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Medicaid Administrative Claiming For Adults and Children

Medicaid Administrative Claiming For Adults and Children

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Medicaid Administrative Claiming For Adults and Children

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  1. Medicaid Administrative Claiming For Adults and Children Rethinking Cost Claiming Service Activities

  2. Presenters Charles Williams NC Department of Health and Human Services Social Service Program Coordinator Division of Aging and Adult Services charles.williams@dhhs.nc.gov Jeff Olson NC Department of Health and Human Services Local Support Team Manager Division of Social Services/Child Welfare Section jeffrey.olson@dhhs.nc.gov

  3. Purpose of this Training Introduce Medicaid Administrative Claiming opportunities Outline parameters for use of MAC Provide examples of allowable activities

  4. New opportunities • More adults and children can receive services • Allows other qualified staff to serve

  5. Overview Under Title XIX of the Social Security Act, section 1903(a)(7), federal payment is available at a rate of 50 percent for amounts expended by a state “as found necessary by the Secretary for the proper and efficient administration of the state plan,” per 42 Code of Federal Regulations (CFR) 433.15(b)(7).

  6. Overview Medicaid Administrative Claiming (MAC) activities must be “in some way connected with administering services covered under the state plan” (Medicaid State Plan Manual section 4302.2). Time billed to MAC must be directly related to medical assistance to Medicaid covered services under North Carolina’s Medicaid State Plan. (see Administrative Memo)

  7. Medicaid “admin” claiming identifies expenditures related to activities • They include: • Medicaid Outreach; • Medicaid Eligibility Determinations; • Referral to Medicaid Services; • Medicaid Case Planning, Review, and Management; • Development of an Individual Plan of Care for Medicaid Services; • Coordinating transportation needed to access Medicaid services.

  8. What you need to know Medicaid Administrative Claiming Basics

  9. MAC Basics for Workers • Allows • Coordination of Medicaid services when an individual is receiving other services • Activities have to be connected to accessing Medicaid services covered under Medicaid State Plan • Claiming of travel and documentation time when it is connected to Medicaid services • New administrative claiming for specific activities for Medicaid covered services

  10. MAC Basics for Fiscal Staff FFP is Federal 50% County 50% Uncapped federal funding Activities recorded on day sheets and reported on the DSS-1571 rather than NCTracks billing No cost settlement required Only one cost center for both adult and children

  11. NC Medicaid Eligible Population Adults and Children who are Medicaid Eligible who needs assistance in accessing Medicaid services under the NC Medicaid State Plan (including Health Choice) And/Or Adults and Children who are served through Medicaid Outreach and/or requires assistance in completing a Medicaid application in order to access Medicaid services

  12. 4 Coding Categories(see MAC Desk Guide) Categories of Activities

  13. Categories for Activity Coding Referral, Coordination and Monitoring of Medicaid Services (SIS code 340) Arranging Transportation Services for Client to Access Medicaid Services (SIS code 343) Outreach for Medicaid Services (SIS code 342) Facilitating an Application for the Medicaid Program (SIS code 341)

  14. Referral, Coordination and Monitoring of Medicaid Services (SIS code 340) • Referring and/or coordinating Medicaid covered services for individuals that have: • functional impairments or mental health disabilities, and/or • substance abuse/addiction disorders • Performing assessments to identify health and mental health needs in advance of referrals or evaluations • Care coordination of needed Medicaid covered medical, mental health or substance abuse services (1 of 3)

  15. Referral, Coordination and Monitoring of MedicaidServices (SIS Code 340) • Monitoring and evaluating the Medicaid covered medical components of the individual’s service plan for effectiveness in addressing needs • Preparing documentation for interdisciplinary planning meetings, case planning meetings, etc. • Participating in treatment plan meetings (2 of 3)

  16. Referral, Coordination and Monitoring of Medicaid Services (SIS Code 340) • Gathering information for facilitating prior authorizations • In-home training of parents or family to improve the coordination/delivery of Medicaid services • Follow-up contact to ensure that an individual has received the prescribed Medicaid services (3 of 3)

  17. Arranging Transportation Services for Client to Access Medicaid Services (SIS Code 343) • Scheduling or arranging transportation services that assist the individual or family to access necessary care or treatment by health/mental health care providers • Includes activities such as related paperwork, clerical activities, or staff travel required to arrange transportation (1 of 3)

  18. Arranging Transportation Services for Client to Access Medicaid Services (SIS Code 343) • It does not include: • provision of the actual transportation service as a direct service • activities that contribute to the actual billing of transportation • accompanying an individual to Medicaid services as an administrative activity (2 of 3)

  19. Staff Travel and Transportation Services for Client to Access Medicaid Services • See example (Staff Travel and Transportation) (3 of 3)

  20. Outreach for Medicaid Services (SIS Code 342) • Used when performing activities that inform individuals about: • available Medicaid services, • how to access Medicaid services, • the importance of accessing medical, mental health, aging, functional/developmental disability, and alcohol and drug services and • the importance of maintaining a routine place for health care (1 of 4)

  21. Outreach for Medicaid Services (SIS Code 342) • General activities include: • bringing persons into the Medicaid system for the purpose of determining eligibility and • arranging for the provision of Medicaid services. • Includes all related paperwork, clerical activities, or staff travel required to perform these activities. • Both written and oral methods may be used. (2 of 4)

  22. Outreach for Medicaid Services (SIS Code 342) • Specific activities include: • Developing, disseminating or presenting materials to inform individuals about Medicaid services and where to obtain services • Informing individuals and families about the benefits and availability of services provided by Medicaid • Informing individuals and their families on effectively accessing, using, and maintaining participation in all health and mental health resources under the federal Medicaid Program (3 of 4)

  23. Outreach for Medicaid Services (SIS Code 342) • Assisting in early identification of individuals who could benefit from the health/mental health services provided by Medicaid • Assisting the Medicaid agency to fulfill objectives of the Medicaid program by: • Informing individuals of the benefits of prevention • Helping individuals and families use health/mental health resources • Assuring that health/mental health problems are diagnosed and treated early (4 of 4)

  24. Facilitating an Application for the Medicaid Program (SIS code 341) • Used when: • assisting an individual or family to make application for Medicaid or • assisting an individual to maintain Medicaid eligibility • Includes all related paperwork, clerical activities or staff travel required to perform these activities. (1 of 2)

  25. Facilitating an Application for the Medicaid Program (SIS code 341) • Includes: • Verifying an individual’s current Medicaid eligibility status • Explaining Medicaid eligibility rules and the Medicaid eligibility process • Assisting individuals or families to complete a Medicaid eligibility application • Assisting individuals or families to gather information and documents for the Medicaid application (2 of 2)

  26. More on MAC for Adults

  27. Adult Wards of the DSS The county department of social services (DSS) can bill MAC activities for a beneficiary for whom the DSS has been appointed legal guardian and if the activities meets requirements for MAC

  28. Adult Payees of the DSS The county department of social services (DSS) can bill MAC activities for a beneficiary for whom the DSS has been appointed the Payee if the beneficiary is Medicaid eligible and if the activities meets requirements for MAC

  29. Special Assistance In Home (SA-IH) The county department of social services (DSS) can bill MAC activities in conjunction with to case management for SA-IH participants You MUST document how these activities are assist an individual in accessing Medicaid service

  30. More on MAC for Children

  31. Child Welfare In Child Welfare, the identified federal and state benchmarks associated with CFSR’s are Safety, Permanence and Well Being for children MAC coding can be used for time spent on activities to meet health and mental health well being needs of children open for CWS who are Medicaid beneficiaries.

  32. Child Welfare MAC cannot be used for any activities focused solely on Safety and Permanency. Other funding sources must be used for those activities. MAC can also be used for In Home cases in which children are not at serious risk of foster care placement, but health and behavioral health needs exist that if appropriately addressed, could prevent future maltreatment.

  33. Child Welfare Agencies may also want to consider this claiming for activities involving prevention. MAC can be used for “third track” situations in which a CPS report is received and not accepted for assessment, but there are needs identified that could be addressed to prevent future reports or assist the family to overcome a health/behavioral health crisis

  34. Applying MAC Activities in Case Work Are you ready to do the MAC-arena?!

  35. Adult and Children Case StudiesIn this corner……. Adult workers Children workers

  36. So, Now What?(MAC Activities Flow chart)

  37. DSS-5027 for MAC codes 340 & 343 Document beneficiary’s request on the 5027 Open/update a service information record A signature is not required when individual is opened on the DSS-5027 for MAC If MAC and another service is opened on DSS-5027 a signature is not required for MAC but would be for the other service If MAC is added to the DSS-5027 where there is already an existing service, a signature is not required for MAC

  38. Medicaid Administrative Claiming that DOES NOT require a 5027 Medicaid Outreach (SIS code 342) Facilitating an Application for the Medicaid Program (SIS code 341)

  39. Assess the Client’s Environmentand Functional Status Assess needs for medical, educational, social or other services Determine the need for accessing Medicaid service under the State Plan For Adult Services, use the Adult Services Functional Assessment(DSS-6220) Children’s Services will complete the Strengths and Needs Assessment DSS-5229 and the DSS-5010

  40. Claiming MAC Reimbursement for the Assessment (carving out) • Only those items related to accessing Medicaid services can be billed as a MAC activity • Conduct the entire assessment and then make a determination of how much is related to accessing Medicaid Services

  41. Service Plan DSS-6221 for Adult Services Service Plan should include: • The service needs identified during the assessment • Strategies for locating and referring the recipient to programs and providers that will meet the recipient needs • Goals for the outcome of case management • The service needs, strategies, goals and dates must be supported by the assessment information

  42. Service Plan DSS-5239 or 5240 for Child Welfare Service Plan should include: • Specific health and or behavioral health needs of the child identified during the assessments • Strategies for locating and referring the child to programs and providers that will meet the child’s needs • Name(s) of the person(s) responsible for accomplishing these activities

  43. Claiming MAC Reimbursement for Service Plan Goals (carving out) • Regardless of whether a goal can be billed to MAC, all identified needs should be addressed!! • Goals that can be billed to MAC are those that assists in accessing Medicaid Services under the NC Medicaid State Plan

  44. MAC Activities during the CPS Assessment The child’s specific needs must be identified and documented through the SDM tools Documentation must include identifying strategies and activities to address the health and behavioral health needs A description of the activities

  45. Monitoring/Follow up by the Worker The expectation is that adult and children services will follow their normal procedures for case planning including monitoring and follow up. Theses will be discussed in the breakout groups (adults and children services do not use the same forms)

  46. Find your Groups Again Adults Children

  47. Day Sheet (DSS-4263) • All social workers must follow the documentation guidelines, and correctly fill out the day sheet to ensure that activities are being properly documented (Day sheet training guide)

  48. Monitoring MAC activities will be monitored periodically according to the DHHS Monitoring Plan

  49. What have we learned today? Test your Knowledge

  50. QUESTIONS?Frequently Asked Questions (FAQs) see handout WRAP UP