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Medicaid in Schools

The school setting provides a unique opportunity to deliver healthcare services to children and adolescents, especially those enrolled in Medicaid. School-Based Health Services (SBHS), including but not limited to preventive care, mental health and substance use disorder (SUD) services, physical and occupational therapy, and disease management have been shown to improve both health and academic outcomes. Schools play an important role in bridging equity gaps among students in low-income and rural communities where access to healthcare services may be more limited. Medicaid Administrative Claiming (MAC) plays a significant role in the mapping, connecting and sustaining access to healthcare services for children.

CMS 2023 Administrative Claiming Guide

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Medicaid in Schools

Medicaid Administrative Claiming (MAC)

MAC is a Medicaid reimbursement program which allows education agencies (EAs) to be reimbursed for a portion of the costs associated with providing administrative activities that support the provision of medical services covered under the State Medicaid Plan.

Federal/state leveraging partnership
Kindergarten - 21
Including but not limited to children in special education
Covered MAC activities include:

Outreach – assistance with Oregon Health Plan (OHP) application, eligibility and understanding covered services and providers
Referral, coordination and monitoring of Medicaid covered health services
Medicaid-covered health services program planning, policy development and interagency coordination to assess or improve access the care

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MAC Leveraging

Reimbursement authority

Pursuant to 42 CFR 433.50, a unit of government is authorized to participate in Federal Financial Participation (FFP) by providing the non-federal share of public funds for Medicaid reimbursement for covered services.
The Education Service District (ESD) certifies by its signature on the MAC intergovernmental agreement (IGA) that the non-federal matching funds it transfers to OHA are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds and all sources of funds are allowable.
In addition, school districts and ESDs both complete cost pool certifications to authorize by signature they have excluded all federal funds from the claim computation.

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MAC Leveraging Form

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MAC Participation

MAC participation must occur through an ESD that holds a MAC intergovernmental agreement (IGA) with OHA.

What education agencies (EAs) can participate under an ESD who holds a MAC IGA with OHA?

ESDs
Public school districts
Public charter schools
Public recovery schools

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MAC Participation

An ESD who holds a MAC IGA with OHA must establish the following:

MAC sub-agreements for each participating EA detailing responsibilities of both parties.
Prior to onboarding each new EA, provide projected MAC revenue to OHA to ensure increased participation will not exceed the current IGA not-to-exceed amount. Submit IGA amendment requests to OHA as needed.
Support each EA in developing their unique cost pool, conducting and reviewing the random moment time study (RMTS) per claim period as part of the compiled total claim.
Support EAs in establishing a MAC coordinator and local site coordinators who provide annual MAC trainings to staff, establish RMTS processes and timelines, notify staff of RMTS weeks/day, review RMTS claims supporting documentation, and follow-up and monitor the RMTS claiming process.

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Cost Pool Development

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Cost Pool Development

Developing an accurate cost pool is critical.

Cost pool is defined as the actual (not estimated) total salary and benefits paid by each survey period for staff participating in the MAC survey.
Staff supported entirely by federal funds may not be included in the cost pool or survey.
Staff partially paid through federal funds may be included in the cost pool.
Only the non-federal fund portion of employee’s cost is reported. The employee must report their entire paid work time in the survey.

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Cost Pool Development

Step one: Identify appropriate staff

Include both certified and classified staff who:

Routinely have contact with students and their families to create opportunities to provide Medicaid outreach and coordinated care activities as outlined in the MAC coding guide or have direct supervision of employees who do.
Hold administrative roles essential to acquisition and retention of health services provided in the education setting

Exclude maintenance and food services staff, bus drivers, short-term subs, extra-duty contracts and volunteers (non-paid staff). These groups have limited contact with students to provide MAC services or are not paid employees.
If an employee is hired mid-survey period, they may not participate until the next full survey period.

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Cost Pool Development

Step one (continued): Contracted employees

Staff may participate under the district or ESD they are paid by or contracted for, on the corresponding survey date assigned to that agency.
For contracted employees of education agencies, both education agencies a formal agreement must be made between agencies as to which agency the employee will participate under if both are MAC participants.

For example, if a school district contracts with an ESD for nurse services and both the ESD and the school district are participating in MAC, the two agencies must come to a formal agreement identifying which agency the nurse will participate under.
All other MAC requirements for participation must also be met.

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Personnel Reporting MAC Activities

Common MAC participants

Administrators
Special educators
School safety & prevention specialists
Educational assistants
Secretaries
TSPC school counselors*
TSPC school psychologists*
TSPC school social workers*

*TSPC recognized providers not enrolled and billing SBHS direct services.

MAC claimable categories

B1 – Medicaid/OHP outreach and facilitating Medicaid/OHP Eligibility
C1 – Referral, coordination, monitoring and training of Medicaid OHP services
D1 – Medicaid/OHP transportation and translation
E1 – Program planning, policy development, and interagency coordination related to medical services

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Personnel Reporting MAC activities

Example SBHS Recognized Providers

Speech Language Pathologist (SLP)
Occupational Therapist (OT)
Certified Occupational Therapist Assistant (COTA)
Physical Therapist (PT)
Licensed Physical Therapy Assistant (LPTA)
Registered Nurse (RN)
Unregulated Assistive Person (UAP)
Licensed Clinical Psychologist
Licensed Clinical Social Worker
TSPC school counselors (enrolled & billing)
TSPC school psychologists (enrolled & billing)
TSPC school social workers (enrolled & billing)

Claimable categories

B1 – Medicaid/OHP outreach and facilitating Medicaid/OHP eligibility
C1.4 – Training
E1 – Program planning, policy development, and interagency coordination related to medical services

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Cost Pool Development

Step two: Identify actual salary and benefits paid

After identifying appropriate staff for the cost pool, report the actual salary and benefits paid for each individual participating in the RMTS to the Multnomah ESD (MESD) for input into the MAC data capture system.

Stipends subject to payroll taxes may be included.

Ensure all federal funds have been removed.
Exclude substitute pay and extra duty contracts (i.e., coaching).

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Cost Pool Development

Step three: Remove federal funds from cost pool

Only general fund and non-federal fund sources may be included in the cost pool.
Remove all federal funds from the cost pool as per federal regulations from:

Salary and benefits of each employee in the cost pool
Services and supplies costs, indirect or other allowable personnel expenses

Examples of federal funds expended by ESDs and districts:

IDEA
Title I
Title 9
Federal grants

Maintain documentation detailing how federal funds applicable to salary, benefits and OPE have been removed from the cost pool.

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Pruning the Cost Pool

ESDs and school districts should establish a process to evaluate their cost pool on a systematic basis, assessing classifications and individuals impact on the claim.

Pruning the cost pool is an acceptable practice to present a more effective claim and reduce administrative burdens.
Remove staff who do not routinely perform MAC activities.

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Cost Pool Pruning Methods

Example methods for pruning

Remove any staff who, over the course of a determined period, never report claimable MAC activities.
Blindly survey staff utilizing local scenarios of claimable MAC activities to determine whether staff perform MAC activities.
Remove staff who have limited contact with students and their families to provide MAC activities.

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Dual Participation

Dual Participation Background

SBHS-recognized providers OAR 410-133-0120, employed or contracted by an education agency, are allowed to participate in both SBHS Medicaid programs:

Direct services
Medicaid Administrative Claiming (MAC)

Education agencies that elect to have SBHS-recognized providers participate in both SBHS Medicaid billing programs must meet dual participation requirements.

Costs recovered through dual participation may not exceed the actual costs associated with providing direct services or MAC activities. If participating in multiple leveraging programs, the cost billed and reimbursed may not exceed the actual cost of the individual providing the service.
Duplicate claiming is prohibited. The same activity or service provided by an individual for the same child or family may only be claimed once. Claiming the same service through multiple leveraging methodologies is duplicate claiming.

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Dual Participation Requirements (cont.)

Administrative activities reimbursed cannot reflect any direct or indirect activities related to providing a direct medical service.
Activities provided by SBHS-recognized providers are considered integral to or an extension of a direct medical service and may not be reimbursed under MAC. These include the following health related activities:

Follow up and monitoring
Assessment
Education
Counseling
Consultation
Related direct services billing activities

This does not apply to activities provided by TSPC-licensed school psychologists, school social workers and school counselors when their education agency elects not to bill SBHS direct services.

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Dual Participation Limitations

SBHS-Recognized Providers

Practitioners recognized under OAR 410-133-0120 employed or contracted by school districts or ESDs cannot claim C1 activities that are considered integral to or an extension of a direct or consultative medical service.

C1.1 – Referral
C1.2 – Coordination
C1.3 – Monitoring

This applies regardless of whether the district is an enrolled Medicaid provider accessing reimbursement.

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Dual Participation

TSPC Referrals

Referral, care coordination and follow-up of Medicaid-covered health services to TSPC licensed school psychologists, counselors and social workers are claimable when the TSPC practitioner is actively enrolled and billing Medicaid.
If a TSPC school psychologist, counselor or social worker is enrolled and billing direct services the referrals they make for Medicaid-covered health services to Medicaid enrolled providers for students are reported under code F.
Referrals for Medicaid-covered health services to Medicaid enrolled providers made by TSPC practitioners who are not enrolled and actively billing Medicaid are claimable under MAC code C1.

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Dual Participation

When a health aide provides the following direct medical services, they must be reported under code F.

Personal care services (PCS) trained by a supervisory level SBHS-recognized provider within their scope of practice or
Nursing procedures delegated by a Registered Nurse (RN) pursuant the Nurse Practice Act

Training, monitoring, care coordination and follow-up activities performed by the individual performing direct services are considered integral to and/or an extension of direct services and must be reported under code F.

PCS is defined under OAR 410-133-0040 (36).

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Personal Care Services Examples

Personal Care Services	SBHS Recognized Provider	MAC Code
Transfers to changing table from wheelchair, changing/removing AFOs, standby assistance with mobility	Physical Therapist/Health Aide	F
Diapering, bathroom support for hygiene	Registered Nurse/Heath Aide	F
Feeding of meals as per Occupational Therapy feeding/choking protocol	Occupational Therapist/Health Aide	F
Behavior intervention plan for emotional dysregulation as per Behavioral Supports Plan	TSPC School Psychologist/Health Aide	F

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Delegated Nursing Procedures Examples

Delegated Nursing Services	SBHS Recognized Provider	MAC Code
Gastrostomy tube feedings/flushes	Registered Nurse/Heath Aide	F
Suprapubic intermittent catheterization emptying	Registered Nurse/Heath Aide	F
Seizure rescue medication administration	Registered Nurse/Heath Aide	F

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Cost Attestation/Certification

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Cost Certification

IGA Level Cost Pool Certification

Cost pool certification with the ESD who holds an IGA with OHA certifies the following:

All federal funds have been removed by all education agencies participating in MAC through sub-agreements with the ESD
No duplicate claiming of funds have occurred, including the cost of personnel applied to the ODE state approved indirect rate computation (indirect rate application is optional)
The amount billed and reimbursed does not exceed the cost attributed to the individual(s) providing the service
The ESD and all sub-agreement holders agree to dual participation requirements

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Dual Participation Attestation

The dual participation attestation certifies the ESD and all education agencies participating under the ESD through MAC sub-agreements acknowledge:

The same activity or service provided by an individual for the same child/family may not be claimed through different leveraging methodologies
Administrative activities reimbursed cannot reflect any direct or indirect activities related to providing a direct medical service
If a MAC RMTS participant participates in both Medicaid SBHS direct services and MAC, the MAC time study results must be validated against direct services claims to ensure no duplication of claim has occurred.
If duplication of claim occurs, the education agency will be responsible for reconciliation and payback of claim.

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RMTS Procedures

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Procedures for Assigning RMTS Dates

Procedures:

OHA will provide ESDs with five randomly selected RMTS dates prior to each survey period.
ESDs with an OHA MAC IGA will assign RMTS dates to participating education agencies (EAs) without influence or input.

The ESD must assign all five dates among their participating EAs.
If the ESD has fewer than five participating EAs, the ESD must assign a different survey date of the five to each EA participating in addition to the ESD.

The ESD will inform the EAs of the week (not the specific date) of their assigned RMTS date prior to the first day of the applicable survey period. This will allow EAs ample time for scheduling and training.
It is the responsibility of the ESD level coordinator to inform EAs of their RMTS date no greater than one business day prior to the assigned date.

The MAC data capture system is designed to auto-inform EAs via email of their RMTS date no greater than one business day prior to the assigned date, but it is ultimately the responsibility of the ESD level coordinator to ensure this occurs.

EAs will accomplish their survey on the date assigned.

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MAC Survey Periods

Survey periods:

Fall: September 1 - December 31
Winter: January 1 - March 31
Spring: April 1 - June 30

Spring includes remainder of contract salary and benefits expended by June 30.

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Responsibilities and Best Practices

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OHA Responsibilities

OHA MAC training provides staff with:

Training materials, including a complete MAC coding guide, OHP enrolled provider list, and documentation forms in the MAC data capture system
A description of the survey process

Survey periods (fall, winter, spring)
RMTS dates
Cost pool development

An understanding of:

What is claimable as an administrative activity in the school setting
Activity codes and how to report them in the MAC data capture system
How and when to complete supporting documentation
How to access technical assistance

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Audit Requirements

Maintain MAC claim supporting documentation for seven years from the date a claim is paid. Provide MAC coordinator contact information and be available to OHA for MAC claim review.

Who is responsible:

ESD (under MAC IGA w/OHA)
School District or ESD (under MAC sub-agreement w/ESD)
Business Office (all supporting financial documents)

Examples of supporting documentation:

MAC intergovernmental agreement and sub-agreements
MAC training logs for in person or virtual trainings
MAC training materials
Records supporting activities performed (i.e., emails, certifications, chat messages, phone call documentation)
Documentation review process
Financial data (i.e., cost pool reports and cost pool certification forms)
State share leveraging payments
Annual Project Report form

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ESD Processes

Best practices for internal processes to support MAC system

Establish a schedule of events calendar for submission deadlines to share with your EAs.
Prior to submitting cost pool files, verify all necessary data is included, and exclude periods in job titles or location fields.
Provide MESD with the list of untrained staff to be removed from the survey for each district.
Provide MESD with a list of in progress (not submitted) surveys for removal for each district once survey is closed.
Verify data in system is correct before each survey week begins:

Survey schedule
District survey assignments
District closure dates (preplanned and weather/emergency related)

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ESD Processes (cont.)

Before requesting OHA’s financial review, verify

All surveys have reached accepted status
Salary/benefit files are loaded
Medicaid-eligible percentage applied by county is correct
Indirect rates applied are correct
Cost pool participants completed their survey
Federal funds have been removed
No dual claiming has occurred
Cost pool certification form is completed and signed

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District Processes

Best practices for internal processes to support MAC system

Establish an annual calendar of scheduled of events, deadlines and processes to ensure activities are completed by deadlines and supporting documentation is maintained.
Prior to submitting the cost pool file to the ESD, notify the ESD of any names and email changes from the previous survey period to ensure data in the MAC system is correct.
Review sampled staff in MAC system prior to each survey to identify any changes to emails, names, FTE, job titles, and funding that need correction. Submit corrections to MESD no later than one week prior to your assigned survey week.
Review untrained status in MAC system and ensure all staff are trained prior to survey week.

Submit non-automated training logs no later than the Monday prior to an EA’s assigned survey week.

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Training Requirements

ESD level trainers must attend a face-to-face MAC training provided by OHA annually (AI and notetaker applications are not allowed to replace in person trainings).

ESD-level trainers who hold a MAC IGA with OHA must schedule and provide training to ESD and school district staff who participate under MAC sub-agreements to cover all aspects of the MAC reporting process.
All RMTS participants must receive training no less than once annually prior to an assigned survey date.
Training may be facilitated using the OHA MAC Staff Training slide deck via the web-based MAC training module or facilitated by a MAC coordinator trained by OHA or by a MAC coordinator who OHA trained.
Staff must sign a training log or sign in electronically (maintaining an electronic record of attendance).

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Training Requirements (cont.)

Training requirements

Training sign-in sheets for in person or two-way interactive technology facilitated interactive trainings are required to be maintained for a period of seven years.

If two-way interactive technology is used to facilitate trainings, best practice is for video screens to be on to monitor attendance and participation ensuring training requirements are met.

Employees who complete an annual MAC training on the survey date are ineligible to complete that survey. Their training will be valid for the next survey period.
Trainers must submit training logs to MESD no later than the Monday prior to the EAs assigned survey week.
Utilize and support access to the MAC data capture system for reporting.

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Trainer Responsibilities for Documentation

Complete a review of the survey results and obtain necessary supporting documentation from staff.

"The State Medicaid agency and EA must maintain documentation that clearly indicates how the time study results are determined. Accordingly, the time study methodology and instructions, as well as all records and information that support the administration and results of the study to support the claims submitted by the State Medicaid agency must be retained. Some State Medicaid agencies currently include an area on time study forms for a brief narrative description of the Medicaid activity, function, or task being performed to meet this requirement.” (Reference: 2023 CMS Comprehensive Guide to Medicaid Services and Administrative Claiming, pages 93-94)

It is critically important for additional documentation to be maintained to verify the appropriateness of the claims and to limit the risk of audit findings.

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Documentation Requirements

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Documentation Review

All claimable time in the MAC RMTS must be reviewed within 30-business days by the District and ESD coordinators before submission to OHA for a final review:

1) District coordinator

2) ESD coordinator

3) OHA

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Documentation Review

Verify staff have completed original supporting documentation within three business days of the RMTS assigned date which includes the survey date. Supporting documentation must be reviewed for each claimable time segment and associated activity code.

The documentation must:

Be brief and concise
Use descriptive words from the MAC coding guide such as referred, coordinated, and monitored
Describe the claimable activity performed only
Not identify individual students or families by name
Include the enrolled OHP provider’s name if C1.1, C1.2 or C1.3 activities are reported
Complete supporting documentation in the MAC data capture system

Maintain all supporting documentation in the event of a MAC audit.

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MAC Activity Reporting

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How is MAC Time Reported?

The MAC web-based survey is used to record activities staff perform during their paid work hours. Staff must report each activity performed using the code category that best fits.

All activities reported must be organic in nature, meaning they:

Took place as a normal part of the person’s work
Align with their job description/role
Were in no way pre-planned with influence to target an RMTS date to increase MAC claim reimbursement

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Activity vs. Outcome

Staff must report the claimable MAC activity performed on the survey date even when the outcome may be unknown.

Example:

On an RMTS day, a TSPC school counselor (not enrolled in direct services) reports C1.1 on their MAC survey to represent they gathered information in advance of a referral for a child’s mental health evaluation with the local county mental health department, an OHP enrolled provider.
At the time of the RMTS, the school counselor may not know the outcome of the referral, which is acceptable and does not change the reporting of the activity on the RMTS date.

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MAC Facts

MAC survey participants do not need to know if a student is eligible for OHP.
When survey participants refer, coordinate care or follow up with an OHP-enrolled medical provider they must document the enrolled provider’s name in the RMTS.
The RMTS measures the activity performed, not the outcome.
The RMTS determines time spent on both claimable and non-claimable activities.
The RMTS is designed to record paid work activities based on 15-minute segments. The activity codes recorded must represent the predominant activity performed.
Notification will be sent to MAC survey participants by email from noreply@mesd.k12.or.us 24 hours before an RMTS date and again the day of the RMTS with login instructions.
Once a survey is open, survey participants have three business days to submit.
Claimable time must be supported by documentation.

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MAC Coding

Coding reminders for survey participants

Log-in under your education agency name and email address
Over/under reporting of time:

Report the full workday
Report paid work time for both claimable and non-claimable activities
Report paid breaks, lunch and absences as non-claimable
Report unpaid time by leaving it blank (i.e., unpaid lunch, shortened workday)

Submit your survey

Do not submit survey until time coded and activities performed have occurred.
Save survey as you go and submit when your workday is complete.

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OHP/Medicaid

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Medicaid (OHP) Outreach

Medicaid outreach activities are those performed to inform eligible or potentially eligible individuals about Medicaid and how to access the Oregon Health Plan.

Oregon Health Plan

A state-sponsored Medicaid program providing all Oregon’s uninsured children access to no cost or affordable, comprehensive, health insurance coverage.

OHP Covers Me Information https://www.oregon.gov/oha/hsd/ohp/pages/ohpcoversme.aspx
Use this tool to assist in determining if applying for OHP is for you https://ohim.checkbookhealth.org/#/

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OHP Coverage

OHP covers most health care needs for kids including:

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

OHP coverage length varies by child’s age

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OHP Eligibility

Three key qualifiers for no-cost or low-cost coverage

Age: Must be under the age of 19 (19th birthday)
Residency: Must live in Oregon
Income

2026 OHP Federal Poverty Level Chart

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OHP Application Assistance

OHP application: Oregon Health Plan application/renewal

General information on OHP qualifications
Apply with an online application
Renew your OHP
Manage your information online

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OHP/Medicaid Covered Services

Health services

Well-child exams
Immunizations

Referral, care coordination and outreach for immunizations are not a covered service when performed in association with specified exclusion reporting dates identified in the Immunization Law Handbook)

Routine physicals
Maternity and newborn care

Medical services

Preventive services such as well-child check ups
Laboratory or x-rays
Treatment for most major diseases
Hospital stay
Substance abuse
Vision care, routine screenings, and glasses
Hearing services, hearing aids, and batteries
Home health care
Specialists care and referrals
Physical, occupation, and speech therapy
Medical equipment and supplies

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OHP/Medicaid Covered Services

Dental services

Preventive services (cleaning, fluoride treatments, sealants for children)
Routine services (fillings, x-rays)
Dental check ups
Tooth removal
Dentures
24-hour emergency care
Specialist care and referrals

Mental health services

Evaluations
Therapy
Consultations
Medication management
Programs for daily and community living

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MAC Activity Coding

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MAC Activity Codes

MAC claimable service categories

B1 Medicaid outreach – Oregon Health Plan (OHP)
C1 Gathering information in advance of a referral, referrals, care coordination, and monitoring of OHP covered health services and trainings related to the administration of OHP and for early identification for need of health care services for children in the school setting (Child specific)
D1 Coordinating transportation, providing and coordinating translation services to understand OHP covered health services
E1 Medicaid covered service program planning, policy development, and interagency coordination (every student may benefit)

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MAC Activity Codes

Non-claimable codes

A – School related and educational activities
B2 – Non-Medicaid/OHP outreach
C2 – Referral, coordination, monitoring and training on Non-Medicaid/OHP services
D2 – Non-Medicaid/OHP transportation/translation
E2 – Program planning, policy development and interagency coordination related to non-medical services
F – Direct medical services

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School-Related and Educational Activities

Code A (non-reimbursable)

A is used to report any school-related activities not covered by OHP, including but not limited to:

Classroom instruction
Grading papers
Supervision of staff
Recess duty
Student discipline
Developing curriculum (including health related)
Developing a student’s plan of care
Participation in IEP and 504 meetings
Paid time off

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B1 – Medicaid/OHP Outreach

B1.1 - Informing children and their families of how to effectively access, use, and maintain participation in Medicaid/OHP

Includes describing the range of services, and distributing OHP literature

Examples:

Shared OHP eligibility requirements and range of benefits with a family.
Developed and compiled materials to inform families how and where to obtain OHP benefits.
Worked with school counselor to answer a family’s questions about OHP benefits and eligibility requirements.
Informed an uninsured student’s grandmother about OHP benefits.
Explained to a parent who lost employment benefits what OHP covers and how to access when no longer covered by private insurance.

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B1 – Medicaid/OHP Outreach

B1.2 - Assisting the student/family to access, apply for, and/or complete the Medicaid/OHP application.

Includes coordinating transportation and providing and coordinating translation related to OHP application and gathering appropriate information.

Referred a family for OHP application assistance and helped obtain an application for Medicaid/OHP through our Family Support Center.
Phone call with a parent regarding documentation requirements for the OHP application. Explained time frame and importance of all required documentation.
Assisted a family with resources necessary for them to apply for OHP.
Assisted family in gathering information necessary to apply for OHP.
Provided necessary forms to apply for OHP.

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B1 – Medicaid/OHP Outreach

B1.3 - Checking a student and/or family’s OHP status.

May be performed by reviewing the family’s medical card, contacting the local ODHS office, on-line eligibility check, working with in-district staff who have access to checking Medicaid eligibility.

Informed a parent how to check the status of their child’s OHP eligibility.
Checked on OHP eligibility status of a student.
Verified a student was not insured and discussed access to OHP.

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B1 – Medicaid/OHP Outreach

B1.4 - Contacting pregnant and parenting teenagers about the availability of Medicaid/OHP for prenatal and well baby care programs.

Spoke with student regarding Medicaid/OHP for prenatal care.
Reviewed availability of services covered under Medicaid/OHP prenatal and well baby programs (excludes WIC and SNAP benefits).

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C1 – Referral, Coordination, Monitoring and Training

C1.1 Referral (includes gathering information in advance)

Referring students for medical, mental, and dental health services, substance abuse evaluation and services covered by OHP. All referrals must indicate enrolled OHP provider of service. Includes related paperwork, clerical activities, or staff travel necessary to perform these activities.

Examples:

Gathered information on a student identified during a vision screening as needing further evaluation for an eye exam.
Discussion with team regarding the health needs of a student who just returned from an out-of-state school. Parent reports regression, team discussed and made referral to county mental health agency (Medicaid provider).
Met with student and mother regarding student’s substance abuse issues. Referral made to county health department (Medicaid provider).
Referred a student with mental health needs to county mental health (Medicaid provider.)
Gathered information from the parents and school nurse in advance of a referral for a student with dental health needs.

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C1 – Immunization Considerations

Claimable

Administrative activities performed as part of a referral to assist families in accessing immunizations from Medicaid enrolled providers are claimable as C1.1 when the referral:

Is to an enrolled Medicaid provider and
Does not fall on an immunization exclusion reporting date (immunization exclusion is an educational �requirement for attendance).

Non-claimable C2

Administrative activities performed for immunization exclusion requirements:

Performing a primary review summary
Mailing exclusion orders
Completing a county immunization status report
State-mandated health screenings such as hearing and vision, are the responsibility of the education agency and are not claimable under the MAC program for reimbursement

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Student Referrals for Medical Services

Referrals made for Medicaid-covered health services provided by SBHS recognized providers who work for enrolled Medicaid providers and who are billing Medicaid are claimable. These include, but are not limited to:

School districts (SDs)
Education Service Districts (ESDs)
Public health agencies
Hospitals
Mental health agencies
Medical clinics
Private practices

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Student Referrals for Medical Services

An education agency does not have to be an enrolled and participating Medicaid direct services billing provider to report referrals to Medicaid enrolled service providers in the community.

Referrals made to SBHS-Recognized Providers employed or contracted by a school district or ESD that are not Medicaid enrolled providers are not claimable.
Oregon Administrative Rules (OARs) now recognize TSPC School Psychologists, School Counselors and School Social Workers as Recognized Providers. Referrals made to TSPC School Psychologists, School Counselors and School Social Workers enrolled as Medicaid providers for the purpose of a health evaluation, diagnostic testing and behavioral health counseling are now claimable MAC activities.

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Non-Claimable Referrals

Referrals made to non-enrolled SBHS-Recognized Providers

Referrals for a health evaluation, diagnostic testing, and behavior counseling services are not claimable if the SBHS Recognized Provider is not enrolled with Medicaid.

Referrals for state-mandated health services

Referring students/parents for required immunizations on mandatory exclusion dates as required by education is not a claimable MAC activity.

Referrals to non-Medicaid health care providers, such as:

School districts and ESDs that are not enrolled as a Medicaid provider or not actively participating in Medicaid billing
Some private health providers

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C1 – Referral, Coordination, Monitoring and Training

C1.2 Coordination

Coordinating the delivery of medical, mental, dental, and substance abuse services covered by OHP. All care coordination must indicate enrolled OHP provider of service. Include related paperwork, clerical activities, or staff travel necessary to perform these activities.

Coordinating Medicaid covered health services during Youth Services Team and CARE Team meetings (only report the portion of the meeting related to the Medicaid-covered activity).
Discussion with school counselor regarding student who needs physical and mental health services, including how to assist the family in gaining access to services through OHP.
Contacting local OHP provider to determine resources available for student needing glasses.
Coordinating the delivery of medical services for a student with depression with administration, student, family, and ODHS with a Medicaid provider.

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C1 – Referral, Coordination, Monitoring and Training

C1.3 Monitoring

Monitoring the delivery of Medicaid covered health services, including on the IEP. Providing follow-up contact to ensure a child received prescribed medical, dental, or mental health services covered by OHP. All monitoring activities reported must indicate the enrolled OHP provider of service. Includes related paperwork, clerical activities, or staff travel necessary to perform these activities.

A special education teacher working with a student receiving Medicaid covered health services on an IEP attends a team conference or meets individually with a therapist to evaluate the medical component(s) of an IEP (excludes actual IEP meeting).
A classroom teacher makes follow-up contact with an enrolled Medicaid provider to ensure student received services prescribed or referred for.
The school counselor (not enrolled or billing direct services) refers a student to an enrolled OHP provider for mental health services. After the appointment, the school counselor follows up with the parent to coordinate care and changes in medication.

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C1 – Referral, Coordination, Monitoring and Training

C1.3 - The following monitoring activities are NOT reimbursable:

Activities performed during development of an IEP and/or formal IEP meetings. Code A.
Monitoring minor acute health conditions, such as scratches, bruises, headaches, colds, application of Band-aids or administration of non-prescriptive medications. Code F.
Monitoring required by delegation from a Registered Nurse, such as seizure, catheterization, g-tube feeding and blood sugar monitoring. Code F.
Monitoring of a diagnosed health condition regardless of the severity of type of health condition. Code F.
The provision of direct medical services are not claimable. Activities that are integral to or an extension of a direct medical service are considered direct medical services. Code F.
Activities related to the development of an IEP, including related paperwork, clerical activities, or staff travel necessary to perform these activities. Code A.
Performing personal care services (PCS) such as bathroom hygiene, diapering, wheelchair lifts, or feeding trained by SBHS recognized providers (i.e. RN, PT, OT). Code F.

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C1 – Referral, Coordination, Monitoring and Training

C1.4 Training

Coordinating, conducting or participating in training events or seminars regarding the benefits of Medicaid covered services. This includes related paperwork, clerical activities, or staff travel required to perform these activities. Training examples:

How to assist families in accessing Medicaid covered services.
How to more effectively refer students to Medicaid covered services.
Enhancing early identification, intervention, and screening for Medicaid covered services.
Improving the delivery of Medicaid covered services.
Participating in a training that covers the administrative requirements of the Medicaid program or Medicaid covered services.

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C1 – Referral, Coordination, Monitoring and Training

C1.4 Training

To determine if a training you participated in or coordinated qualifies as reimbursable under MAC code C1.4, ask the following questions:

Does the training improve the delivery of Medicaid-covered health services?
Does the training enhance the early identification, intervention, screening or referral of students with special health needs for Medicaid covered health services?
Does the training cover the administrative requirements related to Medicaid covered health services?

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C1 – Referral, Coordination, Monitoring & Training

C1.4 - Non-claimable trainings

State-mandated trainings required annually, including:

First aid training
CPR training
EPI training
Blood-borne pathogens training
Safe Schools trainings

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D1 – Transportation/Translation

D1.1 - Scheduling and arranging transportation to OHP covered services.

Includes administrative activities (related paperwork, clerical activities, staff travel time, etc.) required to arrange and schedule transportation services for a child and their family to understand Medicaid covered health services being provided.
The physical provision of transportation services must be coded A.

D1.2 - Scheduling, arranging or providing translation for OHP covered services.

Arranging translation services (oral and signing) to assist the individual in accessing and understanding necessary care or treatment covered by Medicaid.
Developing translation materials that assist individuals in accessing and understanding necessary care or treatment covered by Medicaid.

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E1 – Program Planning, Policy Development and Interagency Coordination

E1.1 - Developing strategies and policies to assess or increase the capacity of school medical, dental, mental or substance abuse programs (includes workgroups).

E1.1 activities are those performed for the potential benefit of any student, not specific to an individual or small group of students. Examples include:

Worked with school nurses and school counselors to increase access to health services for students.
Reviewed current mental health support system for effectiveness.
Reviewed strategies to better identify and provide access to treatment for students with asthma.
Collaborated with school administrators to develop processes to ensure students are receiving Medicaid-covered health services while attending school.

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E1 – Program Planning, Policy Development and Interagency Coordination

E1.2 - Working with other agencies and providers to improve the coordination, collaboration, and delivery of medical, mental, dental, and substance abuse services.

E1.2 are activities performed for the potential benefit of any student, not specific to an individual or small group of students. Examples include:

Attended a community meeting to discuss ways to improve access and delivery access to mental health services for students.
Attended a community health resource meeting to identify gaps in existing support systems and collaborate with various agencies about districtwide health needs.
Collaborated with other agencies regarding options and programs available to better serve students with mental health needs.
Collaborated with local dentist to provide dental sealant clinic.

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E1 – Program Planning, Policy Development and Interagency Coordination

E1.3 - Monitoring the medical, mental, dental and substance abuse health delivery system in schools.

E1.3 activities are those performed for the potential benefit of any student, not specific to an individual or small group of students. Examples include:

Developing advisory or work groups of health professionals to consult, advise and monitor the delivery of health care services to school populations.
Evaluating the need and effectiveness of medical services provided in the school setting.
Monitoring or assessing the process for referring students to community health services such as a school-based health center.

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F – Direct Services (Non-reimbursable)

F - Direct services

Activities that are considered integral to, or an extension of direct medical services, are not reimbursable (i.e., patient follow-up, patient assessment, patient counseling, patient education, patient consultation, and billing activities). Report these activities under code F.

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RMTS Instructions and Best Practices

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MAC Survey Instructions

Steps required to complete the MAC survey:

Access the MESD website at https://mac.apps.mesd.k12.or.us/

Select “Survey Sign In”
Enter your work email address then click “Send Login Link to Email”

To begin the survey process, click the link in your email from noreply@mesd.k12.or.us

Check the box if you are a SBHS-recognized provider and select license type

TSPC School Psychologists, Counselors and Social Workers will receive a pop-up question after identifying their license type asking if they are an actively enrolled provider and billing Medicaid

Select yes or no

Enter paid work hours
Enter unpaid hours
Code time (include documentation when required)
Submit the survey

Survey activities may not be reported and submitted until they have occurred.
Save your results as you go
Submit when your workday is complete

Note: Paid absences are reported as Code A.

Unpaid lunch is left blank.

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MAC Documentation Requirements

When individuals report claimable MAC activities they must perform the following:

Enter supporting documentation before submitting the survey.
If a referral, care coordination or monitoring of OHP services occurs, select the name of the OHP provider from the dropdown box. If the OHP enrolled provider is not available, click “other” and type it in.
Record brief and concise supporting documentation. Only provide documentation related to claimable activities.
If more than one claimable activity occurs in a 15-minute time segment, record only the predominate activity.
Multiple activities performed under different code types must be recorded under the related code to include documentation for every entry.
Use descriptive words from the MAC coding guide in supporting documentation, such as referred, coordinated, or monitored.
Do not identify the individual student or family by name.

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Coding Accuracy

Coding accuracy reminders

Report only paid work hours.
Exclude extra duty contract hours and volunteer time.
Report paid time off under code A (i.e. vacation, holidays, personal, sick, and bereavement leave).
Before signing out of an incomplete survey, save it.
Once completed, submit the survey within the three business days to include the RMTS date.

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MAC Resources

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OHP Resources

MAC website hosted by MESD

https://sites.google.com/cascadetech.org/mac

Oregon County Health Department Directory

http://public.health.oregon.gov/ProviderPartnerResources/LocalHealthDepartmentResources/Pages/lhd.aspx

Oregon Health Policy Board – What’s Happening with Health Care in Oregon

http://www.oregon.gov/oha/OHPB/Pages/index.aspx

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MAC Resources

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Contacts

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Contacts

Training provided by:

Oregon Health Authority - Medicaid Division

School-Based Health Services

Medicaid Administrative Claiming

Contact:

Lasa Baxter, OHA SBHS Medicaid Operations and Policy Analyst

Email: medicaid.sbhs@oha.oregon.gov

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Thank You

Medicaid Division

School-Based Health Services Program

Medicaid.sbhs@oha.oregon.gov

You can get this document in other languages, large print, braille or a format you prefer free of charge. Contact the School-Based Health Services Medicaid program at medicaid.sbhs@oha.oregon.gov.