Medical Reimbursement Programs for California Transit Systems Cal ACT Spring Conference April 21, 2008

Definitions / More Alphabet Soup  MAA: Medi-Cal Administrative Activities. Activities that have been identified as necessary for the proper and efficient administration of the Medi-Cal program  MAA Claim Plan – A plan submitted to the State identifying staff, the MAA activities they will perform, and the methodology used for reimbursement for the various activities

More Definitions…  MAA Claiming Unit – A Claiming unit is a grouping of staff based on budgetary unit(s) within an agency affiliation. Claiming units are identified in the MAA claim plan  MAA Invoice – The mechanism used to request MAA reimbursable costs from the State

Yes, In Fact, More Definitions…  CMS – Center for Medicare and Medicaid Services  CMS is the Federal Agency that sets policies and procedures for the MAA program and provides the reimbursement for MAA

Definitions Concluded For Now  MAA Claim Plan – A plan submitted to the State identifying staff, the MAA activities they will perform, and the methodology used for reimbursement for the various activities  MAA Invoice – The mechanism used to request MAA reimbursable costs from the state

MAA Activities 1.Outreach 2.Facilitating Medi-Cal Application 3.Arranging/Providing Transportation 4.Contracting for Medi-Cal Services and MAA 5.MAA Coordination and Claims Administration 6.Program Planning and Policy Development 7.MAA Implementation Training

Medical Transportation Includes those activities that either arrange or provide non-emergency, non-medical transportation of Medi-Cal "eligibles" to Medi-Cal services

Activities that Accomplish This  Making an appointment for transportation  Arranging for someone to transport the individual  Transporting the Individual  Accompanying the individual when it is medically necessary by an aide or attendant  Providing bus and trolley tokens for the individual to get to a Medi-Cal appointment

Eligible Modes of Transportation  Taxis  Buses (Mini-Buses, Public Transportation, etc.)  Trolleys  Cars

Ineligible Modes of Transportation  Wheelchair Vans (This refers to “medical” or program specific non- public transportation)  Ambulances

Target Population  Transportation can be provided to Medi-Cal only clients or all clients that need transportation to a Medi-Cal covered service  Target Population must be described in the Claim Plan

Medi-Cal / Essence of Intergovernmental Relations  In California there seems to be a misperception that public transportation providers are not eligible for Medi-CaL reimbursement  Fortunately, this isn’t the case

State & Local Participation  Although MAA is a federal program, the State of California, Department of Health Services, MAA/TCM Branch administers it. The County of San Diego’s LGA works with the State on MAA matters and directly with the CMS program  The LGA is responsible for the administration of the MAA program at the local level. All MAA providers must go through the LGA to participate in the program and to receive MAA reimbursement

How to Participate in MAA  As Provided by the LGA, the Prospective Provider Questionnaire, must be completed to the LGA for review  If preliminary requirements are met, a meeting is set-up with the LGA where the program’s infrastructure and matchable revenues are explored  LGA requests approval from the State

Participation / Payment  Once Claim Plan approved by State a program can invoice, retroactively to the identified quarter  Rate of reimbursement varies given the nature of 4 way redistributive funding

Redistributive Funding Stream  Federal Government  State Government  LGA  Eventually the Transportation Provider, as “one of many" claimants, is reimbursed per the invoice

Other Claimants  Hospitals  Probation  Health and Human Services  Aging and Independent Services  Many, many other similar programs

The Transportation Providers Responsibilities as Claimant / Coordinator  MAA Coordinator: Employee appointed to act as representative on MAA matters and to ensure program adheres to MAA County, State, and Federal Guidelines  Maintenance of the Audit File

Duties Associated with MAA Coordinator Main contact with LGA on MAA matters Attend MAA provider meetings held by the LGA Attend MAA workshops Coordinate any requests for MAA site visit

Duties Continued Maintain and up-date the MAA Guidelines provided by the LGA Communicate changes in MAA policies and procedures to appropriate staff Establish and maintain the MAA audit file Attend the annual MAA Train-the-Trainer session Oversee the completion of the MAA Claim Plan and Quarterly Invoice

Elements of an Audit File MAA Claim Plan and Amendments Current Organizational Chart and Job Descriptions of staff participating in MAA Invoice Contracts

Invoice Components Supporting source documentation for the quarterly invoice Methodology used to calculate Medi- Cal percentages Documentation supporting transportation / direct charge costs MAA invoices for prior three years

Contracts  MOA with the LGA  Copies of staffing sub-contracts  If any of the above items are not located in the audit file, a notation must be made in the file where the item is stored

Consultant Services (Not Mine ) The LGA contracts with a consultant to assist the LGA with various activities including;  Training and technical assistance  Assistance to providers in developing procedures for managing their MAA program  Technical assistance to providers  Participation in bi-monthly provider meetings

Consultant Services Continued…  Assistance to new providers in preparation of the claim plan and Quarterly invoice  Requests for the consultant must go through the LGA and must be reviewed and approved in advance by the LGA

Purpose of MAA Claim Plan  Provide a description of the types of MAA activities that will be performed  Categories of staff that will perform them  Completed Plan contain the information that will be used to create the program’s invoice

Contents of the Claim Plan Certification Statement General Description of the Claiming Unit Functions Description of Claiming Unit Staffing Grid (NA) Activity Codes that staff may code to (NA) The Claim Plan Review Record

Local and State Review  LGA Review: LGA submits all claim plans to the state, develops timelines for submission and notifies programs of any new requirements  State Review: Claim Plans must be submitted to the State no later than October 31 for the first quarter of the State Fiscal Year and by the last day of any subsequent quarter

Continued  State reviews all Claim Plans and either approves the Plan or requests additional information from the LGA  Significant concerns or open questions are forwarded up to the CMS for review (Feds)

Claim Plan Amendments  Claim Amendment Checklist  LGA Completes the Checklist and other documents  Program is provided instructions from LGA regarding required submissions

MAA Claiming Plan Amendment Checklist

MAA Invoice  Invoice Worksheet  Direct Charge Worksheet  Funding Worksheet

Invoice Worksheet Incorporates information from the funding and direct charge worksheets to produce the basis of the claim and amount of reimbursement

Direct Charge Worksheet  Most pertinent part of invoice to public transportation providers  Worksheet that displays costs that can be charged to MAA using a methodology identified in the Plan  For example, Contracted Costs minus Revenues for the Quarter

Direct Charges Continued Editorial  Balancing between all “attributable costs” and integrity of Audit File  MTS simply uses purchased transportation after revenues are deducted  Fully Allocated Cost Recovery is of diminishing proportional limited return

Funding Worksheet  Not pertinent for MTS invoice that only captures direct costs  Used to display funding sources for costs reported  Sorted by Medi-Cal, federal, state general fund, etc.) and cost pool

Invoice Worksheet  Time Survey Results (NA)  Medi-Cal Percentage  Actual expenditures for the quarter covered by the invoice  Funding sources supporting the expenditures (NA)

Medi-Cal Percentage (Two Methods)  LGA will supply the Countywide average (Percentage for prior FY)  A Case Count can be used per a methodology described in the approved Claim Plan  MTS has an FFP rate of 50%

Actual Expenditures  NO BUDGET ESTIMATES (Actuals only)  Must be for quarter claimed  Back up report for transportation needs to contain trip-by-trip confirmation

Direct Charge Worksheet  Costs of transportation services for Medi-Cal clients going to medical based appointments are recorded here  Direct charges recorded on the invoice much be described in the Claim Plan

Quality Assurance Coordinator’s Responsibilities Audit File Annual Site Visit MAA Bi-monthly Meeting and Workshop

Conclusions  Very Dynamic and Subject to Change  The LGA may be reluctant due to lack of awareness, risk management concern or official agency policy  Current State & Federal Legislative Proposals and Budget Recommendations jeopardize the future  These same Realities complicate Universal and Consistent Awareness

Metaphorically Speaking…  Medi-CAL is like ADA insofar as being the subject of ubiquitously inconsistent interpretation from entities with varying, dynamic and unclear levels of authority

THANK YOU! Max Calder