Municipal Medicaid 
Program 
 
 
Charter School Meeting 
 

Agenda
?	Introduction
?	Direct Service Claiming
>	Overview
>	Requirements
>	Reference Materials
>	Eligibility
>	Claim submission
?	Administrative Activity Claiming	
>	Overview
>	Requirements
>	Time Study
>	Reference Materials
 



Direct Service Claiming
Direct Service Claiming: Overview
?	Objective:  Reimburse providers for Medicaid health-related services provided 
to Special Education students as prescribed in their IEP.
?	Providers submit claims using:
>	Bundled rate system based on a student’s Special Education classification (prototype), or;
>	Fee-For-Service system for Special Education team meetings, home assessments, and 
private duty nursing services.
	
Direct Service Claiming: Requirements
?	IDEA/IEP
>	Providers can only claim for health-related services provided to students through a valid IEP 
(in accordance with IDEA requirements).
>	Note:  504 students do not qualify for reimbursement because they do not receive services 
through an IEP.
?	Medicaid Eligible
>	Students must be MassHealth enrolled.




Direct Service Claiming: Requirements
?	Provider Qualifications
>	Services must be provided by qualified health care providers as defined by Medicaid 
regulations.
>	Qualified providers currently include: lic. therapists, OT/PT certified aides supervised by lic. 
therapists, RN, LPN, lic. Psychologists, School Psychologists, etc.
?	Attendance
>	Submit claims for every day that a student is in attendance (regardless of whether the 
student receives a service on that day).
Direct Service Claiming: Requirements
?	Documentation of Services
>	Documentation of Medicaid services must be maintained to ensure that services prescribed 
in an IEP are delivered.
>	Municipal Medicaid providers may only file claims for those students for whom they have a 
documented record of Medicaid services delivered.
>	Documentation must be completed for all Special Education health-related services. 
>	Documentation requirements are effective 10/1/03.




Direct Service Claiming:  Requirements
?	Services provided by assistants or aides must be supervised by a licensed 
professional.
?	Documentation forms completed by assistants or aides must be co-signed by a 
licensed professional.
?	Signatures:
>	The signature of the medical professional authorizing services must comply with generally 
accepted standards for record keeping within the applicable provider type as they may be 
found in laws and regulations of the relevant board of registration.



Direct Service Claiming:  Procedure Codes
Direct Service Claiming:  Reference Materials
?	For additional information related to Direct Service Claiming refer to:
>	Operational Guide for School Districts (included with handouts)
>	Municipal Medicaid Billing Guide (included with handouts)
>	Provider Bulletins (included with handouts)
?	For program related questions contact UMass                    at 508-856-8631.
?	For claim submission/processing related questions    contact EDS at 800-325-
5231
>	After July 1, 2005:  800-841-2900 
Eligibility Verification
Administrative Activity Claiming
Administrative Claiming:  Overview
?	Objectives:
>	To identify the level of Medicaid-related administrative costs incurred by school districts 
associated with the provision of school-based health services.
>	To quantify the level of Medicaid administrative support activities performed by school-
health personnel.





Administrative Claiming:  Requirements
?	Time Study:
>	Isolates time spent performing Medicaid-reimbursable administrative activities.
>	Completed for five consecutive school days during three quarters of the year by salaried, 
contract, full-time and part-time personnel.
?	Time Study data is combined with: 
>	Salary, fringe benefits, materials, capital, specialized transportation and indirect costs.
>	The percentage of Medicaid eligible students among the total student population of a 
district.







Administrative Claiming:  Time Study
?	OT, PT, Speech Therapists/Assistants/Aides
?	RN, LPN, Assistants/Aides
?	Psychologists, Interns
?	Audiologists, Hearing/Vision Specialists
?	Psychiatrists, Physicians
?	Case Managers, School Adjustment Counselors, Guidance Counselors, Social Workers
?	Special Education/Pupil Support Directors, Assistants, Clerical Staff, Team Chair Personnel
?	Nursing Director, Assistants, Clerical Staff

*Completed by school personnel whose job function includes performance 
of Medicaid administrative activities.

Administrative Claiming:  Time Study
?	Reimbursable Medicaid Administrative Activities:
>	Informing, outreach and training to individuals or families about Medicaid services
>	Facilitating Medicaid eligibility process
>	Provider networking, program planning
>	Care planning, coordination, monitoring and referral for Medicaid services
>	Family planning referrals
>	Coordination of transportation/translation services





Administrative Claiming:  Time Study
?	Non-Reimbursable Activities:
>	Information, outreach and training to individuals or families about social/vocational services 
or programs
>	All direct services (therapies, counseling, etc)
>	Care planning, coordination, monitoring and referral for non-Medicaid services
>	Training to families or school personnel regarding general school or education topics
>	Coordination of transportation/translation services for non-Medicaid services





Time Study:  Activity Code Descriptions
Activity Code A:  Medicaid Outreach & Training

>	Activities would include bringing potential eligibles into the Medicaid system for the purpose 
of determining eligibility & arranging for the provision of Medicaid services.  
>	Coordinating, conducting, or participating in training events and seminars for outreach staff 
regarding the benefits of the Medicaid program, how to assist families to access Medicaid 
services. 
>	Related paperwork, clerical activities or staff travel required to perform these activities.
>	Written and oral methods may be used.  

Example: Talking to other staff, students and families about the Medicaid Program, referral process and 
health-related services.
Time Study:  Activity Code Descriptions
Activity Code B:  Facilitate/Assist in Medicaid Eligibility Process

>	School staff should use this code when assisting an individual in becoming eligible for 
Medicaid. Activities would include explaining Medicaid rules and eligibility process. 
>	Include related paperwork, clerical activities or staff travel required to perform these 
activities. 
>	Written and oral methods may be used. 

Example: Assisting in the completion of the enrollment forms in order to apply for Medicaid Services.
Time Study:  Activity Code Descriptions
Activity Code C:  Provider Networking/Program Planning/Interagency 
Coordination

>	Performing activities associated with the development of strategies to improve the 
coordination and delivery of Medicaid covered services to school age children.
>	Performing collaborative activities with other agencies. 
>	Include related paperwork, clerical activities or staff travel required to perform these 
activities. 
>	Written and oral methods may be used. 

Example: Building a bridge between community providers and school clinicians in an effort to build 
resource relationships.



Time Study:  Activity Code Descriptions
Activity Code D:  Individual Care Planning, Monitoring, Coordination & Referral

>	Gathering information in advance of making referrals for Medicaid covered services. 
>	Making referrals or arranging Medicaid covered medical services.
>	Coordinating or monitoring the delivery of Medicaid covered medical services.
>	Monitoring and evaluating the Medicaid service components of the IEP.
>	Providing information on the child’s medical health service plan to other staff and parents.
>	Coordinating the follow up care on the medical services requested.
>	Related paperwork, clerical activities or staff travel required to perform these activities. 
>	Written and oral methods may be used.  

   Example: When you contact a family about the medical referral, screening 
      or evaluation process.



Time Study:  Activity Code Descriptions
Activity Code E:  Transportation & Translation Related to Medicaid Services

>	Arranging for or providing transportation services from the school     to and/or from Medicaid 
covered services.
>	Arranging for or providing translation services (including signing) for students or families 
regarding Medicaid covered health related issues.
>	Related paperwork, clerical activities or staff travel required to perform these activities. 
>	Written and oral methods may be used.  

Example: Providing signing services that assist the family in understanding medical treatment.

Time Study:  Activity Code Descriptions
Activity Code F:  Family Planning Referral

>	Identifying and referring adolescents who may be in need of family planning services.
>	Administrative activities that act to delay or prevent the onset of pregnancy. 
>	Coordinating family planning activities in the school setting.
>	Include related paperwork, clerical activities or staff travel required to perform these 
activities. 
>	Written and oral methods may be used. 

Example: Referring an adolescent to an outside agency for the purpose of delaying or preventing the 
onset of pregnancy.

Time Study:  Activity Code Descriptions
Activity Code G:  Direct Service

>	Providing care or treatment to an individual in order to correct or improve a specific 
condition.  
>	Providing counseling services to treat health, mental health or substance abuse conditions.
>	Performing routine or mandated screenings such as vision, hearing, scoliosis etc.
>	Attending an IEP meeting.
>	Include related paperwork, clerical activities or staff travel required to perform these 
activities. 
>	Written and oral methods may be used.  

Example: Providing occupational therapy to a student and recording results in the student’s health 
record.

Time Study:  Activity Code Descriptions
Activity Code H:  General Administrative 
Activities & Overhead

>	Performing activities that are not directly assignable to other program activities.  
>	Covers any non-work related time including paid vacation, sick or personal time, lunch or 
break time and unscheduled non-school days such as snow days .
>	General supervision of staff.
>	Include related paperwork, clerical activities or staff travel required to perform these 
activities. 
>	Written and oral methods may be used. 

Example: Attending administrative staff meetings.

Time Study:  Activity Code Descriptions
Activity Code I:  Non-Health Related Activities

>	Any other school-related activities that are not health related, such as social services, educational and 
teaching services, employment and job training.
>	Providing classroom instruction, correcting papers or compiling report cards.
>	Providing general supervision of students, such as in the lunchroom or on the playground.
>	Include the development, coordination, and monitoring of a student’s educational plan. 
>	Include related paperwork, clerical activities or staff travel required to perform these activities. 
>	Both written and oral methods may be used. 

Example: Preparing lesson plans or correcting papers.


Time Study: Activity Code Changes
?	Travel Time: Code your travel time as you would code the purpose of the 
travel
>	If you travel between schools to perform direct service, then use activity code G. 
>	If you travel to attend a Medicaid in-service training use activity code A.



Time Study: Reminders
?	Time study participants must be properly trained.
?	Time study can be completed by:
>	Random sample of personnel in each job grouping.
>	100% for all personnel in each job grouping.
?	Participation is based on actual job functions that 
  are performed, not on job title.
>	School district personnel that perform Medicaid administrative activities are 
eligible to participate in the time study.
Time Study: Participants
Time Study: Participants
Claim Calculation:  Steps to Completing a Claim
?	Step 1:  Calculate Time Study Results
?	Step 2:  Develop Detailed Expenditure Report
>	Salaries	
>	Fringe Benefits
>	Materials and Supplies
>	Out of District Tuition Payments 
?	Step 3:  Quarterly Claim Calculation
?	Step 4:  Capital Calculation 
?	Step 5:  Specialized Transportation Calculation
?	Step 6:  Claim Summary


Claim Calculation:  Time Study Results
Claim Calculation:  Detailed Expenditure Report
Claim Calculation:  Fringe Benefit Calculation
Claim Calculation:  Fringe Benefit Calculation
Claim Calculation:  Out of District Tuition
Claim Calculation:  Detailed Expenditure Report
Claim Calculation: Medicaid Eligibility Rate
?	Quarterly ratio of Medicaid eligible students in the school district 
divided by the total number of students registered in the school 
district served in the Local Education Authority.

Number of Medicaid Eligible students in the district for the quarter 
Total number of students in the district for the quarter



Claim Calculation: Medicaid Eligibility Rate
?	Steps to calculating Medicaid Eligibility Rate:
>	Gather quarterly school district enrollment information. 
>	Obtain Medicaid recipient eligibility information from the Office of Medicaid 
for the same quarter. 
>	Complete a data match utilizing one of the following:
?	WebRevs (800-462-7738)
?	MassHealth toll-free number (800-554-0042 or 800-833-7582)
?	Direct match using the quarterly eligibility lists distributed by MassHealth.


Claim Calculation: 
General Administrative Overhead Factor
?	Percentage of time spent on activity codes A-F (C, D, E and F are multiplied 
by the Medicaid Eligibility Factor) divided by the percentage of time spent on 
activity codes A-I (excluding H) for each job position grouping. 

{% of A + % of B + (% of C * Medicaid Eligibility Factor) + (%D * Medicaid Eligibility Factor) + (% of E * 
Medicaid Eligibility Factor) 
+ (% of F * Medicaid Eligibility Factor)} 
% of A + % of B + % of C + % of D + % of E + % of F + % of G + % of I

	Note: If no allowable administrative activities are performed, no time associated with the administrative 
overhead factor can be claimed.
Claim Calculation
Claim Calculation: Capital 
?	Identify the following:
>	Acquisition costs of the school district’s buildings and improvements.
>	Acquisition costs of the school district’s equipment that is not included in the 
amount above (“major movable equipment”). 
>	Current interest expense associated with land, equipment, school building 
acquisition, construction, fabrication, reconstruction, and remodeling. (See OMB 
Circular A-87 (B).

Claim Calculation: Capital 
?	Complete the following steps:
>	Multiply the sum of building and fixed asset acquisition costs and major movable equipment 
acquisition costs by the annual use allowance. 
>	Add the sum of the above calculation to the net interest expense.
>	Calculate the capital percentage:
 				Total Capital 
District–wide salaries and fringe benefits 






 
Claim Calculation: Specialized Transportation 
?	Gather actual quarterly specialized transportation costs for Special Education 
students. 
?	Calculate the following percentages:

Number of Special Ed. students who have transportation in their IEP for a medical reason 
Total Number of Special Ed. students who receive specialized transportation

Total Number of Medicaid Eligible Special Ed. students in the district for the quarter 
Total Number of Special Ed. students in the district for the quarter 

?	Multiply the above factors by the updated state-wide average of time spent 
receiving Medicaid covered services.

Claim Calculation: Specialized Transportation 
?	Specialized transportation: Transportation in a vehicle used to furnish such 
transportation service that is specially equipped/staffed to accommodate 
individuals with specialized medical needs.
Claim Calculation: Indirect Cost Rate
?	Identify your school district’s most recent unrestricted indirect cost 
rate for federal grants by contacting the Department of Education 
at 781-338-3300 or visiting their website, www.doe.mass.edu.
Claim Calculation Summary
Claim Calculation: Summary of Changes
?	Capital Costs/Calculation:
>	 Use acquisition costs instead of Annual Valuation.
>	 Calculate the ratio of capital to total of annual budgeted district 
     wide salaries and fringe benefits.
>	 Apply capital percentage rate to total of gross claim amounts from expenditure reports and 
specialized transportation.
>	 No longer use square footage percentages.
				
?	Updated Percentages:
>	Transportation:  State-wide average of time spent receiving Medicaid covered services. 
>	Out of District:  Room and board discount factor for residential tuition calculation.
>	Out of District:  Percentage of time spent in health-related services.
Claim Calculation:  Certification
?	The accuracy of the quarterly claim must be certified by an 
authorized district official from the participating LEA and 
documented on a Quarterly Claim Certification form. 
>	The Quarterly Claim Certification form must be included with  the claim at 
the time of submission.
>	The Quarterly Claim Certification form must be on school district letterhead.
?	Refer to Page 16 of the Claiming Manual.
Claim Submission Requirements
?	Quarterly Claim Certification
?	Quarterly Claim Calculation Summary
?	Quarterly Claim Calculation 
?	Quarterly Specialized Transportation Calculation
?	Capital Calculation 
?	Fringe Benefit Calculation
?	Detailed Expenditure Report
?	State-wide Summary Worksheet for Out of District Schools
?	Time Study Summarization
?	Claims are submitted to:
Univ. of Mass. Medical School
Municipal Medicaid Program
100 Century Drive
Worcester, MA  01606
Claim Submission Requirements
?	Claims are due to the Center 15 days after the close of the 
quarter.
?	Exception:  All claims that are being submitted under the last 
allowable quarter are due 15 days prior to the close of that quarter. 
>	If you plan to submit a claim for the September 2003 quarter, it is due by 
September 15, 2005.
Administrative Claiming:  Reference Materials
?	For additional information related to Administrative Activity  Claiming refer to:
>	Time Study Training Manual
>	Claiming Manual for School-Based Administrative Activities
>	Provider Bulletins (included with handouts)
?	For all questions contact UMass at 508-856-8631.
?	To receive an electronic copy of the Time Study or Claiming Manual e-mail 
UMass at munimed@umassmed.edu