1. Administrative Claiming: New Guidelines, New Opportunities
NAME Conference
September 25, 2003

2. 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

3. OVERVIEW

4. 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

5. 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.

6. Summary of Key Changes Change Impact
Provider Participation in the Medicaid Program
Administrative Activities are reimbursable to the extent the activity supports a Medicaid direct service and that the school is an enrolled and participating FFS provider
Referrals only to Medicaid providers
For many states, FFS rates do not currently include costs related to making referrals. States can document referrals or apply a provider participation rate.
Child Find & IEP development related activities
For most states, this provision reduces the scope of reimbursable activities compared to their existing program. This includes removing from the program all activities associated with Child Find and pre-IEP activities, IEP meetings, and review/revision of IEPs. Schools are reimbursed for these activities in a few states that authorize service coordination or targeted case management.
MAC activities supporting services provided free of charge
Reduces the scope of administrative activities to the time related to direct services listed on a Medicaid eligible student’s IEP or for which the district is billing third party insurance for non-Medicaid eligible students.

7. Summary of Key Changes Change Impact Elimination of SPMP
This policy went into effect on January 1, 2003 and is confirmed in the guidelines. There is no longer a distinction of skill requirements for activities performed by school health professionals. Therefore, FFP of 75% is not allowed for activities performed by school health professionals, e.g. nurses, therapists, psychologists, etc.
Time Study Mechanism
Random moment sampling (RMS) is the CMS recommended time study mechanism. RMS requires participants to document activities in any given randomly selected 15-minute interval in the quarter.
Effective Date
New Programs – Guidelines are effective immediately
Existing Programs – The Guidelines are effective at the beginning of the school year, i.e. the October-December 2003 quarter.
Application of Medicaid Eligibility Discount
All activity codes except for Medicaid Outreach and Facilitating Medicaid Application are to be discounted by applying the Medicaid Eligibility Rate (MER).

8. Evaluating the Impact of the Key Changes
Issue
How To Evaluate Impact Using Existing Time Study Results – By Activity Code (AC)
Estimated Average Claim Reduction
IEP Related Activities
This includes all pre-IEP activities, IEP meetings, and review/revision of IEP.
In the absence of more precise TS data, move 50% of time allocated to the AC that includes this activity to a non-reimbursable AC. %
Child Find
Includes all activities associated with Child Find.
In the absence of more precise TS data, move 50% of the time units in the Medicaid Outreach AC to a non-reimbursable AC.
0 - 23%
SPMP Enhanced FFP
FFP of 75% not allowed for activities performed by school health professionals, e.g. nurses, therapists, psychologists
Recalculate existing claim using only 50% FFP.
3 - 10%
*Claim impact varies based upon each state’s prior implementation of these changes.

9. Evaluating the Impact of the Key Changes
Issue
How To Evaluate Impact Using Existing Time Study Results & Activity Codes (AC)
Est. Average
Claim
Reduction
Application of MER
All time study results except for the two AC’s noted below must be discounted by the MER.
Apply MER to TS results for all AC’s except Medicaid Outreach and Facilitating Medicaid Eligibility codes.
0 - 30%
Provider Participation
Schools must be enrolled and participating in the FFS program and the direct services must be included in the FFS program to claim for the majority of MAC activities.
For a district that is not participating in the State’s FFS program make all codes except Medicaid Outreach and Facilitating Medicaid Eligibility non-reimbursable; OR
For those MAC participants whose direct services are not included in the FFS program move their MAC reimbursable time to a non-reimbursable AC.
0 - 69% %

10. IMPLEMENTATION CONSIDERATIONS

11. 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

12. 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.

13. CHALLENGES & SOLUTIONS

14. 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

15. 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 state’s 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

16. 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 state’s 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

17. 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

18. 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 everyone’s 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

19. Sample Technology Opportunity & Benefits
Medicaid
Education
Schools
Implement a Statewide Technology Solution
Electronic
Web-based
Ease of maintenance
Data collection, State Reporting and Claims Processing is centralized, standardized and outsourced
Ability to easily monitor statewide statistics, results and compliance at the State
Help to ensure claim accuracy
Position agencies as leaders in efficient use of technology and e-government
Minimal technology requirements
Simple to use, centralized tracking and reporting capabilities
Easy to implement add-on solutions

20. Implementation/Expansion of FFS Program
Opportunity
Medicaid
Education
Schools
Enhance FFS Program
Implement a school-based FFS program
Ensure high district participation to offset a portion of MAC reduction
Expand list of reimbursable services in existing program
Streamline program requirements
Rebase existing rates, if outdated
Offset the reduction of MAC revenue
Reduce administrative documentation necessary to access funds
Increase school district participation and understanding
Increase federal Medicaid revenue to the State
A simplified and streamlined FFS billing program
Reduce any cumbersome FFS requirements
Alleviate redundant paperwork

21. Implementation of Targeted Case Management
Opportunity
Medicaid
Education
Schools
TCM Program
States may provide targeted case management services
TCM includes services which assist an eligible individual in gaining access to medical, social, educational and other services
Reach out beyond the bounds of Medicaid program to coordinate a broad range of services necessary to the optimal functioning of a Medicaid client
Increase federal Medicaid revenue to the State
States desiring to provide these case management services may do so by amending their State plans
Given the targeted nature of the program, States must submit a separate plan amendment for each target group
Ability to obtain reimbursement for activities no longer reimbursable under MAC:
Assessment
Care Planning
Referral & Linkage
Monitoring / Follow-Up

22. Questions?
For additional information regarding the Medicaid Administrative Claiming or Fee For Service Programs, please contact any of the individuals below:
Deloitte
Roberta Puffer
(847)
Ken Crow
(847)
Lisa Carnes
(847)