Administrative Claiming: New Guidelines, New Opportunities

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Administrative Claiming New Guidelines, New
Opportunities

• NAME Conference

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Agenda

• Administrative Claiming Guide Overview
• Summary of key changes
• Impact comparison across states
• Approaches to Implementation
• Interpretations and approval requirements
• Approaches in various states
• Challenges Affecting States Schools
• Increased audit activity and documentation
  requirements
• Consistency across states and CMS regions
• Strategies to Address Challenges
• Statewide program models
• Technology solutions
• Alternative avenues for obtaining reimbursement
• Questions

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OVERVIEW
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Importance of Medicaid Funding for Schools

• Funding for State and Federal Mandates
• - Immunizations and periodic health screenings
• - IDEA
• - NCLB
• Critical Relationship of Good Health and School
  Performance
• - Attendance -------- Academic Performance
  -------- Behavior
• - Schools traditionally had to use funds
  intended for instruction to
• address students health needs
• Congressional Intent Clear expression of intent
  that schools access Medicaid reimbursement to
  support schools provision of FAPE

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MAC Program Overview

• Since 1994 states have been participating in the
  MAC program to assist schools in partially
  funding the activities and services they are
  required to perform to address the unmet health
  needs of students.
• Reimbursable activities include those directed to
  individuals and families to provide information
  about the Medicaid Program, encourage individuals
  to apply, and assist in obtaining Medicaid
  services from available resources and providers
  of medical care.
• The MAC program is separate from but
  complimentary to the direct service (FFS)
  program.
• The MAC program allows school systems to function
  as an administrative arm of the State Medicaid
  Agency in support of the proper and efficient
  administration of the State Medicaid Plan.

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Summary of Key Changes
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Summary of Key Changes
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Evaluating the Impact of the Key Changes
Claim impact varies based upon each states
prior implementation of these changes.
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Evaluating the Impact of the Key Changes
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IMPLEMENTATION CONSIDERATIONS
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Implementation Approaches Key Considerations

• Timeframe for Implementation
• Based on state categorization under the
  guidelines
• Category 1 States
• Must be in compliance no later than October 1,
  2003
• No impact on claims for prior periods
• Category 2 States
• Effective immediately programs will be reviewed
  and approved based on the provisions contained in
  the final Guide
• Resolve claims for prior periods using a
  backcasting methodology
• Recommended Short-Term Action Steps
• Understand how CMS has categorized your state
• Determine necessary revisions to program or
  implementation plan
• If applicable, discuss how pending or unresolved
  claims will be paid
• If applicable, discuss appropriate methodology
  for reconciling past claims

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Sample Approaches to Implementation

• Submit Implementation Plan
• The Guide recommends the submission of an
  implementation plan
• Many states have created and submitted
  implementation plans to address how their
  existing program will change to meet the
  guidelines
• Submit Revised Cost Allocation Plan
• CMS has indicated that if a State has already
  submitted a comprehensive Cost Allocation Plan,
  they may not need to submit a separate
  implementation plan
• States with existing Cost Allocation Plans may
  not need to submit an implementation plan, but
  may need to make modifications to their CAP
• Take No Action
• Some states have heard that the implementation
  timeframe is somewhat flexible and are taking no
  action at the present time
• Not a recommended approach creates the highest
  level of risk for the state

States should be proactive and make
recommendations regarding their implementation
plans with CMS. CMS has indicated a willingness
to consider state-specific alternatives and
recommendations.
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CHALLENGES SOLUTIONS
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Challenges Affecting States

• MAC Program Changes
• Implementation of significant program changes
• Tight implementation timeframe
• Estimated loss in MAC revenue of 30-75
• Increased Administrative Requirements
  Regulations
• Increased documentation requirements
• Program administration oversight
• CMS reviews and OIG audits
• Communication
• Each State approaches the guidelines uniquely
• Communication may be difficult to interpret
• Proactive communication is required
• State Budget Cuts
• Funding and staffing decreases
• Do more with less
• Potential Reduction in District Participation
  Levels

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Strategies to Address These Challenges

• Increased Training Communication
• Maintain high level of communication with
  Regional CMS staff
• Provide CMS with proactive implementation plan
  based on states needs
• Maintain strong communication between the state
  agencies and with the districts
• Consideration of a Statewide Model
• Administer the MAC program at the state level
• Opportunity to coordinate the administration of
  MAC and/or FFS programs to streamline
  documentation, program management and oversight
• Consideration of Technology Solutions for MAC
  and/or FFS
• Assist both the State and the schools with
  reporting and monitoring
• Enhance program oversight capabilities while
  reducing administrative burden for the State and
  districts
• Improve documentation and efficiency
• Scope Expansion of Fee-for-Service (FFS) Program
• Implementation of Targeted Case Management (TCM)
  Program

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Training Communication

• Inter-Agency
• Work collaboratively with both State Department
  of Education and Medicaid
• Develop a comprehensive plan to address the
  guidelines which meets the unique needs of the
  state and districts
• Ensure oversight and monitoring responsibility is
  adequately addressed
• CMS
• Maintain high level of communication with
  Regional CMS staff
• Provide CMS with proactive implementation plan
  based on states needs
• District Training
• Provide communication regarding the guidelines
• Resultant process and administration changes
• Estimated impact to district reimbursement for
  budget purposes
• Understand the districts key concerns and
  training needs
• Ensure adequate training is provided regarding
  the new changes, time study codes and
  documentation requirements

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Consideration of a Statewide Model

• States may opt to administer the MAC program at
  the state level
• Current direction of the program supported by CMS
  
• Opportunity to coordinate the administration of
  MAC and/or FFS programs
• Streamline documentation, program management and
  oversight
• The schools, Medicaid, and Education may not have
  sufficient resources and/or technology to address
  these issues sufficiently
• Consider outsourcing statewide program
  implementation and oversight
• State Level Implementation Funding Through
  Revenue Sharing
• Some States retain a portion of the Medicaid
  Revenue to cover administrative expenses
• Offset costs of statewide system
• Optimize revenue collection to the state and
  schools
• Align interests of state and schools for optimal
  program design

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Potential Technology Solutions

• Total statewide MAC solution could include
• Technology Solution
• Implementation
• Outsourcing Solution
• State could also elect to track all MAC FFS
  activities in one system
• Solution can be created to package and automate
  residual MAC program with expanded and enhanced
  FFS program
• Improve documentation and efficiency for both MAC
  and FFS while reducing paperwork burden
• The solution should align everyones interests
• Common issues overlapping requirements
• Opportunity for enhanced reporting and monitoring
• An ideal solution should
• Provide a state-wide, long-term vision and
  implementation approach
• Create the opportunity for enhanced reporting and
  monitoring
• Maintain district flexibility and independence
• Allow for creative financing alternatives

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Sample Technology Opportunity Benefits
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Implementation/Expansion of FFS Program
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Implementation of Targeted Case Management
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Questions?

• For additional information regarding the Medicaid
  Administrative Claiming or Fee For Service
  Programs, please contact any of the individuals
  below
• Deloitte