1. ICN Session Fiscal September 16, 2003
Medicaid Administrative Claiming for School-based Services (MACSS) in Iowa
ICN Session
Fiscal
September 16, 2003

2. Agenda Background - EPSDT
Agency Participation - Organizational Structure
Working with Billing Agents
Staff Participation
RMS Time Study
Activity Codes
The Quarterly Claim
Required Matching Funds
10% Reserve Funds
Contingency Fees
Training
DHS Reviews
Annual Report
Audit File
Getting Started
Responsibilities of Lead Agency
Accountability for all Schools
On-line Resources
State Level Contacts
Process for Questions and Answers

3. Background
MACSS is a process by which Federal Financial Participation may be claimed for administrative case management activities carried out in a school setting that are necessary for the proper and efficient administration of Iowa’s Medicaid State Plan for children ages 0-21 (through age 20).
MACSS supports Iowa’s EPSDT Care for Kids program.

4. Iowa’s EPSDT (Care for Kids) Program
Early = Children should receive quality health care beginning at birth and continuing through childhood including identification, diagnosis, and treatment of medical conditions as early as possible.
Periodic = Children should receive screening and preventive care at regular intervals throughout childhood (age 0 through 20) according to standards set by responsible professional groups.
Screening = Children should be screened for conditions, diseases, or abnormalities to initiate further diagnosis and receive early and continuing treatment of these conditions. Services shall include vision, hearing, medical, dental, and mental health screenings.

5. Iowa’s EPSDT (Care for Kids) Program
Diagnosis = Children should receive further evaluation for conditions or signs identified in the periodic screens that indicate further treatment may be required.
Treatment = Children should receive treatment that involves the correction of health problems identified in the screening and diagnosis components of EPSDT.

6. Agency Participation
Agreements will be established with school districts only.
Time studies include only school district employees.
No contracted staff may be included in time studies.
Must have sufficient public unrestricted funds derived from state, county, or local generated revenues to match federal reimbursements.
May not be used as match for other programs.

7. Agency Participation Organizational structure
Lead agency status will be limited to one school district per county.
Lead school district must participate in MACSS.
Other school districts may participate under the lead agency.
Annual agreements established
Lead agency agreement with DHS
Sub-agency agreement(s) with lead agency
Fiscal year = July 1 through June 30

8. MACSS Organizational Structure
Centers for Medicare and Medicaid Services (CMS)
Iowa Dept. of
Human Services
Iowa Dept. of
Public Health
Interagency Agreement
Technical Assistance
Lead School District
Billing Agents
(if applicable)
Sub-agreement
Other School Districts
Billing Agents
(if applicable)

9. Working with Billing Agents
Contracting with billing agents is the prerogative of local participating school districts.
Role for billing agents:
Assist schools in compiling the Quarterly Claim
Provide technical assistance
Provide additional trainings following the state required trainings
Assist schools in gathering information for response to the Medicaid State Agency regarding inquiries, audit findings, claim resolution, etc.

10. Staff Participation
Staff participating in time studies may include employees serving in schools who……...
Facilitate Medicaid outreach / enrollment / eligibility determination.
Provide administrative support for Medicaid related activities.
Do not include staff who………
Provide ONLY direct care or educational services.
Have positions that are 100% supported by grant funds.
Bill service coordination under the Medicaid LEA program.

11. Staff Participation Appropriate staff may include: Nurses Counselors
At-risk Coordinators
Health Care Associates
Interpreters / Translators for medical services
Other paraprofessionals
Psychologists
Social Workers

12. RMS Time Study
Time studies will be conducted through a process known as Random Moment Sampling (RMS).
Computer generated random worker - moments are selected for the quarter (3,000 statewide / quarter).
For a given sample moment, the worker completes the RMS Observation Form.
Who were you with?/ What were you doing?/ Why were you performing this activity?
Signature and Date
Certified time coder from Lead Agency codes the activity.
Time code percentages included in an agency’s claim are based upon statewide coding percentages.

13. RMS Time Study Process for Implementation
One month before start of quarter, Lead Agency sends DHS a list of staff to be included in the time study for each participating agency (lead and subs).
DHS generates the worker-moments for the upcoming quarter.
Two weeks prior to start of quarter, DHS sends RMS Observation Forms and sample control lists to lead agency.
Lead agency distributes RMS Observation Forms and instructions to their own staff and sub-agency.
Completed RMS Observation Forms are returned to lead agency weekly.
Certified coder at lead agency assigns activity codes.
Completed forms are returned to DHS MACSS Auditor weekly.

14. Activity Codes
Code 1.a. Outreach and Facilitating Eligibility for Non-Medicaid Programs
Code 1.b. Outreach and Facilitating Eligibility for Medicaid & hawk-i
Code 2. School Related Educational Activities
Code 3. Direct Medical Services

15. Activity Codes
Code 4. a. Coordination of Transportation for Non-Medicaid Services
Code 4. b. Coordination of Transportation for Medicaid Services
Code 5. a. Non-Medicaid Translation
Code 5. b. Translation Related to Medicaid Services

16. Activity Codes
Code 6. a. Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services
Code 6. b. Program Planning, Policy Development, and Interagency Coordination Related to Medical Services
Code 7. a. Non-Medicaid Related Training
Code 7. b. Medicaid Related Training

17. Activity Codes
Code 8. a. Referral, Coordination, and Monitoring of Non-Medicaid Services
Code 8. b. Referral, Coordination, and Monitoring of Medicaid Services
Code 9. General Administration
Code 10. Not Scheduled to Work

18. The Quarterly Claim
Links staff costs associated with the time invested in Medicaid related activities to determine the claim
Incorporates the Medicaid eligible percentage of children
Applies the appropriate Medicaid provider percentage to Code 8.b.
Provides for removal of revenue to be offset from the claim
Applies the 50% Federal Financial Participation Rate

19. The Quarterly Claim Consists of 3 components
Salaries and Benefits Report
Revenues Worksheet
Invoice
Use of DHS Excel format is required.
Red triangle in cell: Information is provided as to what should be entered into that cell.
Print feature is included for each page.

20. The Quarterly Claim Salaries and Benefits Report Enter agency name.
Enter total quarterly salaries as reported in payroll journal.
Enter total quarterly benefits as reported in payroll journal.
Under Cost Pool #1, enter employees that participate in the RMS Time Study by name and position. Enter corresponding salary and benefits for the quarter.
Under Cost Pool #3, enter superintendents, principals, assistant principals, and their supporting clerical staff (if clerical are in Source Codes 2320 & 2400) by name and position. Enter corresponding salary and benefits for the quarter.

21. The Quarterly Claim Revenues Worksheet Enter agency name.
Total Quarterly Revenues
Report all revenues for the quarter except the entire 1100, 1200, 2100, and 3100 series source codes.
MACSS Reimbursements
Report under Cost Pool #1 the gross MACSS reimbursements received in the quarter (before 10% reserve and lead agency / other fees are deducted).
Medicaid LEA reimbursements
Report under Cost Pool #1 all Medicaid LEA reimbursements received in the quarter except those for service coordination.

22. The Quarterly Claim Revenues Worksheet Federal Revenue
Report all revenues for the quarter in the 4000 series source codes that apply to staff in Cost Pools 1 & 3.
State and Intermediate Revenue
Report restricted revenues for the quarter in source codes 2000 and 3000 that apply to staff in Cost Pools 1 & 3.
Other Revenue Sources
Report other revenue sources for the quarter such as contracted costs from other agencies, fees paid by clients, insurance payments, and other 3rd party reimbursements that apply to staff in Cost Pools 1 & 3.

23. The Quarterly Claim Invoice Enter agency name.
Enter travel and training costs for the quarter for staff in each of the three cost pools.
Cost Pool #1: Includes costs for staff in the RMS time study.
Cost Pool #2: Includes costs for all staff other than those included in Cost Pools #1 and #3.
Cost Pool #3: Includes costs associated with Superintendents, Principals, and Assistant Principals, and their supporting clerical staff (if clerical are in Source Codes 2320 & 2400).

24. The Quarterly Claim Invoice
Enter RMS Time Study results for each time code.
Use statewide RMS Time Study results.
Enter units of time (not percentages).
Enter the Department of Education’s unrestricted indirect cost rate for the school district (established annually).
Can be found at

25. The Quarterly Claim Invoice Enter percentage of Medicaid recipients.
Free & reduced lunch percentages are no longer allowed.
CMS requires tracking of actual Medicaid enrolled children.
The Iowa Department of Education will be conducting a sample survey of children enrolled in Iowa schools to determine a statewide rate of Medicaid eligible children.
All participating school districts will be provided information as to the statewide rate to be included in the claim.
Maintain documentation of the percentage of Medicaid eligibles for the audit file.

26. The Quarterly Claim Invoice Enter Medicaid provider percentage.
CMS requires tracking of providers to whom students are referred or with whom services are coordinated or monitored.
These providers may include physicians, dentists, psychologists, psychiatrists, opticians, and other providers such as pharmacies.
To determine the Medicaid provider percentage, divide the number of Medicaid providers by the total number of providers to whom students are referred or with whom services are coordinated or monitored. (Percentage is applied to Code 8.b.)

27. The Quarterly Claim Invoice Medicaid provider percentage
Website link to list of Medicaid providers will be provided by the Department of Education.
Tracking form will be completed by each coder.
Submit tracking document with initial claim.
Maintain documentation of the Medicaid provider percentage for the audit file.

28. The Quarterly Claim
One Purchase Order/Payment Voucher is due to Sally Nadolsky within 180 days of the end of each quarter (September 30, December 31, March 31, June 30)
Include all 3 pages (Salaries and Benefits Report, Revenues Worksheet, and Invoice) for the lead agency and each sub-holder.
Include the tracking document for providers and determination of Medicaid provider percentage.

29. Required Matching Funds
Each school district must certify required non-federal matching funds.
For every federal dollar received, a equal amount of match is required.
Federal Financial Participation is 50%
Agency certifies the other 50% as match
Source must be public unrestricted funds.
Designated matching funds must not be used as match for another grant / program.
Signed certification is required on each invoice.

30. 10% Reserve Funds
Agreement requires a minimum of 10% of the federal reimbursement to be held in reserve.
Are used to offset any disallowance identified in an audit. If disallowance exceeds the amount in reserve, the agency is responsible for total disallowance.
Must be in a separate line item or separate account.
Must be held for a rolling 5 year time period.

31. Contingency Fees
DHS withholds up to 5% of claim to support the RMS time study, review of claim, and technical assistance.
Lead agency may retain percentage of the sub-holder claim for administering the program.
Must have supporting documentation for amount withheld (update annually).
Must cover costs without profit-making.
Billing agencies
Fees must be related to the cost of processing.
May not assess percentage dependent upon federal reimbursements collected per CFR and OMB regulations.

32. Training
Certification of fiscal training is required for the staff person preparing the claim for each participating agency.
Contact Janet Beaman for training needs.

33. DHS Reviews Oversight will occur on a regular basis.
Desk reviews of both coding and quarterly claim
Review of 10% of coding each quarter
Review of quarterly claim and supporting documentation each quarter
At a minimum, biennial in-depth desk reviews
Periodic on-site reviews

34. Annual Report Lead agency submits to Sally Nadolsky at DHS each year
Due by September 30
Includes summary of fiscal elements for the claiming year for both lead and sub-agencies
Includes narrative report on use of funds for both lead and sub-agencies
Per contract must be used to expand or enhance health related services for children.

35. Audit File Audit file must be retained for 5 years Components:
Coding policies
Job descriptions reflecting activities claimed
Table of organization
Documentation of the Medicaid eligible percentage
Documentation supporting the determination of the Medicaid provider percentage
Accounting information for cost pools and revenues

36. Audit File
Components
Computations and calculations for preparation of quarterly claim
Documentation of DE unrestricted indirect cost rate for the school
Documentation of matching funds
Use of reimbursed funds
Documentation of 10% held in reserve
Documentation of analysis of administrative fees assessed to sub-agencies (for Lead Agencies)
Documentation of technical assistance & training

37. Getting Started
Determine whether participating as lead agency or sub-agency.
Establish MACSS agreement (lead or sub) each year.
New contracts to begin October 1, 2003 – June 30, 2004.
New coding structure and RMS time study anticipated to begin January 1, 2004.
School districts that have no previous experience with the program may begin when RMS time study is implemented.

38. Getting Started Identify key contact personnel for MACSS.
Certified coder from lead agency and certified back-up coder
Contact persons for RMS Time Study and Fiscal components
Determine appropriate staff for inclusion in the RMS time study.
Provide list of participating staff by name and position to Lead Agency and then DHS.
Update job descriptions and Table of Organization.
Establish process for tracking providers.

39. Responsibilities of Lead Agencies
Submits Lead Agency agreement to DHS
Enters into sub-agreements with other appropriate entities as sub-holders
Provides technical assistance to sub-holders
Provides pertinent communications to sub-holders
Provides list of coders by name & position to DHS for lead agency and sub-holders each quarter
Provides Observation Forms and worker-moments to lead agency staff and sub-holders for each quarter
Designates certified coder and back-up who code lead agency and sub-holder activities

40. Responsibilities of Lead Agencies
Submits coded Observation Forms to DHS auditor weekly
Develops lead agency Quarterly Claim and receives those of sub-holders
Provides quality assurance review of sub-holder claims
Submits one PO/PV to DHS for both lead and subs quarterly (with required supporting documents)
Maintains Lead Agency audit file
Coordinates on-site reviews of lead and sub agencies
Responsible to DHS for all disallowances identified in state and federal audits

41. Accountability for all Schools
Recognize the authority of the State Medicaid Agency regarding policies, rules, & regulations
Assure proper and efficient administration of the Medicaid State Plan through compliance with
CMS Medicaid School-based Administrative Claiming Guide, May 2003
OMB Circular A-87
45CFR Parts 74 and 95
42 CFR (f) and
State requirement to participate in RMS time study

42. Accountability for all Schools
Provide responses to Medicaid State Agency regarding inquiries, audit findings, claims resolution, etc.
Certify sufficient public unrestricted funds for match (those not used as match for other programs)

43. On-line Resources
CMS Medicaid School-Based Administrative Claiming Guide, May 2003
OMB Circulars A-87 and A-133
Iowa Department of Education Uniform Financial Accounting for Iowa LEAs and AEAs

44. State Level Contacts Sally Nadolsky Anieta O’Hair Janet Beaman
Training & Technical Assistance:
Janet Beaman
IA Dept. Public Health
Lucas State Office Building
321 East 12th Street
Des Moines, IA
Phone:
FAX:
MACSS
Auditor & Invoice Processing:
Anieta O’Hair
IA Dept. Human Services
Hoover State Office Building
1305 East Walnut
Phone:
FAX:
Lead Agreements & Annual Report:
Sally Nadolsky
Phone:
FAX:

45. State Level Contacts
For the Medicaid Local Education Agency (LEA) program
Dann Stevens, Consultant
Iowa Department of Education
Grimes State Office Building
400 East 14th Street
Des Moines, IA
Phone:
FAX:

46. Process for Questions and Answers
Questions may be submitted at anytime.
Written responses will be developed for those questions submitted by Wednesday, October 15th.
Submit to Janet Beaman at
Written responses will be sent to all participants.