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Welcome to the Health & Human Services  LHD Medicaid Administrative Training
Contact/Resource Information <ul><li>Sandra Brabandt </li></ul><ul><ul><li>Phone:  512 491-1314 </li></ul></ul><ul><ul><li...
Agenda <ul><li>Morning Session </li></ul><ul><li>9:00 a.m. – 12:00 a.m.   </li></ul><ul><li>Program Overview </li></ul><ul...
<ul><li>Program Overview </li></ul>
What is Medicaid Administrative Claiming (MAC)? <ul><li>MAC is an administrative program that provides Texas state agencie...
Medicaid Federal Medicaid Reimbursement for Administrative Activities associated with linking students to appropriate Medi...
Time Study Methodologies <ul><li>The purpose of the Medicaid administration project is to ensure access of eligible indivi...
Time Study Log Requirement <ul><li>CMS requires: </li></ul><ul><ul><li>a minimum of 750 valid or accurate WDLs for each pe...
Time Study & Claiming Timeframes  <ul><li>Federal Fiscal Year Quarters  </li></ul><ul><ul><li>Quarter 1 – October 1 thru D...
The Purpose of the Time Study <ul><li>The time study will measure the amount of time spent by the eligible staff on Medica...
RMTS Process Overview   Quarterly processes . .  . Determine who performs MAC activities Determine how much reimbursable a...
<ul><li>Mandatory Participation Requirements </li></ul>
HHSC Responsibilities •  HHSC provides program oversight and guidance for all program participants  •  HHSC works with app...
Local Roles & Responsibilities <ul><li>Program/Financial Coordinator: </li></ul><ul><li>Serve as liaison with HHSC  </li><...
MAC Required Documentation for Participation <ul><li>Each LHD that  plans to participate in the MAC program must complete ...
MAC Audit File <ul><li>Each LHD is required to maintain a quarterly MAC audit file and must include the following:  </li><...
<ul><li>Selecting Time Study Participants  </li></ul><ul><li>& </li></ul><ul><li>Applying the  </li></ul><ul><li>Time Stud...
Medicaid Covered Services <ul><li>Physicians’ services </li></ul><ul><li>Hospital review </li></ul><ul><li>Clinic services...
Time Study Staff Selection <ul><li>Who should time study  </li></ul><ul><ul><li>Program Coordinators will select staff who...
Time Studied Staff Training <ul><li>Program Coordinators </li></ul><ul><ul><li>identify training needs among staff and con...
Time Study Training Reminders  <ul><li>The activity description should be a detailed response, and provide information tha...
Miscellaneous Reminders <ul><li>Activity and TS Codes - Indirect activities that directly support the activity go with the...
Travel / Transportation  <ul><li>Travel vs. transportation </li></ul><ul><li>Travel = staff time to and back from a locati...
1 – Facilitating Medicaid Eligibility <ul><li>Examples of activities: </li></ul><ul><ul><li>Verifying current Medicaid eli...
2 – Facilitating Non-Medicaid Eligibility <ul><li>Examples of activities: </li></ul><ul><li>Verifying eligibility for Medi...
3 – Medicaid Outreach (SPMP) <ul><li>Examples of activities: </li></ul><ul><li>Designing and implementing strategies to id...
4 – Medicaid Outreach  <ul><li>Examples of activities: </li></ul><ul><li>Informing general population or groups of individ...
5 – Non-Medicaid Outreach  <ul><li>Examples of activities: </li></ul><ul><li>General health education programs or campaign...
6 – Referral, Coord & Monitor Medicaid  <ul><li>Examples of activities: </li></ul><ul><li>Making referrals for and/or coor...
6 – Referral, Coord & Monitor Med. cont’d <ul><li>Gathering any information that may be required in advance of these refer...
7 – Ref. Coord & Mon. Medicaid (SPMP)  <ul><li>Examples of activities: </li></ul><ul><ul><li>Making referrals for and/or c...
7 – Ref. Coord & Mon. Medicaid (SPMP) cont. <ul><li>Examples of activities:   </li></ul><ul><li>Participating in inter/int...
8 – Ref. Coord & Mon. Non-Medicaid   <ul><li>Examples of activities: </li></ul><ul><li>Screening and making referrals for,...
9 – Medicaid Transportation &Translation <ul><li>Examples of activities: </li></ul><ul><li>Arranging translation or transp...
10 – Medicaid Provider Relations <ul><li>Examples of activities: </li></ul><ul><li>Recruiting new Medicaid providers. </li...
11 – Program Planning Development,  & Interagency Coordination <ul><li>Examples of activities: </li></ul><ul><li>Working w...
12 – Program Planning Development  & Inter Coord (SPMP) <ul><li>Examples of activities requiring the licensed SPMP: </li><...
13  – DIRECT SERVICES   <ul><li>Examples of activities: </li></ul><ul><li>Direct clinical and treatment services, such as:...
14  –   NON-MEDICAID, OTHER EDUCATIONAL AND SOCIAL SERVICES   <ul><li>Examples of activities: </li></ul><ul><ul><li>Provid...
15 – General Administration <ul><li>Examples of activities: </li></ul><ul><li>Receiving and/or presenting training </li></...
L – Lunch <ul><li>Use for unpaid lunch time </li></ul>
O – Off <ul><li>Use if personnel are in an “off-duty” status during part of their scheduled workday. </li></ul><ul><li>Use...
<ul><li>  Please return by  </li></ul><ul><li>1:30 p.m. </li></ul>Break – Lunch
The Worker Day Log
Example: WDL 8/15/09 8/15/09 Took coffee break; spoke to family planning patient about EPSDT services for her Children; he...
<ul><li>Let’s  </li></ul><ul><li>test our  </li></ul><ul><li>knowledge </li></ul>
2009 Training Questionnaire Answers <ul><li>1.  False </li></ul><ul><li>2. True </li></ul><ul><li>3.  False </li></ul><ul>...
The Financial Process   <ul><li>•  Discuss the Federal Fiscal Year (FFY) 2009   financial  reporting process for the MAC p...
Claiming Reimbursement <ul><li>The  four (4) elements of a MAC Claim are: </li></ul><ul><ul><li>Time study results  </li><...
Time Study Results
Example: WDL 8/15/09 8/15/09 Took coffee break; spoke to patient about EPSDT services for Children; helped pt. fill out Me...
Determining Reportable Costs  <ul><li>• Report  quarterly  expenditures on a cash or modified accrual basis.  </li></ul><u...
What costs can I report?  <ul><li>•  Compensation TS Participant Staff </li></ul><ul><ul><li>Employee Salaries </li></ul><...
<ul><li>Report all Revenue Contributions such as:  </li></ul><ul><ul><li>MAC Reimbursement </li></ul></ul><ul><ul><li>Loca...
Medicaid Eligibility Rate <ul><li>Methodologies  </li></ul><ul><ul><li>Identifying the Medicaid Percentage on a Case-by-Ca...
Agency Info & MER – Pg 1 1 2 3 4 1 – Contract # Service Period 2 – Agency Name 3 -  Invoice # 4 – Medicaid Eligibility Rate
Understanding Cost Pools <ul><li>For purposes of the Agency Invoice, expenditures and revenues are placed in one of four C...
<ul><li>Cost Pools Cont. </li></ul><ul><ul><li>Cost Pool #3 – For time study participants there are those costs, revenues,...
Reporting Revenues <ul><li>UNRECOGNIZED REVENUES: </li></ul><ul><ul><li>Medicaid Admin Reimb. </li></ul></ul><ul><ul><li>O...
Revenues – Pg 2
Reporting Expenditures – Page 3   Unstudied Staff
Reporting Expenditures – Page 4 Clerical  Travel/Training Operating TS  Staff - Salary/benefits NON SPMP TS Staff w/Job Ca...
Reporting Expenditures – Page 5 Clerical  Travel/Training Operating TS  Staff - Salary/benefits SPMP  TS Staff w/Job Categ...
Quarterly Summary Invoice  <ul><li>Signing the Quarterly Summary Invoice (QSI) certifies that the following items are true...
QSI
Affiliate Agency Annual Report <ul><li>Purpose of the Annual Report  </li></ul><ul><ul><li>Report data will be used for co...
Q & A
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LHD MAC Training Presentation

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  • Need to speak to the acronyms of TS, MER, and IDCR.
  • If you have not submitted you Intergovernmental Agreement for FFY 2008 please do so immediately to Vicki Echols MAC HHSC 11209 Metric Blvd., Mail Code H360, Austin, TX 78758.
  • Transcript of "LHD MAC Training Presentation"

    1. 1. Welcome to the Health & Human Services LHD Medicaid Administrative Training
    2. 2. Contact/Resource Information <ul><li>Sandra Brabandt </li></ul><ul><ul><li>Phone: 512 491-1314 </li></ul></ul><ul><ul><li>Fax: 512 491-1983 </li></ul></ul><ul><ul><li>Email: [email_address] </li></ul></ul><ul><li>Serena Lee </li></ul><ul><ul><li>Phone: 512 491-1329 </li></ul></ul><ul><ul><li>Fax: 512 491-1983 </li></ul></ul><ul><ul><li>Email: [email_address] </li></ul></ul><ul><ul><li>The LHD Manual & this Training presentation will be available on the HHSC </li></ul></ul><ul><ul><li>website located at: </li></ul></ul><ul><ul><li>h ttp://www.hhsc.state.tx.us/medicaid/programs/rad/AcuteCare/MAC/Main.html </li></ul></ul>
    3. 3. Agenda <ul><li>Morning Session </li></ul><ul><li>9:00 a.m. – 12:00 a.m. </li></ul><ul><li>Program Overview </li></ul><ul><ul><li>Medicaid Administrative Claiming </li></ul></ul><ul><li>Mandatory Participation Requirements </li></ul><ul><ul><li>State and Local Responsibilities </li></ul></ul><ul><ul><li>Participation Documents </li></ul></ul><ul><ul><li>MAC Operating Plan </li></ul></ul><ul><ul><li>Compliance and Oversight </li></ul></ul><ul><ul><li>Audit File </li></ul></ul><ul><li>The Time Study & the Time Study Process </li></ul><ul><ul><li>Selecting your time study staff </li></ul></ul><ul><ul><li>Medicaid Covered Services </li></ul></ul><ul><ul><li>Category determination </li></ul></ul><ul><ul><ul><li>SPMP </li></ul></ul></ul><ul><ul><ul><li>Non-SPMP </li></ul></ul></ul><ul><ul><li>TS Code Training </li></ul></ul><ul><ul><li>The Worker Day Log </li></ul></ul><ul><li>Afternoon Session </li></ul><ul><li>1:30 p.m. – 4:30 p.m. </li></ul><ul><li>Cost & Financial Reporting </li></ul><ul><ul><li>Claiming Reimbursement </li></ul></ul><ul><ul><ul><li>QSI </li></ul></ul></ul><ul><ul><ul><li>MAC Invoice </li></ul></ul></ul><ul><ul><ul><li>Claim Submission </li></ul></ul></ul><ul><ul><li>Agency Annual Report </li></ul></ul><ul><li>Questions </li></ul><ul><li>Future Goals </li></ul>
    4. 4. <ul><li>Program Overview </li></ul>
    5. 5. What is Medicaid Administrative Claiming (MAC)? <ul><li>MAC is an administrative program that provides Texas state agencies and public affiliates the opportunity to submit reimbursement claims for administrative activity that supports their Medicaid program. In order for a cost to be allowable and reimbursable under Medicaid, the activities must: </li></ul><ul><ul><li>be found to be necessary for the proper and efficient administration under the Texas Medicaid State Plan; </li></ul></ul><ul><ul><li>must adhere to applicable requirements as defined in Medicaid statute, section 1903(a)(7) of the Act and implementation regulations in 42 CFR, 430.1 and 42 CFR 431.215, follow the provisions under OMB Circular A-87, 45 CFR Part 74 and 95; and </li></ul></ul><ul><ul><li>use an appropriate claiming mechanism to identify and categorize administrative activities performed by agency employees or contracted staff. </li></ul></ul>
    6. 6. Medicaid Federal Medicaid Reimbursement for Administrative Activities associated with linking students to appropriate Medicaid/health-related services Medicaid Administrative Claiming (MAC) An entitlement program designed to provide health-related services to categorically needy populations Medicaid Definitions
    7. 7. Time Study Methodologies <ul><li>The purpose of the Medicaid administration project is to ensure access of eligible individuals to Medicaid services. HHSC's Cost Allocation Plan provides that claims for Medicaid administration will be based on time studies approved by the Single State Agency - The Health and Human Services. The two methodologies approved by CMS and HHSC are: </li></ul><ul><ul><li>The Worker-Day-Log (WDL) Methodology </li></ul></ul><ul><ul><li>Mid Month Methodology </li></ul></ul>
    8. 8. Time Study Log Requirement <ul><li>CMS requires: </li></ul><ul><ul><li>a minimum of 750 valid or accurate WDLs for each period. </li></ul></ul><ul><li>To insure a valid sample is completed and submitted HHSC requires: </li></ul><ul><ul><li>a minimum of 800 WDLs </li></ul></ul>
    9. 9. Time Study & Claiming Timeframes <ul><li>Federal Fiscal Year Quarters </li></ul><ul><ul><li>Quarter 1 – October 1 thru December 31 </li></ul></ul><ul><ul><li>Quarter 2 – January 1 thru March 31 </li></ul></ul><ul><ul><li>Quarter 3 – April 1 thru June 30 </li></ul></ul><ul><ul><li>Quarter 4 – July 1 thru September 30 </li></ul></ul><ul><li>. </li></ul>
    10. 10. The Purpose of the Time Study <ul><li>The time study will measure the amount of time spent by the eligible staff on Medicaid Allowable activity. </li></ul><ul><li>Time study results allow the LHD calculate MAC claims for reimbursement. </li></ul>
    11. 11. RMTS Process Overview Quarterly processes . . . Determine who performs MAC activities Determine how much reimbursable activity is performed Determine actual costs associated with these activities Apply reimbursement rates (TS, MER,) to calculate a claim Participant Identification Time Study MAC Financial Data Collection MAC Claim Calculation
    12. 12. <ul><li>Mandatory Participation Requirements </li></ul>
    13. 13. HHSC Responsibilities • HHSC provides program oversight and guidance for all program participants • HHSC works with appropriate federal agencies to design and implement programs • HHSC conducts ongoing program review, to include: <ul><li>Time Study results </li></ul><ul><li>Compliance with training requirements </li></ul><ul><li>Documentation compliance </li></ul>
    14. 14. Local Roles & Responsibilities <ul><li>Program/Financial Coordinator: </li></ul><ul><li>Serve as liaison with HHSC </li></ul><ul><li>Verifies and updates quarterly Tim Study (TS) Participant Lists </li></ul><ul><li>Trains the eligible participants on the TS process </li></ul><ul><li>Coordinates and/or follows up regarding TS compliance, i.e., review of TS Logs </li></ul><ul><li>Coordinates with the MAC Financial Program Coordinator to create and/or maintain the MAC Audit file </li></ul><ul><li>Submit MAC participation documents </li></ul><ul><li>Must be listed as a Program Coordinator on the MAC Operating Plan </li></ul><ul><li>Conducts detailed reviews and checks each claim and applicable backup documentation prior to submission for reimbursement </li></ul>
    15. 15. MAC Required Documentation for Participation <ul><li>Each LHD that plans to participate in the MAC program must complete and submit the following six documents: </li></ul><ul><ul><li>MAC Operating Plan </li></ul></ul><ul><ul><li>Interagency Agreement </li></ul></ul><ul><ul><li>Direct Deposit Form </li></ul></ul><ul><ul><li>Vendor Information Form </li></ul></ul><ul><ul><li>Payee Number Application </li></ul></ul><ul><li>The documents will only need to be completed once, with the exception of the following: </li></ul><ul><ul><li>The MAC Operating plan is currently due annually June 15 of each FFY or within 30 days of any changes </li></ul></ul><ul><li>These documents and the instructions are included the LHD MAC Implementation Guide and will be available soon on HHSC website located at: </li></ul><ul><li>http://www.hhsc.state.tx.us/medicaid/programs/rad/AcuteCare/MAC/Main.html </li></ul>
    16. 16. MAC Audit File <ul><li>Each LHD is required to maintain a quarterly MAC audit file and must include the following: </li></ul><ul><ul><li>Copies of computations used to calculate financial costs </li></ul></ul><ul><ul><li>Copies of any worksheets or spreadsheets used in developing the financial costs reported on the State website </li></ul></ul><ul><ul><li>A listing of other costs </li></ul></ul><ul><ul><li>A detailed listing of all revenues offset from the claim, by source </li></ul></ul><ul><ul><li>Signed copy of the approved annual operating plan </li></ul></ul><ul><ul><li>Copies of all training materials given to staff, dated for the quarter they were used </li></ul></ul><ul><ul><li>Copies of documentation verifying time study participant training for each quarter </li></ul></ul><ul><ul><li>Copy of signed and submitted quarterly financial certification form </li></ul></ul><ul><ul><li>MAC Program Coordinator’s job description </li></ul></ul>
    17. 17. <ul><li>Selecting Time Study Participants </li></ul><ul><li>& </li></ul><ul><li>Applying the </li></ul><ul><li>Time Study Codes </li></ul>
    18. 18. Medicaid Covered Services <ul><li>Physicians’ services </li></ul><ul><li>Hospital review </li></ul><ul><li>Clinic services for children under 21 </li></ul><ul><li>Limited maternity care clinics </li></ul><ul><li>Lab and X-ray services </li></ul><ul><li>Home health care </li></ul><ul><li>THSteps/EPSDT screens and services </li></ul><ul><li>Medically needed oral surgery and dentistry for adults (not routine dentistry) </li></ul><ul><li>Pharmacy services (prescription drugs) </li></ul><ul><li>Rehabilitative mental health and mental retardation services </li></ul><ul><li>Family planning </li></ul><ul><li>Services provided by licensed clinical psychologist, licensed clinical social workers, and licensed professional counselors </li></ul><ul><li>Comprehensive Care Program (CCP) services for children under 21 including services by private duty nurses, physical, occupational, and speech therapy, durable medical equipment, medical supplies, psychiatric hospital care, and services by dieticians </li></ul><ul><li>School Health and Related Services (SHARS) </li></ul><ul><li>Targeted Case Management for pregnant women and children under 1 </li></ul><ul><li>Hearing aids and related audiologists’ services </li></ul><ul><li>Diagnostic assessment services for person with mental retardations and mental illness </li></ul><ul><li>Optometry and eyeglasses </li></ul><ul><li>Emergency medical services </li></ul><ul><li>Private duty nursing for children under 21 </li></ul><ul><li>Intermediate care facilities for the mentally retarded </li></ul><ul><li>Physical therapy </li></ul><ul><li>Rehabilitation services for chronic medical conditions </li></ul><ul><li>Hospice services </li></ul><ul><li>Day Activity and Health Services (DAHS) </li></ul><ul><li>“ Medicaid services” refers to medically related services covered under the Texas State Medicaid Plan. The following list identifies services used most frequently by recipients. </li></ul>
    19. 19. Time Study Staff Selection <ul><li>Who should time study </li></ul><ul><ul><li>Program Coordinators will select staff who spend a minimum of 10% of their work time annually on Medicaid administrative activities. Examples of staff categories are: </li></ul></ul><ul><ul><ul><li>EPI Specialist’s </li></ul></ul></ul><ul><ul><ul><li>RN’s </li></ul></ul></ul><ul><ul><ul><li>LVN’s </li></ul></ul></ul><ul><ul><ul><li>CSA’s </li></ul></ul></ul><ul><ul><ul><li>Clerk’s/Receptionist’s </li></ul></ul></ul><ul><ul><ul><li>Physician’s </li></ul></ul></ul><ul><ul><ul><li>Psychologist’s </li></ul></ul></ul><ul><ul><ul><li>Social Worker </li></ul></ul></ul><ul><ul><ul><li>Contracted Staff (not eligible as SPMP’s) </li></ul></ul></ul><ul><ul><li>Staff selected fit into one of two categories </li></ul></ul><ul><ul><ul><li>SPMP or Skilled Professional Medical Staff </li></ul></ul></ul><ul><ul><ul><ul><li>Must have an employer to employee relationship </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Must meet Professional/Educational Requirements </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Job Function must meet the basic criteria of an SPMP </li></ul></ul></ul></ul><ul><ul><ul><li>Non-SPMP </li></ul></ul></ul>
    20. 20. Time Studied Staff Training <ul><li>Program Coordinators </li></ul><ul><ul><li>identify training needs among staff and contractors. </li></ul></ul><ul><ul><li>ensure training is provided quarterly to maintain compliance with procedures as established by the Medicaid Administrative Claiming Guide. </li></ul></ul><ul><ul><li>notify statewide coordinator of needs for additional training or assistance. </li></ul></ul>
    21. 21. Time Study Training Reminders <ul><li>The activity description should be a detailed response, and provide information that supports the coded used. </li></ul><ul><li>Please train your Time Study Participants to provide the definition of any acronyms they may use in describing their activity in support of the codes used. </li></ul><ul><li>If the participant was not working, the activity description should indicate whether the participant was on paid, unpaid time off or at lunch. </li></ul>
    22. 22. Miscellaneous Reminders <ul><li>Activity and TS Codes - Indirect activities that directly support the activity go with the code </li></ul><ul><ul><li>Related paperwork including documentation </li></ul></ul><ul><ul><li>Staff round trip travel </li></ul></ul><ul><ul><ul><li>Clients home </li></ul></ul></ul>
    23. 23. Travel / Transportation <ul><li>Travel vs. transportation </li></ul><ul><li>Travel = staff time to and back from a location to provide a service or perform an activity. </li></ul><ul><li>Transportation = taking the client to and back from a service or activity. “Similar to a taxi service.” Includes wait time. </li></ul><ul><li>Travel that includes the client = Travel </li></ul>
    24. 24. 1 – Facilitating Medicaid Eligibility <ul><li>Examples of activities: </li></ul><ul><ul><li>Verifying current Medicaid eligibility status. </li></ul></ul><ul><ul><li>Explaining Medicaid eligibility rules and eligibility process to families. </li></ul></ul><ul><ul><li>Assisting an applicant to fill out a Medicaid eligibility application. </li></ul></ul>
    25. 25. 2 – Facilitating Non-Medicaid Eligibility <ul><li>Examples of activities: </li></ul><ul><li>Verifying eligibility for Medicaid for the purpose of developing eligibility for NON-Medicaid programs </li></ul><ul><li>Assisting an applicant to fill out applications for such Non-Medicaid programs </li></ul><ul><li>Providing necessary forms and packaging all forms for Non-Medicaid eligibility determination </li></ul>
    26. 26. 3 – Medicaid Outreach (SPMP) <ul><li>Examples of activities: </li></ul><ul><li>Designing and implementing strategies to identify pregnant women who may be at high risk of poor health outcomes because of drug usage, poor nutrition, or lack of appropriate prenatal care. </li></ul><ul><li>Designing and implementing strategies to identify with children with special needs who may be at high-risk of poor health outcomes because of abuse or neglect. </li></ul><ul><li>Contacting pregnant and parenting teens about the availability of prenatal, family planning and child health care services available under Medicaid. </li></ul><ul><li>Note: Report under this code only that portion of time spent in these activities which specifically address Medicaid outreach. Report the non-Medicaid portion of these outreach campaigns under Code 5 (for example, general health education programs). </li></ul>
    27. 27. 4 – Medicaid Outreach <ul><li>Examples of activities: </li></ul><ul><li>Informing general population or groups of individuals about the availability of Medicaid services such as EPSDT medical and dental services and CCP. </li></ul><ul><li>Informing individuals and/or families about the availability of Medicaid services. </li></ul><ul><li>Informing women about the availability of specific Medicaid services such as prenatal care and family planning services. </li></ul><ul><li>Facilitating Medicaid objectives of the EPSDT program by: </li></ul><ul><ul><li>Informing Medicaid eligible individuals about preventative health services of the Medicaid program. </li></ul></ul><ul><ul><li>Informing children and their families on how to use health resources and maintain their involvement in the EPSDT. </li></ul></ul><ul><ul><li>Informing individuals with disabilities about the availability of Medicaid services. </li></ul></ul>
    28. 28. 5 – Non-Medicaid Outreach <ul><li>Examples of activities: </li></ul><ul><li>General health education programs or campaigns addressed to the general population (e.g., dental hygiene, anti-smoking, alcohol reduction, etc.). </li></ul><ul><li>Outreach campaigns directed toward encouraging individuals and/or families to access social, educational, legal or other services not covered by Medicaid. </li></ul><ul><li>Health fairs addressing issues of healthy lifestyles. </li></ul><ul><li>Non-Medicaid portions of general outreach campaigns (see discussion under Codes 3 and 4). </li></ul>
    29. 29. 6 – Referral, Coord & Monitor Medicaid <ul><li>Examples of activities: </li></ul><ul><li>Making referrals for and/or coordinating medical examinations. </li></ul><ul><li>Making referrals for and/or coordinating dental examinations (for under </li></ul><ul><li>age 21 only). </li></ul><ul><li>Providing information about, making referrals for, and/or </li></ul><ul><li>Scheduling EPSDT screens and appropriate immunizations. </li></ul><ul><li>Working with children and pregnant women or, on their behalf, with </li></ul><ul><li>staff and other providers to identify, arrange for and coordinate </li></ul><ul><li>services covered under Medicaid that may be required as the result of </li></ul><ul><li>screens, evaluations or examinations. </li></ul>
    30. 30. 6 – Referral, Coord & Monitor Med. cont’d <ul><li>Gathering any information that may be required in advance of these referrals or evaluations. </li></ul><ul><li>Participating in inter/intra-agency meetings to coordinate or review a child’s or pregnant woman’s need for Medicaid covered services. </li></ul><ul><li>Providing follow-up contact to ensure that a child or pregnant woman has received the prescribed services. </li></ul><ul><li>Coordinating the completion of the prescribed services, termination of services, and the referral and transition of the child or pregnant woman to other Medicaid service providers as may be required to provide continuity of care. </li></ul><ul><li>Providing information to other staff and/or providers on the medical plans and services for the child or pregnant woman. </li></ul>Examples of activities:
    31. 31. 7 – Ref. Coord & Mon. Medicaid (SPMP) <ul><li>Examples of activities: </li></ul><ul><ul><li>Making referrals for and/or coordinating medical evaluations for clients with health problems or special health needs. </li></ul></ul><ul><ul><li>Making referrals for and/or coordinating dental evaluations for clients (under age 21 only) with health problems or special health needs. </li></ul></ul><ul><ul><li>Providing information about, making referrals for, and/or scheduling EPSDT screens, exception to periodicity screens and appropriate immunizations for children who are not on schedule and/or who have special needs or health problems. </li></ul></ul><ul><ul><li>Gathering any information that may be required in advance of these referrals or evaluations. </li></ul></ul>
    32. 32. 7 – Ref. Coord & Mon. Medicaid (SPMP) cont. <ul><li>Examples of activities: </li></ul><ul><li>Participating in inter/intra-agency meetings to coordinate or review a child’s or pregnant woman’s need for Medicaid covered services. </li></ul><ul><li>Providing follow-up contact to ensure that a child or pregnant woman has received the prescribed services. </li></ul><ul><li>Coordinating the completion of the prescribed services, termination of services, and the referral and transition of the child or pregnant woman to either other Medicaid service providers as may be required to provide continuity of care. </li></ul><ul><li>Providing information to other staff on the medical plans and services for the child or pregnant woman </li></ul>
    33. 33. 8 – Ref. Coord & Mon. Non-Medicaid <ul><li>Examples of activities: </li></ul><ul><li>Screening and making referrals for, and coordinating access to, social and educational services such as child care, employment, job training, and housing. </li></ul><ul><li>Providing follow-up contact to ensure that the client has followed through the referral and is receiving the needed non-Medicaid service. </li></ul><ul><li>Scheduling, arranging and/or providing transportation and/or translation services to assist the client in accessing non-Medicaid services, such as grocery shopping, WIC appointments, housing, school etc. </li></ul><ul><li>Making referrals to, coordinating and monitoring the delivery of medical services not covered by Medicaid (e.g. adult dental services). </li></ul>
    34. 34. 9 – Medicaid Transportation &Translation <ul><li>Examples of activities: </li></ul><ul><li>Arranging translation or transportation services for Medicaid services. </li></ul><ul><li>Providing translation or transportation services for Medicaid services. </li></ul>
    35. 35. 10 – Medicaid Provider Relations <ul><li>Examples of activities: </li></ul><ul><li>Recruiting new Medicaid providers. </li></ul><ul><li>Providing technical assistance and support to new providers about Medicaid. </li></ul><ul><li>Providing information to providers on Medicaid policy and regulations. </li></ul>
    36. 36. 11 – Program Planning Development, & Interagency Coordination <ul><li>Examples of activities: </li></ul><ul><li>Working with other agencies providing Medicaid Services to improve the coordination and delivery of services </li></ul><ul><li>Focusing Medicaid services on specific populations or geographic areas </li></ul>
    37. 37. 12 – Program Planning Development & Inter Coord (SPMP) <ul><li>Examples of activities requiring the licensed SPMP: </li></ul><ul><li>Working with other agencies providing Medicaid Services to improve the coordination and delivery of services </li></ul><ul><li>Focusing Medicaid services on specific populations or geographic areas </li></ul>
    38. 38. 13 – DIRECT SERVICES <ul><li>Examples of activities: </li></ul><ul><li>Direct clinical and treatment services, such as: </li></ul><ul><ul><li>Obtaining or reviewing medical history information. </li></ul></ul><ul><ul><li>Performing physical examinations. </li></ul></ul><ul><ul><li>Determining diagnosis. </li></ul></ul><ul><ul><li>Reviewing test results. </li></ul></ul><ul><ul><li>Referring for specialized medical services. </li></ul></ul><ul><ul><li>Dispensing medications or supplies. </li></ul></ul><ul><ul><li>Counseling and educating individuals about management of medication routine. </li></ul></ul><ul><li>Counseling and training individuals on parental skills. </li></ul><ul><li>Targeted case management activities, such as individual screening and assessment, crisis intervention, medical services planning and coordination, and monitoring of adherence to individual medical plan. </li></ul><ul><li>Developmental assessments and diagnostic testing. </li></ul><ul><li>Individual and group counseling about issues of physical and mental health or substance abuse. </li></ul>
    39. 39. 14 – NON-MEDICAID, OTHER EDUCATIONAL AND SOCIAL SERVICES <ul><li>Examples of activities: </li></ul><ul><ul><li>Providing family education services. </li></ul></ul><ul><ul><li>Facilitating parent support groups. </li></ul></ul><ul><ul><li>Conducting support groups. </li></ul></ul>
    40. 40. 15 – General Administration <ul><li>Examples of activities: </li></ul><ul><li>Receiving and/or presenting training </li></ul><ul><li>Paid time off/break </li></ul><ul><li>Data entry/billing </li></ul><ul><li>Staff meetings </li></ul><ul><li>Providing general supervision of staff and evaluation of employee performance. </li></ul><ul><li>Establishing goals and objectives oh health-related programs </li></ul><ul><li>Staff training (as a participant or presenter) </li></ul><ul><li>Reviewing program procedures and rules. </li></ul><ul><li>Attending, facilitating or presenting local, regional, and state-wide meetings. </li></ul><ul><li>Developing budgets and maintaining records. </li></ul>
    41. 41. L – Lunch <ul><li>Use for unpaid lunch time </li></ul>
    42. 42. O – Off <ul><li>Use if personnel are in an “off-duty” status during part of their scheduled workday. </li></ul><ul><li>Use to account for non-paid time that may occur during your normally scheduled workday. </li></ul>
    43. 43. <ul><li> Please return by </li></ul><ul><li>1:30 p.m. </li></ul>Break – Lunch
    44. 44. The Worker Day Log
    45. 45. Example: WDL 8/15/09 8/15/09 Took coffee break; spoke to family planning patient about EPSDT services for her Children; helped pt. fill out Med. app. for med. Svc. Help; explained vision services;
    46. 46. <ul><li>Let’s </li></ul><ul><li>test our </li></ul><ul><li>knowledge </li></ul>
    47. 47. 2009 Training Questionnaire Answers <ul><li>1. False </li></ul><ul><li>2. True </li></ul><ul><li>3. False </li></ul><ul><li>4. True </li></ul><ul><li>5. False </li></ul><ul><li>6. True </li></ul><ul><li>7. True </li></ul><ul><li>8 . False </li></ul><ul><li>True </li></ul><ul><li>False </li></ul><ul><li>C </li></ul><ul><li>E </li></ul><ul><li>A </li></ul><ul><li>D </li></ul><ul><li>B </li></ul><ul><li>Code 4 8 Units </li></ul><ul><li>Code 7 3 Units </li></ul><ul><li>Code 2 2 Units </li></ul><ul><li>Code 1 8 Units </li></ul><ul><li>Code 13 5 Units </li></ul><ul><li>Code 15 2 Units </li></ul><ul><li>Code 9 5 Units </li></ul><ul><li>Code 4 2 Units </li></ul><ul><li>Code 13 2 Units </li></ul><ul><li>Code 15 4 Units </li></ul>
    48. 48. The Financial Process <ul><li>• Discuss the Federal Fiscal Year (FFY) 2009 financial reporting process for the MAC program, which include the following: </li></ul><ul><ul><li>Allowable costs for reporting </li></ul></ul><ul><ul><li>The invoicing process </li></ul></ul><ul><ul><li>Quarterly Summary Invoice </li></ul></ul><ul><li>• Define action items and timeframes. </li></ul><ul><li>• Questions </li></ul>
    49. 49. Claiming Reimbursement <ul><li>The four (4) elements of a MAC Claim are: </li></ul><ul><ul><li>Time study results </li></ul></ul><ul><ul><li>Expenditure data </li></ul></ul><ul><ul><li>Revenue data </li></ul></ul><ul><ul><li>Medicaid percentage </li></ul></ul>
    50. 50. Time Study Results
    51. 51. Example: WDL 8/15/09 8/15/09 Took coffee break; spoke to patient about EPSDT services for Children; helped pt. fill out Med. app. for med. Svc. help Time Study Results
    52. 52. Determining Reportable Costs <ul><li>• Report quarterly expenditures on a cash or modified accrual basis. </li></ul><ul><li>• Total allowable costs for participant staff must be reported by category based on the TS participant staff list. The results of the time study are applied and the reimbursable costs are determined. </li></ul><ul><li>All positions on the Participant List must have expenditures entered. </li></ul>
    53. 53. What costs can I report? <ul><li>• Compensation TS Participant Staff </li></ul><ul><ul><li>Employee Salaries </li></ul></ul><ul><ul><li>Payroll Taxes & Benefits </li></ul></ul><ul><ul><li>Contract staff </li></ul></ul><ul><li>Clerical salary/benefits </li></ul><ul><li>Indirect Costs - only if Carve out Method is </li></ul><ul><li>used </li></ul><ul><li>Travel and Training Costs </li></ul><ul><li>Other Operating Costs </li></ul>
    54. 54. <ul><li>Report all Revenue Contributions such as: </li></ul><ul><ul><li>MAC Reimbursement </li></ul></ul><ul><ul><li>Local Government Funds </li></ul></ul><ul><ul><li>Donations to Public Agencies </li></ul></ul><ul><ul><li>Federal Grants </li></ul></ul><ul><ul><li>Matching Funds </li></ul></ul><ul><ul><li>Federal and State Flow-Thru Funds </li></ul></ul><ul><li>MAC funds are considered unrecognized revenue for MAC Financial claiming and reporting purposes. </li></ul>Reporting Revenues
    55. 55. Medicaid Eligibility Rate <ul><li>Methodologies </li></ul><ul><ul><li>Identifying the Medicaid Percentage on a Case-by-Case Basis </li></ul></ul><ul><ul><ul><li>The Medicaid percentage is a fraction, the numerator of which consists of all persons in the agency's or program's caseload or service population who are actual Medicaid recipients. The denominator of the fraction is the total number of persons served by the agency or program during the claim period minus the Medicaid pending clients. The resulting fraction, or percentage of Medicaid recipients in the caseload, should be as current to the quarter of the claim as possible (with the exception of the schools, as noted below). Where this is not feasible, the nearest possible determination should be made. </li></ul></ul></ul><ul><ul><li>Using the Lowest Common Denominator - a State or Countywide Percentage </li></ul></ul><ul><ul><li>Using a Zip Code Proportional Match </li></ul></ul>
    56. 56. Agency Info & MER – Pg 1 1 2 3 4 1 – Contract # Service Period 2 – Agency Name 3 - Invoice # 4 – Medicaid Eligibility Rate
    57. 57. Understanding Cost Pools <ul><li>For purposes of the Agency Invoice, expenditures and revenues are placed in one of four Cost Pools. </li></ul><ul><ul><li>Cost Pool #1 – This is where agency costs, revenues, and time relating to the activities performed by SPMP personnel is compiled. This includes Code 3 - not discounted by MER and Codes 7 and 12 - are discounted by MER. </li></ul></ul><ul><ul><li>Cost Pool #2 – This is where costs, revenues and time relating to activities performed by SPMPs and Non-SPMPs using Codes 1, 4, and 10 - not discounted by the MER and 6,9, and 11 - are discounted by MER. </li></ul></ul>
    58. 58. <ul><li>Cost Pools Cont. </li></ul><ul><ul><li>Cost Pool #3 – For time study participants there are those costs, revenues, and time derived from activities by both SPMPs and Non-SPMPs which are non-Medicaid related (Codes 2, 5, and 8) or those which are direct service activities (Codes 13, and 14). </li></ul></ul><ul><ul><li>Cost Pool #4 – This pool contains costs, revenues, and time for General Administrative services (code 15), staff who provide General Administration to the whole agency and were not time studied, as well as costs which cannot be allocated in more accurate fashion. </li></ul></ul><ul><li>All entries in Cost Pool #4 will be distributed across Cost Pools #1, #2, and #3 in proportion to the Salary and Benefits of staff or contractors. This applies throughout the spreadsheet; even revenues placed into Cost Pool #4 will be distributed to Cost Pools #1, #2, and #3 based on staff salaries and benefits. </li></ul>Understanding Cost Pools
    59. 59. Reporting Revenues <ul><li>UNRECOGNIZED REVENUES: </li></ul><ul><ul><li>Medicaid Admin Reimb. </li></ul></ul><ul><ul><li>Other State Funds </li></ul></ul><ul><ul><li>Local Government Funds </li></ul></ul><ul><ul><li>Donation to Public Agency </li></ul></ul><ul><ul><li>Fed. Emerg. Ass't. Reimb. </li></ul></ul><ul><ul><li>Fed. IV-E Reimbursement </li></ul></ul><ul><li>RECOGNIZED REVENUES: </li></ul><ul><ul><li>Medicaid Fees + Match </li></ul></ul><ul><ul><li>Federal Grants + Match </li></ul></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><li>Insurance </li></ul></ul><ul><ul><li>Fees </li></ul></ul><ul><ul><li>Donations to Contractor </li></ul></ul><ul><ul><li>Other Revenue </li></ul></ul>
    60. 60. Revenues – Pg 2
    61. 61. Reporting Expenditures – Page 3 Unstudied Staff
    62. 62. Reporting Expenditures – Page 4 Clerical Travel/Training Operating TS Staff - Salary/benefits NON SPMP TS Staff w/Job Category TS Units
    63. 63. Reporting Expenditures – Page 5 Clerical Travel/Training Operating TS Staff - Salary/benefits SPMP TS Staff w/Job Category TS Units
    64. 64. Quarterly Summary Invoice <ul><li>Signing the Quarterly Summary Invoice (QSI) certifies that the following items are true and correct: </li></ul><ul><li>I am the officer authorized to submit this form; I have examined this statement and to the best of my knowledge and belief, the expenditures included in this statement are based on the actual cost of recorded expenditures; </li></ul><ul><li>The required amount of state and/or local funds were available and used to pay for total computable allowable expenditures; </li></ul><ul><li>This statement is of expenditures that the undersigned certifies are allocable and allowable to the State Medicaid program; </li></ul><ul><li>I understand that this information will be used as a basis for claims for federal funds and falsification and concealment of material fact may be prosecuted under Federal or State civil or criminal law </li></ul>
    65. 65. QSI
    66. 66. Affiliate Agency Annual Report <ul><li>Purpose of the Annual Report </li></ul><ul><ul><li>Report data will be used for coordinating and planning activities for the Medicaid. </li></ul></ul><ul><li>Report Due Date & Requirements </li></ul><ul><ul><li>The annual report is required from each contracted agency for any Federal Fiscal year (October 1 – September 30) that a claim was submitted by the agency. </li></ul></ul><ul><ul><li>The report is due by the last December 31 of any given federal fiscal year </li></ul></ul>
    67. 67. Q & A
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