Medicaid
Administrative
Claiming For Adults
and Children
Rethinking Cost Claiming Service Activities
1
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
Evan Friedel
N.C. Department of Health and Human Services
Division of Social Services/Child Welfare Section
Children’s Program Representative
Evan.Friedel@dhhs.nc.gov
2
Purpose of this Training
• Introduce Medicaid Administrative
Claiming opportunities
• Outline parameters for use of MAC
• Provide examples of allowable activities
3
New opportunities
• More adults and children can receive
services
• More than a replacement for ARCM
• Allows other qualified staff to serve
• Maybe the best thing since
4
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).
5
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)
6
Administrative Memo
Excerpt
Administrative Memo Excerpt
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
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Medicaid services.
Medicaid Administrative
Claiming Basics
What you need to know
11
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
12
MAC Basics for Workers
(continued)
– Can be provided in any setting, including
facilities*
– Only county staff or contracted worker(not an
contracted agency) can bill for MAC activities
– Day sheets must be completed by DSS staff
or contracted worker for ALL MAC codes
– There are no required CM credential or
experience*
13
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
• Claims are billed only on Part I of the
fiscal note/SIS (No part II or Part IV)
• No cost settlement required
• Only one cost center for both adult and
children
14
What’s the Point?
(example)
• ADMINISTRATIVE TIME FOR COUNTY
STAFF TO ASSIST INDIVIDUALS TO
ACCESS MEDICAID SERVICES UNDER
THE NC STATE MEDICAID PLAN!!!
15
“With great power, comes great
responsibility!”
• Just about everybody who walks in your door
•
•
can receive MAC activities (uncapped funds)
It’s not how much can I bill, but what does my
client need
Got to have an agency plan (Internal)
NC Medicaid Eligible Population
Adults and Children who are Medicaid
beneficiaries who need 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 require assistance in
completing a Medicaid application in order to
access Medicaid services
17
Categories of Activities
4 Coding Categories
(see MAC Desk Guide)
18
Categories for Activity Coding
1. Referral, Coordination and Monitoring of
Medicaid Services (SIS code 340)
2. Arranging Transportation Services for
Client to Access Medicaid Services (SIS
code 343)
3. Outreach for Medicaid Services (SIS
code 342)
4. Facilitating an Application for the
Medicaid Program (SIS code 341)
19
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)
20
Referral, Coordination and Monitoring
of Medicaid Services (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)
21
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)
22
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)
23
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)
24
Staff Travel and Transportation Services for
Client to Access Medicaid Services
• See example (Staff Travel and Transportation)
(3 of 3)
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)
26
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)
27
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)
28
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)
29
Outreach for Medicaid Services
MAC SIS Code 342 activties
(note, this is typically used for individuals/families that are not part of
an open case)
• You create a brochure to explain where Medicaid
services can be obtained in your county
• You work a booth at a health fair and talk to people in
the community about the benefits they could receive
from Medicaid
• You talk with a family about available Medicaid services
and how it will help make them all healthier
• You coordinate the printing of informational packets
about Medicaid services and where they can be obtained
NOT Outreach for Medicaid Services
• You provide information on food stamps to a family that
is applying for Medicaid at your office (This is not MAC.
Providing information on food stamps is not a Medicaid
activity)
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)
31
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)
32
Facilitating an Application for the Medicaid Program
MAC SIS Code 341 activities
• You write down a list of the Medicaid eligibility rules and
explain each one to a family interested in Medicaid services
• You help a gentleman collect the various documents he
needs to complete a Medicaid application
• You help a client renew his Medicaid coverage
• You refer a woman to her local assistance office to
complete an application for Medicaid
• You complete a disability determination application in order
for the individual to obtain Medicaid
NOT Facilitating an Application for the Medicaid
Program
• You help a client complete an application to work at the
local grocery store, so that he can have a job with health
care coverage (This is not MAC. Completing a job
application, or doing anything for private insurance is not a
Medicaid activity.
• You can only bill that portion of time that
is connected to accessing Medicaid
services under the State Medicaid Plan
• If you make a visit or transport a client,
your travel and documentation must
reflect the percentage of Medicaid time
that you billed
• This above is true for all MAC activities
including assessment and service plans
More on MAC for Adults
35
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 meet the requirements for MAC
36
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 meet
the requirements for MAC
37
Special Assistance In Home
(SA-IH)
• The county department of social services
(DSS) can bill MAC activities in conjunction
with case management for SA-IH
participants
• You MUST document how these activities
are assisting an individual in accessing
Medicaid services
38
CAP
(Community Alternatives Program)
26 A) Can CAP staff claim MAC activities while providing case
management activities under a waiver service? (CAP case
management time is still available).
No. To avoid duplicate claiming, allowable administrative activities
that are reimbursed through another program such as CAP cannot
also be claimed under MAC. Staff members providing CAP services
may be able to claim reimbursable administrative activities under
MAC when the coordination of Medicaid services are not
reimbursed under CAP or CAP case management time is no longer
available.
39
CAP
Examples of activities that should be claimed as CAP (when
available) include:
 Assessing
 Care Planning
 Referral and Linkage
 Monitoring and Follow-up
CAP staffs often provide both direct services and administrative
activities. The activities listed on the previous page are direct
services/activities related to CAP. These services are integral to
case management and would be considered duplication of
payment if claimed under MAC when allowed under CAP or
when CAP case management time is still available because
activities are properly paid for as part CAP services and
reimbursed at the federal medical assistance percentage
(FMAP).
40
CAP
26 B) If activities provided to a waiver beneficiary is not billable
to the waiver, can CAP staff bill their time to MAC?
Yes. A few examples of activities (not a comprehensive list) that
could be potentially claimable under MAC by a CAP staff:
 Completing the Service Request Form (SRF)
 Preparing documents and participating in discussion meetings
with supervisor and staff
 Documenting case management activities
 Outreach to Board Members/auxiliary about CAP (Advisory
meeting attendance)
 Outreach to community about CAP services, how to apply,
eligibility criteria, referral
 In-home training to families to improve coordination/delivery
of Medicaid services (CAP does not provide training to
families, just coordinate the referral, link and monitor)
41
 Staff travel to arrange transportation
CAP
26 C) If the allotted case management time has been exhausted
for billable waiver case management activities, could MAC be
used once a CAP beneficiary has exhausted all of their CAP
funds?
Yes. MAC activities can be selected only after time has been
exhausted under CAP. The case management agency must have
supporting documentation that proves case management time
was exhausted as a result of efficient resourcing. Assisting a CAP
beneficiary to access a Medicaid service to remain safely in their
community could be claimed as MAC activities given that
documentation supports exhaustion of case management time
and the need for the participant to have access to a Medicaid
service.
42
CAP/DA Waiver Services
Adult day health

Personal care aide

Home accessibility and adaptation

Meal preparation and delivery

Institutional respite services

Non-institutional respite services

Personal Emergency Response Services

Specialized medical equipment and supplies

Participant goods and services

Community transition services

Training, education and consultative services

Assistive technology

Case management

Care advisor (CAP/Choice only)

Personal assistant (CAP/Choice only)

Financial management services (CAP/Choice only)
An annual calendar allotment of case management is set at 42hours/168units
from January1st -December 31st.

43
CAP
52. Can any other worker, such as APS,
Guardianship, Payee, SAIH, etc., bill allowable MAC
activities for a client that is a current CAP
beneficiary, since they are not the CAP worker?
Yes. Multiple workers can bill time to MAC for working with
a CAP beneficiary when APS, Guardianship, and Special
Assistance is provided.
44
More on MAC for Children
45
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.
46
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.
47
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
48
Applying MAC Activities in Case
Work
Are you ready to
do the
MAC-arena?!
49
Adult and Children Case Studies
In this corner…….
Adult workers
Children workers
50
So, Now What?
(MAC Activities Flow chart)
51
DSS-5027 for MAC codes 340 & 343
• Document the beneficiary’s request on the
•
•
•
•
5027
Open/update a service information record
A signature is not required when an individual
is opened on the DSS-5027 for MAC
If MAC and another service are opened on the
DSS-5027 a signature is not required for MAC
but would be for the other service
If MAC is added to a DSS-5027 where there is
already an existing service opened, a signature
is not required for MAC
52
Medicaid Administrative Claiming
that DOES NOT require a 5027
• Medicaid Outreach (SIS code 342)
• Facilitating an Application for the Medicaid
Program (SIS code 341)
53
Assess the Client’s Environment
and Functional Status
• Assess needs for medical,
educational, social or other services
• Determine the need for accessing
Medicaid services under the State
Plan
• For Adult Services, use the Adult
Services Functional Assessment(DSS6220)
• Children’s Services will complete the
Strengths and Needs Assessment
DSS-5229 and the DSS-5010
54
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 time is
related to accessing
Medicaid Services
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
56
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
57
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
assist in accessing
Medicaid Services under
the NC Medicaid State
Plan
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
59
Monitoring/Follow up by the
Worker
The expectation is that adult and child
services will follow their normal
procedures for case planning including
monitoring and follow up. These will be
discussed in the breakout groups
(adult and child services
do not use the same forms)
60
Find your Groups Again
Adults
NARRATIVES
Children
DOCUMENTATION
61
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)
62
Documentation
DON’T mix notes!!!
Your notes should clearly define which
activities are MAC and which activities
should be billed to another code
(examples)
63
Documentation
(continued)
A mixed note
A good note
I took Jeff to the doctor to
have a check up and have
his medicines refilled.
Afterwards I took Jeff to
visit his sister since he has
been alone a lot and he
needs to get out more.
When we got back to Jeff’s
house, I went over the
instructions that the doctor
had given him. MAC code
340 – 120 minutes
I took Jeff to the doctor to
have a check up and have
his medicine refilled. I
discussed with Jeff the
instructions that the doctor
had given him
MAC code 340 – 90 minutes
I took Jeff to visit with his
sister since he has been
alone a lot and needs to get
out more. Code 330 – 30
minutes
64
PayBack
(Disallowed cost)
• You bill 340 and/or 343 and
the individual is not Medicaid
• You bill 340 and/or 343 and
the individual is not opened
on the DSS-5027
• You bill any MAC code for an
activity that is not allowed
• You bill any MAC code and
there is no documentation
65
Monitoring
• MAC activities will be monitored
periodically according to the DHHS
Monitoring Plan
66
How often will we be
monitored for MAC?
Adult services
Children services
Every Four years
(25 counties per year)
Every Three years
(about 33 counties per year)
Adult services follow the
SSBG schedule of
monitoring
67
MAC Sample Size
Kelly Ripa and Shaquille O'Neal
• Level III Counties
5 claims each SIS code (20)
• Level II Counties
4 claims each SIS code (16)
• Level I Counties
3 claims each SIS code (12)
68
The Monitoring Tool
• Day Sheet Entries/Claims, NOT Records/Cases
Frequently Asked Questions
You got questions…..We got
answers (we hope)
https://dma.ncdhhs.gov/document/medicaid-administrative-claimingmac-adults-and-children
70
What have we learned today?
Test your Knowledge
71
WRAP UP
QUESTIONS?
Certificates
Homework
Class evals
Case Study answers
Frequently Asked Questions (FAQs)
see handout
72
Who You Gonna Contact?
Charles Williams - charles.williams@dhhs.nc.gov
Evan Friedel – evan.Friedel@dhhs.nc.gov
Adult Program Representatives http://www.ncdhhs.gov/aging/adultsvcs/aprlist.htm
Children Program Representatives http://www.ncdhhs.gov/dss/team/CPRList.html
Children Services website - https://nccwta.org
73
Medicaid Administrative Claiming
for Adults and Children
• Last modified on:
December 08,
2015