WHAT IS MEDICAID ADMINISTRATIVE CLAIMING?
The purpose of the Medicaid Administrative Claiming program is to provide Texas School Districts the opportunity to submit reimbursement claims for administrative activity that supports the Medicaid program. In order for the cost to be allowable and reimbursable under Medicaid, the activities must be found to be necessary for the proper and efficient administration under the Texas Medicaid State Plan, and must adhere to applicable requirements as defined in State and Federal Law.
School districts can be reimbursed for certain medical and health-related activities such as outreach services delivered to students within the district, regardless of whether the student is Medicaid eligible or not, and without any impact on other similar services the student may receive outside the district. Outreach services may be provided to a student or their family and may include activities such as coordinating, referring, or assisting the student/family in accessing needed medical/health or mental care services.
Revenue generated from MAC claims is dedicated to the provision of health services and may be used to enhance, improve and/or expand the level and quality of health/medical services provided to all students within the district.
WHAT TYPE OF ACTIVITY IS CONSIDERED "OUTREACH/CASE MANAGEMENT"?
A variety of personnel in local districts currently provide many health-related activities on behalf of their students. These include medical services such as physical therapy, occupational therapy, mental health services, and transportation services. Most schools conduct health screenings for all their students in such areas as vision and hearing. Many school districts employ school nurses to assist with the administration of medications and to assist students who become ill or injured. Some schools operate school-based clinics that provide direct medical services. More and more schools are engaged in Medicaid outreach activities to inform students and their families about the availability of Medicaid and the State Children’s Health Insurance Program (CHIP) and to assist them in applying for these programs.
For example, Student Assistance Program’s may provide comprehensive case management programs for high-risk students. Special education programs perform routine case management and case coordination functions for special education students and coordinate the delivery of related services. Administrators often coordinate and/or become involved in community groups or councils and work to identify gaps or improve the delivery of health-related services to their students.
Front line staff, often perform a range of case management and case coordination functions to insure that students with health-related needs access care in a timely and appropriate manner. District personnel may be asked to provide families with health-related information about their child’s growth and development or what to expect in caring for a student with disabilities or students with developmental delays. School staff in the elementary schools may identify health concerns and provide outreach and information to the family as well as referring them to Medicaid or other federal and state programs to help ensure the child obtains health care. As part of the ongoing case management function performed in the schools, staff may assist families in arranging transportation to take a child to a medical appointment. Staff who maintain the school’s health clinic/office may discover that families of sick children do not have health insurance. Referrals are made to Medicaid when it is suspected that a family may be eligible for services. Other staff, especially those in special education, may facilitate Supplemental Security Income (SSI) applications for special needs students.
Speech, occupational and physical therapists may provide information to parents and other staff about specific health conditions or services to help such conditions. School staff may provide information to students and their parents about the risk of drug and alcohol usage and the signs of abuse or dependency.
School nurses, along with special education personnel, and even office staff are often the first to identify suspected health problems in children and to refer them for diagnosis, treatment of follow-up health, mental health, or substance abuse services. When ongoing health services are necessary and need to be provided in the school setting, school staff is in a position to assist children in appropriately following their health care plans. School nurses may monitor and provide training to aides who perform health procedures.
School psychologists or counselors commonly do crisis intervention in schools. They may perform case management activities with families to ensure the child’s access to mental health or substance abuse treatment services. School staff may be required to assist an injured child in getting immediate medical attention.
HOW DOES THE DISTRICT OBTAIN REIMBURSEMENT?
Prior to submission and reimbursement of any claims made, participating Districts/Programs seeking to submit MAC claims for reimbursement must first enter into a contractual agreement with HHSC and participate in the Random Moment Time Study (RMTS).
To determine allowable Medicaid administrative costs within a local education agency, a quarterly RMTS will be conducted. The RMTS process starts with school districts identifying staff that perform Medicaid allowable activity. Participating staff are then added to a participant list. The participant list is used to randomly select staff to participate in a RMTS. The RMTS measures the amount of time spent on eligible and reimbursable activity for MAC and direct medical services. Once the time study is completed and the results are compiled, they are used to calculate the MAC quarterly claim.
HOW IS THE REIMBURSEMENT DETERMINED?
School districts identify staff that perform Medicaid allowable administrative activities for some part of their work day. These staff will then be eligible to participate in the state wide RMTS and the results will be used in the calculation of the MAC Claim.
A claim will be constructed based on the following formula:
- The percent of allowable time based on the state wide RMTS results.
- The percent of children in the district who are Medicaid eligible.
- The average number of Skilled Professional Medical Personnel (SPMP) and non-SPMPs.
- The average salary of staff in the district who participated in the time study.
For additional information regarding the Medicaid Administrative Claiming (MAC) Project, please send your inquiry to MAC@hhsc.state.tx.us .
For information regarding the Random Moment Time Study (RMTS), please send your inquiry to TimeStudy@hhsc.state.tx.us . Additional information regarding RMTS can be found at the following website link. http://www.hhsc.state.tx.us/medicaid/programs/rad/AcuteCare/Shars/Shars.html
The Office of State Health Services Oversight
Texas Education Agency
1701 N. Congress Avenue
Austin, Texas 78701
512.463.3070
healthandsafety@tea.state.tx.us