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. Outreach2. Facilitating Medi-Cal Application3. Arranging/Providing Transportation4. Contracting for Medi-Cal Services and MAA5. MAA Coordination and Claims
Administration6. Program Planning and Policy Development7. 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 transportationArranging for someone to transport the
individualTransporting the IndividualAccompanying the individual when it is
medically necessary by an aide or attendantProviding bus and trolley tokens for the
individual to get to a Medi-Cal appointment
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 RelationsIn 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 GovernmentState GovernmentLGAEventually the Transportation
Provider, as “one of many" claimants, is reimbursed per the invoice
Other Claimants
HospitalsProbation Health and Human ServicesAging and Independent ServicesMany, 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 workshopsCoordinate 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 fileAttend the annual MAA Train-the-Trainer
sessionOversee the completion of the MAA Claim
Plan and Quarterly Invoice
Elements of an Audit File
MAA Claim Plan and AmendmentsCurrent Organizational Chart and
Job Descriptions of staff participating in MAA
InvoiceContracts
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 LGACopies 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 assistanceAssistance to providers in developing
procedures for managing their MAA program
Technical assistance to providersParticipation 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 StatementGeneral Description of the Claiming Unit
FunctionsDescription of Claiming UnitStaffing 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 ChecklistLGA Completes the Checklist and
other documentsProgram is provided instructions
from LGA regarding required submissions
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 PercentageActual expenditures for the quarter
covered by the invoiceFunding 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 claimedBack 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 ResponsibilitiesAudit FileAnnual Site VisitMAA Bi-monthly Meeting and
Workshop
Conclusions
Very Dynamic and Subject to ChangeThe 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
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