MAC Cost Pool Certification_IGA level 2026.xlsx

	A	C
1	ESD Name
2	Street Address	Date:
3	City, State, Zip Code	MAC quarter:
4	Phone # and Fax #	Total MAC Claim Amount:
5		Agreement (IGA) #:
6		IGA Effective Date:
7	Submit certification to:	IGA Expiration Date:
8	Lasa Baxter
9	lasa.baxter@oha.oregon.gov
10	(enter “MAC Cost Pool Certification” in the subject line)
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14	DESCRIPTION OF CERTIFICATION:
15	By signing this report, I certify:
16	• I certify that all federal funds have been removed from the cost pool for the Education Service District (ESD) and education agencies participating under a MAC sub agreement with the ESD have been removed from the cost pool.
17	• I certify that no duplicate claiming of funds have occurred, including the cost of personnel applied to the Oregon Department of Education (ODE) state approved indirect rate computation. Application of an indirect rate is optional.
18	• Costs included in my education agency’s ODE approved indirect rate have not also been reported as allowable costs in our Medicaid Administrative Claim.
19	• The amount billed and reimbursed may not exceed the cost attributed to the individual(s) providing the service.
20	• Our education agency understands dual participation requirements (see dual participation attestation).
21	• I am authorized to legally bind the education agency.
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23	Legal Name of Education Agency:
24	Signed by:
25	Date of Signature:
26	Print Name of Signor:
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28	*The Authority’s acceptance of cost data provided by provider organizations for the purpose of establishing Medicaid Administrative Claims does not imply or validate the accuracy of the cost data provided as per OAR 410-138-0005 (12).
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31	For questions regarding cost pool certification, contact:
32	Contact Name:
33	Contact Phone:
34	Contact e-mail:
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36	Instructions: Prior to requesting OHA's review of your MAC claim, ESD's must acquire a signed cost pool certification
37	form from each of their participating Districts. After which, the ESD will compile all certifications and submit
38	one certification to OHA on behalf of the complete ESD MAC cost pool. NOTE: Districts will not submit their cost pool certifications
39	to OHA separately.
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