Medicaid Administrative Claiming�Initial and Annual Staff Training

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Revised 8/25/2021

Agenda

• Welcome!
• Overview and History
• Training Requirements and MAC Process
• MAC Activities

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Welcome! �And Thank You!

Overview and History

Overview and History

First – What is Medicaid?

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• Title XIX of the Social Security Act

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• Provides medical assistance to certain low-income individuals

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• States share the cost with the federal government

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• In Oregon, more commonly known as the Oregon Health Plan

What does Oregon Health Plan Cover?

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The Oregon Health Plan covers all health care needs for those who qualify including:

• Medical, dental and vision care
• Regular checkups and preventive care
• Prescription medicines and medical equipment
• Mental health services
• Chemical dependency services

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What is Medicaid Administrative Claiming or MAC

• A function or activity “…found necessary for the proper and efficient administration of the state Medicaid Plan.” In Oregon, the Oregon Health Plan

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• Examples of functions/activities could include:
• Discussing access to health care with an HFO family
• Assisting in identification of families who could benefit from health services provided by Medicaid – the Oregon Health Plan
• Providing referral assistance to families where Medicaid services can be provided
• Contacting first time parents about the availability of Medicaid prenatal and well baby care programs/services

What is Medicaid Administrative Claiming (cont.)

• Federal cost sharing in the expense of administering the Medicaid program
• Reimbursement for half the cost of doing qualifying functions/activities done in the normal course of program operation
• A method of identifying and accounting for time staff spent on administrative activities/functions – such as referral and outreach
• Identification of Medicaid/OHP eligible families is not necessary for the purposes of Medicaid Administrative Claiming

Differences between MAC and Other Medicaid Reimbursements

• Targeted Case Management (TCM)
• Service to a Medicaid eligible individual
• Services provided pursuant to an individual case management plan
• Billing for a specific service at a set rate determined within guidelines found in the State Plan Amendment
• Documentation includes individual case management plan and documented individual case notes recorded

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Differences between MAC and Other Medicaid Reimbursements

• Maternity Case Management (MCM)
• Services to a pregnant, Medicaid eligible woman (individual)
• Expanded prenatal service to include management of non-medical services
• Services pursuant to an individual case plan
• Billing for limited number of visits at a set rate
• Documentation includes individual case management plan and documented individual case notes/records

Medicaid Administrative Claiming or MAC

• Is population based – provided program to all participants by all participating program staff

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• Is total time accounting – all participating staff document time in 4 random time studies per quarter

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• Service is not dependent on an individual case plan

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• Service is reported through the random time study and documented through standard family charts

How is MAC time reported?

The web-based survey is utilized to record activities staff perform during the paid hours of a workday. This is accomplished by reporting the activities in a code category that best fits the activity performed. There are four survey periods per year. Each survey period four random survey dates will be selected.

January – March

April – June

July – September

October - December

Why does Healthy Families Oregon Participate in MAC?

• Through the normal course of service, Healthy Families Oregon work includes Medicaid Administrative Claiming activities and functions

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• Provides additional resources to programs by reimbursing half the cost of providing Medicaid Administrative Claiming activities and functions

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• To maximize program resources by leveraging state general funds with federal resources

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• All Healthy Families programs are required to participate in MAC reimbursement to ensure a large enough pool for billing and reimbursement purposes

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• KEY: Proper coding of staff time and staff costs in needed

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Training Requirements and MAC Process

Documenting This Training

• Federal regulations require that all staff must receive and document both the initial (prior to work with families & prior to participating in MAC) AND annual training on the MAC Codes

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• Record your Initial MAC Training - Prior to Work with Families - on your HFO Required Training Log

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• Record your Annual MAC Training on you HFO Ongoing Training Log

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Random Time Studies

• Four (4) Random Time Study days are selected each quarter

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• Staff track activities in 15-minute increments on these days

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• Together, these days represent how Healthy Families staff spend their time

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• A portion of paid staff salary for Medicaid related activities is reimbursed by Medicaid because Heathy Families is a part of the state’s Medicaid Plan and completes activities that support Medicaid enrollment and utilizations

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• Screening is important! Data from screening is used in Medicaid reimbursement calculations

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Time Study Days

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• Programs are notified five (5) working days before time study days via email

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• Healthy Families staff are reminded of the time study day one day in advance

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• Healthy Families staff respond on the Random Time Study Day by replying to the email

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• Healthy Families staff have five (5) working days to record time study codes in the Medicaid Online Time Tracker (MOTT)

Tracking Time

• Use the code that best reflects the way you spent the most time during each 15-minute period

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• If you are not sure, re-read the codes then ask you manager or supervisor. Contact Central Admin if needed

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• Keep records supporting the MOTT entries (MAC time log, calendars, supervision notes, family files)

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• Maintain confidentiality by locking MAC documents, or using ID numbers, not family names in documentation

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• You need to be able to prove you spent time as claimed

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• Record time in Medicaid Online Time Tracker (MOTT)

General Information for Coding

• Do your preparation and paperwork for visits on the same day so you can include time spent
• Don’t change your schedule or your plans on a Time Study Day
• Supervision related to activities with families is coded the same as the activities themselves, for both Home Visitor and Supervisor
• Family files and supervision notes will be pulled in the case of a federal Medicaid audit, so be sure your records back up you coding choices
• Use the code (see Appendix A) that best reflects the way you spent the most time during each 15 minute period. The codes include the kinds of activities done in the normal course of Healthy Families work. (typical activities are outlined for each code) If you are unsure, verify your choices with program manager or supervisor
• The “1” activity codes are reimbursable and are specifically related to eligible/potentially eligible Medicaid/OHP families. The “2” codes, E, F, and N are not reimbursable

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Monitoring of MAC

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• Monitoring occurs on a regular basis: Supervisors review MAC time study entries after each time study day. This includes discussions during supervision and review of backup documentation

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• Monitoring includes, ensuring codes are properly used and verifying supporting documentation for any billable code (A1, B1, C1, D1)

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• Supervisors and/or Managers maintain a copy of staff’s time study log. Sites are required to maintain documentation related billable codes

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MAC Activities

Overview of the Codes

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• The codes include the kinds of activities done in the normal course of Healthy Families work

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• Some activities are reimbursable, some are not

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• The “1” codes are reimbursable and are specifically Medicaid/OHP related activities

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• The “2” codes, E, F and NHF (or N) are not reimbursable and are the activities not related to Medicaid/OHP

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Medicaid/MAC Claimable Codes

• Medicaid/OHP Outreach Activities and Facilitating Medicaid/OHP Eligibility

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• Referral, Coordination, Monitoring and Training of Medicaid/OHP Services

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• Medicaid/OHP Transportation and Translation

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• Program Planning, Policy Development, and Interagency Coordination Related to Medicaid/OHP Services

Non-Medicaid/MAC Claimable Codes

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• Outreach and Application Assistance for Non-Medicaid/OHP Programs
• Case Planning, Monitoring, Coordination, Referral and Training of Non-Medicaid/OHP Covered Services
• Non-Medicaid/OHP Transportation and Translation
• Coordination Related to Non-Medicaid/OHP Services
• Direct Health Care Services
• General Administration/Other Services
• Non-Healthy Families Typical Activities (not F)

A1 – Medicaid/OHP Outreach Activities and Facilitating Medicaid/OHP Eligibility

Summary: 

This code should be used when performing activities that inform eligible or potentially eligible individuals about Medicaid/OHP. This code should also be used when describing the range of services covered under Medicaid/OHP, how to access and obtain them, and the benefits of Medicaid/OHP preventative services. Use this code when assisting children and their families in applying for and becoming eligible for Medicaid/OHP. Activities for obtaining and sharing information for Medicaid/OHP outreach and facilitating Medicaid/OHP eligibility can be written or verbal and may occur during meetings, home visits, or over the phone. This includes related paperwork, clerical activities, and staff travel required to perform these activities. Please note it is not necessary that the child/family actually receive Medicaid/OHP in order for this code to be used. 

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A1 – Medicaid/OHP Outreach Activities and Facilitating Medicaid/OHP Eligibility

• Informing Medicaid eligible and potential Medicaid eligible children and families about the benefits and availability of services provided by Medicaid (including preventative treatment and screening).

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• Informing pregnant and parenting women and teens about the availability of Medicaid-covered prenatal and well-baby care programs, immunizations, birth control options and services.
• Developing and/or compiling materials to inform individuals about the Medicaid program (including EPSDT) and how and where to obtain those benefits.
• Assisting families in gathering information related to the application and eligibility determination process for an individual, including resource information and third-party liability (TPL) information, as a prelude to submitting a formal Medicaid application.
• Helping a family to fill out an OHP application, explaining eligibility rules, eligibility, process and reminding families to reapply to keep status current.
• Referring an individual or family to a local assistance office to complete application for Medicaid benefits.

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A1 – Medicaid/OHP Outreach Activities and Facilitating Medicaid/OHP Eligibility

• Assisting an individual or family in collecting/gathering required information and documents for the Medicaid application.
• Identifying enrolled providers to obtain Medicaid covered services, such as: immunizations, well child exams, dental services, mental health services.
• Informing parents/families on how to appropriately access/use Medicaid-covered medical care/services.
• Encouraging families to access medical/dental and/or mental health services provided by Medicaid program.
• Preparing, presenting and disseminating child health related materials identifying Medicaid-covered services, and how to access such services including preventative health care and substance abuse prevention programs, related staff travel and paperwork.
• Participating as a Medicaid eligibility outreach outstation. NOTE: excludes determining eligibility.

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A2 – Outreach and Application Assistance for Non-Medicaid Non-PHP Services

Summary: 

Activities that assist the child/family in gaining access to non-Medicaid/OHP services and effectively utilizing social services and community wellness programs. (Included are housing, commodities, food banks, Women's Infant and Children Program ("WIC"), foster care, financial assistance, exercise and weight loss programs, energy assistance, child care, after school programs, friendly visitor and vocational services.) Providers that are not enrolled with Medicaid or part of Medicaid Managed care network of providers and activities that assist the child/family in applying for these services, including form preparation, related staff travel, clerical, and paperwork. 

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A2 – Outreach and Application Assistance for Non-Medicaid Non-PHP Services

• Informing families about general health education programs or campaigns and how to access them, conducting, scheduling or promoting these programs.

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• Scheduling and promoting activities which educate individuals about the benefits of healthy lifestyles, home safety and accident prevention.
• Non-Medicaid/OHP outreach directed toward encouraging persons to access social, educational, legal or other services not covered by Medicaid/OHP.
• Explaining eligibility rules and the eligibility process to prospective applications for NON-OHP programs, providing the necessary forms and packaging all forms in preparation for such NON-OHP services.
• Informing individuals and families about NON-OHP programs, such as Housing, food banks, Foster Care, Financial Assistance for needy families TANF, Food Stamps, Women's Infant and Children (WIC) program, Childcare, Legal Aid and other NON-OHP social or educational programs and referring them to the appropriate agency to make application for such services.
• Referrals and information to assist families in accessing social, education, legal, financial or other non-Medicaid/OHP covered services.
• Providing outreach, developing and verifying initial and continuing eligibility for the Free and Reduced Lunch Program.

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B1 – Referral, Coordination, Monitoring and Training of Medicaid/OHP Covered Services

Summary: 

Staff should use this code when making referrals for, coordinating, and/or monitoring the delivery of, (Medicaid-covered) services. This code may also be used when coordinating or participating in training events and seminars regarding the benefits of the Medicaid/OHP program, how to assist families to access Medicaid-covered services, and how to more effectively refer participants for services. Activities that are an integral part of or an extension of direct medical services are not claimable as an administrative activity and must be reported as E. Note: Targeted case management is also not claimable as an administrative activity and must be reported as E. Claimable activities reported include related staff travel, clerical, and paperwork. 

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B1 – Referral, Coordination, Monitoring and Training of Medicaid/OHP Covered Services

• Gathering information in advance of a referral for a Medicaid-covered service utilizing questionnaires - New Baby Questionnaire and portions of the Assessment and Family Intake/Update which are related to Medicaid/OHP services.

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• Gathering information in advance of a referral utilizing Ages and Stages Questionnaire (ASQ) and the ASQ-SE (Social-Emotional) for early identification of age appropriate child development and/or delays to assure health and developmental problems are found diagnosed and treated.

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• Scheduling immunizations, coordination of immunizations for children.

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• Coordinating or referring for early Medicaid covered medical consultation and evaluations, including Early Intervention services.

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B1 – Referral, Coordination, Monitoring and Training of Medicaid/OHP Covered Services

• Coordinating medical care with partnering agencies also serving the family such as Early Intervention and/or Community Health Nurses.

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• Making referrals for and coordinating Medicaid covered screenings, examinations, assessments and evaluations for Medicaid-covered and medical services (health, vision, dental, developmental, substance abuse, etc.)

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• Referring for Medicaid covered prenatal postpartum, and newborn medical care, pre-pregnancy risk prevention activities, and family planning.

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• Contacts with parents regarding their child's Medicaid covered healthcare needs.

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• Gathering background information and supportive data such as social history and medical history. Helping families meet goals related to Medicaid covered services and coordinating medical care with partnering agencies also serving the family such as Early Intervention and/or Community Health Nurses.

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B1 – Referral, Coordination, Monitoring and Training of Medicaid/OHP Covered Services

• Arranging for or coordinating child specific Medicaid-covered services.

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• Participating in or coordinating training which improves the delivery of Medicaid/OHP services, enhances early identification, intervention, screening and referral of children with special needs.

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• Monitoring, coordination and training of Medicaid/OHP services: for vulnerable children and families including agency staffing to coordinate Medicaid/OHP services for child health and development (does not cover Individual Family Support Plan meetings).

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• Related supervision, staff travel and paperwork.

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B2-Case Planning, Monitoring, Coordination, Referral and Training of Non-Medicaid/OHP covered services

Staff should use this code when: 

• Assessing and monitoring of the home learning environment using standardized forms, creating and disseminating information on positive and interactive learning environments, providing or arranging for reading material for the child, providing or arranging for age appropriate toys. 
• Classroom instruction or presentations, preparation, related paperwork and travel, attendance at conferences, providing educational or career guidance or consultation. Includes related staff travel, clerical, and paperwork. 
• Case management of social services and community wellness programs (including housing, commodities, food banks, WIC, foster care, financial assistance, exercise and weight loss programs, energy assistance, child care, after school programs, friendly visitor and vocational services) and arranging transportation for these services. Making referrals for and coordinating the delivery of these social services and community wellness programs. Arranging transportation for these services and coordinating or participating in training events and seminars for these services. Includes related staff travel, clerical, and paperwork. 

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B2-Case Planning, Monitoring, Coordination, Referral and Training of Non-Medicaid/OHP covered services

Staff should use this code when (continued): 

• Making direct referrals to social services such as housing, energy assistance, educational and/or special education, childcare, education and Early Intervention, vocational and transportation to these services, etc., monitoring and follow-up. Includes related staff travel, clerical and paperwork. 
• Participating in or coordinating training which improves the delivery of non-Medicaid/OHP services. 

Examples: 

• Helping families meet non-Medicaid covered related goals
• General education and referrals about topics like nutrition, normal breastfeeding, exercise, wellness, attachment, infant development
• Sharing toys, making toys
• Literacy
• Parent child interactions

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C1 – Medicaid/OHP Transportation and Translation

Summary: 

Assisting an individual to obtain transportation to services covered by OHP, arranging for translation services to facilitate access to OHP services. This does not include the provision of the actual transportation services, but rather the administrative activities involved in arranging or scheduling transportation to a Medicaid covered service. Translation services must be provided by an individual whose role is performing translation functions to facilitate access to Medicaid covered services. These activities include related paperwork, clerical activities or staff travel required to perform these activities. 

Examples:

• Arranging for or providing translation services (oral and signing) that assist the individual to access and understand necessary care or treatment covered by Medicaid.
• Developing translation materials that assist individuals to access and understand necessary care or treatment covered by Medicaid.
• Scheduling or arranging transportation to Medicaid/OHP covered services.
• Related staff travel and paperwork.

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C2 – Non- Medicaid/OHP Transportation and Translation

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Summary:

�Assisting an individual to obtain transportation to services not covered by Medicaid/OHP, or arranging for or providing translation services related to social, vocational, or educational programs. Include related paperwork, clerical activities or staff travel time required to perform these activities.

Special Note: Use this code when accompanying an individual to non-Medicaid/OHP services.

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D1 - Program Planning, Policy Development, and Interagency Coordination Related to Medicaid/OHP Services

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Summary: 

Performing activities associated with the development of strategies to improve the coordination and delivery of medical/dental/mental health services, and when performing collaborative activities with other agencies and/or providers. Planning and developing procedures to track requests for services; the actual tracking or requests for Medicaid services would be coded under B1 Referral, Coordination and Monitoring of Medical Services. Working internally and with other agencies to improve services expand health and medical services and their utilization to specific target populations, gathering information about their functions, to improve early identification of health and developmental problems, related staff travel, clerical, and paperwork. 

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D1 - Program Planning, Policy Development, and Interagency Coordination Related to Medicaid/OHP Services

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• Notifying medical providers of Healthy Families Oregon services and coordination opportunities.

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• Recruitment of enrolled providers to provide Medicaid covered services, such as: immunizations, well child exams, dental services, and mental health services.

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• Working internally with other agencies and or partners to: identify gaps, develop strategies to improve coordination and delivery of services, expand access and utilization of Medicaid/OHP services (medical, dental, mental health programs), increase provider participation and improve provider relations, and improve collaboration around the early identification of medical/dental/mental problems.

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• Identifying gaps or duplication of medical/dental/mental services and developing strategies to improve the delivery and coordination of these services.

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D1 - Program Planning, Policy Development, and Interagency Coordination Related to Medicaid/OHP Services

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• Developing medical referral sources such as directories of Medicaid providers and managed care plans that will provide services to targeted population groups.

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• Developing a family planning, education, counseling and service program compatible with community norms, locating or developing family planning information and materials and methods of distribution, developing a family planning service referral network.

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• Developing procedures for tracking families' requests for assistance with medical/dental/mental services and providers, including Medicaid. (This does not include the actual tracking of request for Medicaid services.)

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• Working with Medicaid resources, such as the Medicaid agency and Medicaid managed care plans, to make good faith efforts to locate and develop EPSDT health services referral relationships.

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D2 – Coordination Related to Non-Medicaid/OHP Services

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Summary:

�Working internally and with other agencies to improve social services, identify gaps in services, expand and improve capacity to engage in non-Medicaid/OHP services, their utilization by specific target populations; related staff travel, clerical, and paperwork.

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E – Direct Health Care Services

Summary:

�Providing medical care, treatment, and/or counseling services to an individual. This code also includes administrative activities that are an integral part of or extension of a medical service (e.g., patient follow-up, patient assessment, patient counseling, patient counseling, patient education, parent consultations, billing activities). This code also includes all related paperwork, clerical activities, or staff travel required to perform these activities.

• Not used by Healthy Families staff in their role with HFO.

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F – General Administration/Other Services

Summary:�General administrative functions, such as payroll, maintaining inventories, developing budgets, executive direction, lunches, paid leave, educational or professional development conferences, staff meetings, and personnel issues.

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• Paid lunches, breaks, etc.
• Paid time off for vacations, sick days, etc.
• Most trainings, conferences and meetings (not related to Medicaid covered services)
• Working on personnel issues.
• General office work, emails, phone messages filing.
• Establishing goals and objectives of health-related programs as part of an annual or multi-year plan.
• Reviewing agency procedures and rules.
• Attending or facilitating staff or board meetings.
• Performing administrative or clerical activities related to general building or agency functions or operations.
• Providing general supervision of staff, including assistants or volunteers, and evaluation of employee performance.

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Code “N” – Non Healthy Families Activities

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• Time paid by MIECHV
• Unpaid leave
• Time during split shifts
• Time spent working for other programs
• Unpaid long lunches
• Regular days off for part time staff (RTS hits on a non-paid day off for a part time staff
• NOT the same as F (Paid time off is F)
• Use this when appropriate

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Travel and Tips

Travel

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• Code travel time to a home visit based on what you intend to do there, what you have prepared, or what you did (what you did takes precedence over what you prepared)
• In case of no-shows for home visits, code you travel based on what you prepared for the visit
• Code travel to the next home visit based on your plan for that visit or what you did
• Code travel back to the office based on the content or intent of the last visit

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Tips and General Information about Coding�

• Do your preparation and paperwork for visits on the same day so you can include time spent

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• Don’t change your schedule or your plans when a Time Study Day comes along

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• Supervision related to activities with families is coded the same as the activities themselves, for both Home Visitor and Supervisor

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• Family files and supervision notes will be pulled in the case of a federal Medicaid audit

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Thank You!