discuss how this data can be achieved locally; data system and verification methodology.

11. MAC Survey How it Works Random Moment Survey Survey 4 days/qtr
Ten activity codes
15-minute blocks of time
Predominant activity
Random Day
Survey dates and participants are randomly selected
Survey from 8am-6pm
Training
Everyone must be trained before taking survey
Survey is 6 am – 8pm—doesn’t mean you track that entire time frame—just the paid time at work or paid leave.
Survey the time from when you report to work until you are off work time or leave work.
Ten codes are the heart of the survey process and will be explained in detail later in this training.
Ten codes capture everything you do—the “F” code also includes “other.”
The random day process is yet be worked out. Public health will most likely be surveyed 4 or 5 random days per quarter.
Predominant portion of a 15 minute increment—what were you doing during the 15 minutes that made up the most of the that time.
Staff can be randomly chosen, or all staff can be surveyed. More than likely all staff will be surveyed, not a random selection.

12. This is traditional hard copy form; Health departments will be using MESD web-based survey tool
Form used in education---will use this with text changes only.
Front side of form. It is green!
Follow the instructions to fill out the form either here, or at the end of the presentation—where ever is the best fit for time.
Focal points are: Print name and required signature; fill in complete bubble; write in job title, only one code per 15 minute increment.

13. Back side of form—it is green too!
Abbreviated codes are not the entire code. Reference the Codes.
Notes section is not required for use, but staff may use to communicate any special considerations or issues pertaining to the survey.

14. Ten Activity Codes
A1. Outreach and application assistance for Medicaid/OHP Program.
A2. Outreach and Application assistance for non- Medicaid/OHP Outreach.
B1. OHP Referral , Coordination, Monitoring, Training
B2. Non-OHP Referral, Coordination, Monitoring
Training
C1. Medicaid/OHP Transportation and Translation
C2. Non-Medicaid/OHP Transportation and Translation
D1. System Coordination related to OHP services.
D2. System Coordination related to Non-OHP services.
E. Direct Health Care Services.
F. Other work activities.
Notice the parallel coding—this is a federal requirement.
The codes with the number 1 following the letters are the reimbursable activities.
Code A-1 is called a “non-discounted” code. In the formula, the calculation for this code is not discounted or multiplied by the Medicaid eligible percentage because you are outreaching to the entire population.
Codes B1, C-1, and D-1 are called “discounted” codes. In the formula, these codes are discounted or multiplied by the Medicaid eligible percentage because you are conducting activities that benefit the general Medicaid population, i.e. doing referrals, transportation, planning, etc.
All codes include related paperwork, clerical activities, or staff travel required to perform the activities related to the specific code.

15. Code A1: Outreach and Application Assistance for OHP Program
This code should be used for:
Informing individuals on how to access, use and maintain OHP
Assisting in early identification of individuals who could benefit from OHP health services
Explaining OHP eligibility rules and process
Assisting individuals to complete OHP application including translation and comprehension activities
This is the non-discounted code—no Medicaid eligible % used to calculate.
Generally, anything you would do concerning the OHP application is coded here.

16. Code A1 Examples
Informing clients and others about the OHP/Medicaid program and referring them to DHS;
Date stamping and handing out OHP applications to clients.
Providing information regarding Medicaid managed care programs and health plans to individuals and families and how to access that system.
Confirming or verifying with DHS an individual's current Medicaid eligibility status;
Contacting pregnant and parenting teenagers about the availability of Medicaid prenatal and well baby care programs
Pretty much anything anyone does in the form of outreach activities would be coded here

17. Code A-2: Outreach and Application Assistance for Non-OHP Programs
This code should be used for:
Non-OHP outreach; social, educational, legal or other services not covered by OHP
Informing parents/guardians about non-OHP programs: TANF; food stamps; WIC; etc.
Translation of or assisting to comprehend applications to these programs;
Scheduling/promoting activities which educate individuals about the benefits of healthy lifestyles; tobacco cessation, or general nutrition
Parallel of A-1.
These are the social service type programs.
WIC is not paid for by Medicaid, just as TANF and food stamps are federal but not Medicaid.

18. Code A2 Examples
ü     Outreach campaigns directed toward encouraging persons to access social, educational, legal or other services not covered by Medicaid.
ü     Informing an individual or family about programs such as Temporary Assistance for Needy Families (TANF), food stamps, Women’s Infant & Children Program (WIC), day care, legal aid, and other social or educational programs and referring them to the appropriate agency to make application

19. B-1: OHP Referral, Coordination, Monitoring and Training
This code should be used for:
Making referrals for and/or coordinating the medical/developmental health/dental health/mental health and substance abuse services covered by OHP
Providing any information that may be required in advance of these referrals
Providing follow up contact to ensure that a child has received the prescribed health services
Discounted Code.
Code is used when referring to actual OHP covered services.
Any of these activities that are an extension of or integral to TCM/MCM are coded as E, Direct Service.

20. Code B1 Examples
ü     Making referrals for and/or coordinating medical health, dental health, mental health or substance abuse services covered by Medicaid, including medical or physical examinations and necessary medical evaluations
ü     Providing information and making referrals for and/or scheduling Medical screenings.
ü     Arranging for any diagnostic or treatment services, which may be required as a result of a condition identified during an evaluation or screening.
ü     Gathering information that may be required in advance of these referrals or evaluations.

21. More Code B1 Examples
Working with individuals, their families, other staff, and providers to identify, arrange for, and coordinate services covered under Medicaid that may be required as a result of screens, evaluations, or examinations.
The actual referral of an individual to a medical program for Medicaid-covered services.
Training which improves the delivery of Medicaid-covered services, including TCM training
Participating in or coordinating training which enhances early identification, intervention, screening and referral of clients with special health needs to medical services.

22. B-2: Non-OHP Referral,Coordination, Monitoring, and Training
This code should be used if not TCM/MCM for:
Making referrals for social services, community wellness, etc. programs
Gathering any information that may be required in advance of these referrals
Making referrals for educational or vocational programs.
Use this code when referring a family to social services.
Training on non-Medicaid and Medicaid/OHP covered services such as this one on a random day would be coded here.
This is for individuals not on a TCM plan or MCM plan

23. B2 Examples Making referrals for and/or coordinating WIC services.
Working with individuals, their families, other staff, and providers to identify, arrange for, and coordinate social services including housing, food bank, etc.
Assist family in accessing parenting support group to empower parents with optimal parenting skills

24. Code C-1: Medicaid/OHP Transportation and Translation
This code should be used for:
scheduling, arranging or providing transportation to Medicaid/OHP covered services
If destination time is positive, can include the staff travel time back and forth!
scheduling, arranging or providing translation services to assist individual to access and understand necessary care and treatment
IF transportation is being billed as a Fee For Service, then this activity is coded D-2.
Translation is for the Medicaid/OHP covered services, which again, OHP has a fairly broad benefit package.

25. C-2: Non-Medicaid/OHP Transportation and Translation
This code should be used for:
scheduling, arranging or providing transportation to social, vocational and/or other educational programs and activities
scheduling, arranging or providing translation services to assist individual to access and understand necessary non-Medicaid/OHP services
Parallel of Code D-1.
If Fee For Service billed for transportation, then code here.

26. Code D-1: System Coordination Related to OHP Services
This code should be used for:
Working internally and with other agencies to improve OHP services
Identifying gaps, duplications, overlaps of medical services
Developing strategies to access or increase the capacity of medical, developmental, dental, mental health programs
Interagency coordination to improve delivery of OHP services
Discounted code.
System coordination/ early childhood planning and local coordinated comprehensive planning, public health services planning would be included here.

27. D1 Examples
Working internally or with other agencies providing Medicaid services to improve the coordination and delivery of services, to expand access to specific populations of Medicaid eligibles, and to improve collaboration around the early identification of medical problems.
Reducing overlap and duplication in Medicaid-covered services and closing gaps in the availability of services.
Planning and developing strategies to increase Medicaid system capacity and close Medicaid service gaps; includes analyzing Medicaid data related to a specific program or specific group.

28. This code should be used for:
Code D-2: Referral, Coordination and Monitoring of Non-Medicaid Services
This code should be used for:
working collaboratively with other agencies to identify gaps, overlaps or duplication of non-medical/health services, such as vocational, social or educational services
improve coordination, expand access or delivery of non-Medicaid/OHP services
develop strategies to assess or increase the capacity of non-medical, dental and mental health programs
Parallel of Code D-1.
This code applies to the social service, vocational or educational services.

29. D2 Examples
Working internally or with other agencies to improve the coordination and delivery of social services such as housing, food banks, etc.
Coordinating bioterrorism preparedness.
Meeting with community groups to address issues with environmental health systems (water systems, restaurant inspections, etc).
Provide health expertise to a community group on writing a juvenile offender grant, which proposes a new system to respond to juvenile offenders and their parents.

30. CODE E - DIRECT SERVICE
An activity that is done to correct or ameliorate a condition
Any activity that is considered integral to, or an extension of a specified covered service
Does not have to be a billable service
May not have to be performed by a practitioner – administering first aid

31. Code E Examples Code E Examples
Give immunizations at public immunization clinic
TCM/MCM
Providing health/dental/mental health services
Conducting health/dental/mental health assessments/evaluations and diagnostic testing
Administering first aid or prescribed injection or medication to an individual
This code is used for TCM or MCM: as well as those things that are integral to or an extension of TCM or MCM, such as referral, monitoring, and coordinating.
Definition – A service that corrects or ameliorates a condition; doesn’t need to be a licensed practitioner; do not have to bill for it to call it a direct service.
This includes staff that hands out medications to an individual as prescribed.
Administering any first aid by any staff.

32. Code F: Other Work Activities
This code should be used for:
All other job related activities that do not fall under one of the above categories
Paid time off, vacation leave, sick leave, paid lunch, jury duty or any other paid time away from work
Budget development; general supervision
Paid time off.

33. Multiple Leveraging Guidance
Individuals can participate in two leveraging programs-direct and administrative
The time survey is a tool to cost allocated between programs
Handout on the Multiple Leveraging Guidance.

34. Good Information to Know
Staff do not need to know who is Medicaid/OHP eligible
It is the activity of staff that is being measured, not the outcome of the activity
Staff do not need to know all about Medicaid/OHP
Time study determines staff time spent on eligible and non-eligible activities
Formula takes care of eligibles
Medicaid/OHP is comprehensive health plan with broad benefit package.

35. Contacts Fritz Jenkins, DHS fritz.jenkins@state.or.us
Gary Williams, DHS