MEDICAID

1
MEDICAID
2
Medicaid Administrative Claiming--MAC

• vs.
• Targeted Case Management and Maternity Case
  Management

3
MAC

• MAC is for the proper and efficient
  administration of the States Medicaid Plan aka
  the Oregon Health Plan.
• Public Health Departments are reimbursed for
  specific activities that they are already doing.
• Only additional work is taking a survey that
  takes about 10 minutes to complete.

4
Administrative Claiming IS NOT

• Targeted Case Management (Babies First!, CaCoon)
• This is the process by which public health bills
  for health services provided to Medicaid/OHP
  eligible children pursuant to a case management
  plan.
• Maternity Case Management
• This is part of the OMAP benefit and not a
  leveraging program.

5
Medicaid Administrative Claiming Is

• A method of identifying and accounting for the
  time spent by public health programs staff on
  administrative activities such as referral and
  outreach. Reimbursement is then claimed for the
  time spent performing these activities.
• Other than taking the survey and preparing the
  claim, no new work is required.
• Staff do not need to know who is Medicaid/OHP
  eligible.

6
MAC and TCM

• MAC is population based TCM is individual
  Medicaid eligible based
• MAC is total time accounting TCM is billing for
  specific service it is a Code E Direct Service
• MAC provided to all by all staff in cost pool
  TCM is provided only to Medicaid eligibles
  through the State Medicaid Plan amendment
• MAC not dependent on a TCM plan
• Public Health staff can do TCM and MAC- guidance
  is provided by DHS Multiple Leveraging Program
  Participation Guidance

7
TCMs in Oregon

• DD
• Children Adults and Families Medicaid Eligible
  Parents 14 and Over Who Receive AFDC
• SCF/OYA
• Babies First/CaCoon
• HIV (Multnomah only)
• Substance Abusing Parents

8
MAC Claiming Formula

• 1. Cost Pool
• X
• 2. Medicaid eligible percentage
• X
• 3. Percent of allowable time (survey)
• Public Health total claim
• 50 Match Required Net claim

9
Developing the Cost Pool

• Identify appropriate staff routine contact with
  child and family(s)
• Nurses, date stampers, interpreters, health
  educators, program development, etc.
• Do not include janitorial, food service,
  accounting, lab techs, etc.
• Identify actual salary, benefits and other
  personnel expenses
• Remove federal funds from the cost pool
• Cost pool established quarterly

10
Medicaid Eligible Percentage

• Public health programs will use program data to
  establish
• Unduplicated count of individuals in service
• Formula All individuals in service on
  Medicaid/OHP divided by all individuals in
  service
• Percentage is established quarterly

11
MAC Survey How it Works

• Random Moment Survey
• Survey 4 days/qtr
• Ten activity codes
• 15-minute blocks of time
• Predominant activity

• Random Day
• Survey dates and participants are randomly
  selected
• Survey from 8am-6pm
• Training
• Everyone must be trained before taking survey

12
(No Transcript)
13
(No Transcript)
14
Ten Activity Codes

• A1. Outreach and application assistance for
  Medicaid/OHP Program.
• A2. Outreach and Application assistance for
  non- Medicaid/OHP Outreach.
• B1. OHP Referral , Coordination, Monitoring,
  Training
• B2. Non-OHP Referral, Coordination, Monitoring
• Training
• C1. Medicaid/OHP Transportation and Translation
• C2. Non-Medicaid/OHP Transportation and
  Translation
• D1. System Coordination related to OHP services.
• D2. System Coordination related to Non-OHP
  services.
• E. Direct Health Care Services.
• F. Other work activities.

15
Code A1 Outreach and Application Assistance for
OHP Program

• This code should be used for
• Informing individuals on how to access, use and
  maintain OHP
• Assisting in early identification of individuals
  who could benefit from OHP health services
• Explaining OHP eligibility rules and process
• Assisting individuals to complete OHP application
  including translation and comprehension
  activities

16
Code A1 Examples

• Informing clients and others about the
  OHP/Medicaid program and referring them to DHS
• Date stamping and handing out OHP applications to
  clients.
• Providing information regarding Medicaid managed
  care programs and health plans to individuals and
  families and how to access that system.
• Confirming or verifying with DHS an individual's
  current Medicaid eligibility status
• Contacting pregnant and parenting teenagers about
  the availability of Medicaid prenatal and well
  baby care programs

17
Code A-2 Outreach and Application Assistance
for Non-OHP Programs

• This code should be used for
• Non-OHP outreach social, educational, legal or
  other services not covered by OHP
• Informing parents/guardians about non-OHP
  programs TANF food stamps WIC etc.
• Translation of or assisting to comprehend
  applications to these programs
• Scheduling/promoting activities which educate
  individuals about the benefits of healthy
  lifestyles tobacco cessation, or general
  nutrition

18
Code A2 Examples

• ü     Outreach campaigns directed toward
  encouraging persons to access social,
  educational, legal or other services not covered
  by Medicaid.
• ü     Informing an individual or family about
  programs such as Temporary Assistance for Needy
  Families (TANF), food stamps, Womens Infant
  Children Program (WIC), day care, legal aid, and
  other social or educational programs and
  referring them to the appropriate agency to make
  application

19
B-1 OHP Referral, Coordination, Monitoring and
Training

• This code should be used for
• Making referrals for and/or coordinating the
  medical/developmental health/dental health/mental
  health and substance abuse services covered by
  OHP
• Providing any information that may be required in
  advance of these referrals
• Providing follow up contact to ensure that a
  child has received the prescribed health services

20
Code B1 Examples

• ü     Making referrals for and/or coordinating
  medical health, dental health, mental health or
  substance abuse services covered by Medicaid,
  including medical or physical examinations and
  necessary medical evaluations
• ü     Providing information and making referrals
  for and/or scheduling Medical screenings.
• ü     Arranging for any diagnostic or treatment
  services, which may be required as a result of a
  condition identified during an evaluation or
  screening.
• ü     Gathering information that may be required
  in advance of these referrals or evaluations.

21
More Code B1 Examples

• Working with individuals, their families, other
  staff, and providers to identify, arrange for,
  and coordinate services covered under Medicaid
  that may be required as a result of screens,
  evaluations, or examinations.
• The actual referral of an individual to a medical
  program for Medicaid-covered services.
• Training which improves the delivery of
  Medicaid-covered services, including TCM training
• Participating in or coordinating training which
  enhances early identification, intervention,
  screening and referral of clients with special
  health needs to medical services.

22
B-2 Non-OHP Referral,Coordination,Monitoring,
and Training

• This code should be used if not TCM/MCM for
• Making referrals for social services, community
  wellness, etc. programs
• Gathering any information that may be required in
  advance of these referrals
• Making referrals for educational or vocational
  programs.

23
B2 Examples

• Making referrals for and/or coordinating WIC
  services.
• Working with individuals, their families, other
  staff, and providers to identify, arrange for,
  and coordinate social services including housing,
  food bank, etc.
• Assist family in accessing parenting support
  group to empower parents with optimal parenting
  skills

24
Code C-1 Medicaid/OHP Transportation and
Translation

• This code should be used for
• scheduling, arranging or providing transportation
  to Medicaid/OHP covered services
• If destination time is positive, can include the
  staff travel time back and forth!
• scheduling, arranging or providing translation
  services to assist individual to access and
  understand necessary care and treatment

25
C-2 Non-Medicaid/OHP Transportation and
Translation

• This code should be used for
• scheduling, arranging or providing transportation
  to social, vocational and/or other educational
  programs and activities
• scheduling, arranging or providing translation
  services to assist individual to access and
  understand necessary non-Medicaid/OHP services

26
Code D-1 System Coordination Related to OHP
Services

• This code should be used for
• Working internally and with other agencies to
  improve OHP services
• Identifying gaps, duplications, overlaps of
  medical services
• Developing strategies to access or increase the
  capacity of medical, developmental, dental,
  mental health programs
• Interagency coordination to improve delivery of
  OHP services

27
D1 Examples

• Working internally or with other agencies
  providing Medicaid services to improve the
  coordination and delivery of services, to expand
  access to specific populations of Medicaid
  eligibles, and to improve collaboration around
  the early identification of medical problems.
• Reducing overlap and duplication in
  Medicaid-covered services and closing gaps in the
  availability of services.
• Planning and developing strategies to increase
  Medicaid system capacity and close Medicaid
  service gaps includes analyzing Medicaid data
  related to a specific program or specific group.

28
Code D-2 Referral, Coordination and Monitoring
of Non-Medicaid Services

• This code should be used for
• working collaboratively with other agencies to
  identify gaps, overlaps or duplication of
  non-medical/health services, such as vocational,
  social or educational services
• improve coordination, expand access or delivery
  of non-Medicaid/OHP services
• develop strategies to assess or increase the
  capacity of non-medical, dental and mental health
  programs

29
D2 Examples

• Working internally or with other agencies to
  improve the coordination and delivery of social
  services such as housing, food banks, etc.
• Coordinating bioterrorism preparedness.
• Meeting with community groups to address issues
  with environmental health systems (water systems,
  restaurant inspections, etc).
• Provide health expertise to a community group on
  writing a juvenile offender grant, which proposes
  a new system to respond to juvenile offenders and
  their parents.

30
CODE E - DIRECT SERVICE

• An activity that is done to correct or ameliorate
  a condition
• Any activity that is considered integral to, or
  an extension of a specified covered service
• Does not have to be a billable service
• May not have to be performed by a practitioner
  administering first aid

31
Code E ExamplesCode E Examples

• Give immunizations at public immunization clinic
• TCM/MCM
• Providing health/dental/mental health services
• Conducting health/dental/mental health
  assessments/evaluations and diagnostic testing
• Administering first aid or prescribed injection
  or medication to an individual

32
Code F Other Work Activities

• This code should be used for
• All other job related activities that do not fall
  under one of the above categories
• Paid time off, vacation leave, sick leave, paid
  lunch, jury duty or any other paid time away from
  work
• Budget development general supervision

33
Multiple Leveraging Guidance

• Individuals can participate in two leveraging
  programs-direct and administrative
• The time survey is a tool to cost allocated
  between programs

34
Good Information to Know

• Staff do not need to know who is Medicaid/OHP
  eligible
• It is the activity of staff that is being
  measured, not the outcome of the activity

• Staff do not need to know all about Medicaid/OHP
• Time study determines staff time spent on
  eligible and non-eligible activities

35
Contacts

• Fritz Jenkins, DHS
• fritz.jenkins_at_state.or.us
• Gary Williams, DHS
• gary.r.williams_at_state.or.us