NJ DHS - DMAHS

Revised June 20, 2024

NEW JERSEY DEPARTMENT OF HEALTH

SERVICES, DIVISION OF MEDICAL

ASSISTANCE AND HEALTH SERVICES

(DMAHS)

MEDICAID ADMINISTRATIVE

CLAIMING

SPECIAL EDUCATION MEDICAID

INITIATIVE

COST SETTLEMENT PROCESS

GUIDE

Implementation Date – October 1, 2016 Revised August 8, 2013

Revised July 31, 2015

TABLE OF CONTENTS

Medicaid Administrative Claiming & Cost Settlement Process Guide Overview

Implementing Medicaid Administrative Claiming

LEA Staff Activities Included Under Medicaid Administrative Claiming

Medicaid Administrative Claiming Program Time Studies Activities

Time Study Participants

Calculating the MAC Claim

Contractor Level Oversight and Monitoring…

APPENDIX 1 – LEA Assurances and Application for Certification

MEDICAID ADMINISTRATIVE CLAIMING & COST

SETTLEMENT PROCESS GUIDE

Overview

The New Jersey Department of Human Services (DHS), Division of Medical Assistance and Health Services (DMAHS) and individual Local Education Agencies (LEA) share in the responsibility for promoting access to health care for students in the public school system and coordinating students’ health care needs with other providers, thereby preventing costly or long-term health care problems for at risk students. Many of the activities performed by LEA staff meet the criteria for Medicaid administrative claiming. The primary purpose of the Medicaid Administrative Claiming (MAC) Program is to reimburse LEAs for these activities where allowed in this guide. The time study outlined in this guide will be used to calculate the MAC claims and will also be used to calculate the Cost Settlement amount for the Special Education Medicaid Initiative (SEMI) program.

I. Definition

The MAC program, administered by the New Jersey Department of Human Services (DHS), Division of Medical Assistance and Health Services (DMAHS), allows LEAs to be reimbursed for some of their costs associated with school-based health and outreach activities which are not claimable under the Medicaid Fee-For-Service (FFS) program known as the Special Education

Medicaid Initiative (SEMI) program. The school-based health and outreach activities funded under MAC include: referrals of students/families for Medicaid eligibility determinations; providing healthcare information; coordination and monitoring of health services for students; and interagency coordination of services.

Unlike the FFS program, individual claims for each administrative service rendered to or on behalf of a student are not required under the MAC program. However, it is necessary to determine the amount of time LEA staff members spend performing Medicaid-related administrative activitie s.

Time spent by LEA staff on Medicaid administrative activities is captured through the use of random moment time studies. Time study results are then used in a series of calculations to determine the percentage of LEA costs that can be claimed under MAC. MAC reimbursement to LEAs is made from Medicaid federal funds. LEAs are required to maintain documentation of the selected moments for audit purposes.

Medicaid Administrative Claiming Program and Direct School Based Services Guide

This guide serves as the Implementation Plan and as a guide to the LEAs who choose to participate in the SEMI program and the MAC program. It contains the policies and procedures which LEAs will follow to submit an administrative claim to Medicaid for reimbursement. It also addresses audit requirements. In the event the Implementation Plan is revised, the effective date of the revision will be indicated at the bottom of each updated page.

IMPLEMENTING MEDICAID ADMINISTRATIVE CLAIMING

LEAs participating in the New Jersey MAC program must meet a specific set of requirements.

These requirements are as follows:

A signed LEA Assurances and Application for Certification with DMAHS

Time studies completed at prescribed time intervals, Statistically valid time study results, Cost determinations and allocations performed, and

Period-based Medicaid administrative claims prepared and submitted to DMAHS. Periods are defined dates that LEAs will be in session and for which their staff members are compensated.

All participating LEAs will be included in the statewide sample for administrative claiming and/or direct FFS programs. Personnel and cost data will be compiled from each individual LEA.

Medicaid eligibility data will also be applied to each individual LEA. Activity percentages derived from the statewide sample will be applied to each LEA to determine the reimbursement amount.

DMAHS and the LEAs share a common interest in ensuring more effective and timely access to care and the most appropriate utilization of Medicaid-covered services. Promoting activities and behaviors that reduce the risk of poor health and poor health outcomes for the state’s most vulnerable populations is also a major consideration. The school setting provides opportunities to reach children and their families to encourage and assist them in enrolling in the Medicaid program.

This setting also affords an opportunity for the LEAs to deliver direct medical services to Medicaid eligible members. LEAs can create a framework within their own unique environments that allows a seamless health care delivery system for children and helps eliminate many of the barriers to access.

Monitoring of administrative claiming records is required by DMAHS and the Centers for Medicare and Medicaid Services (CMS). MAC payments are the federal share of funds paid for administrative services provided on behalf of Medicaid eligible school children and their familie s.

LEA personnel deliver these services and the LEAs are responsible for payment for services rendered. The LEAs payments to providers are inclusive of the state and federal shares. The MAC claim identifies the federal and state shares of the payment thus allowing the federal share funds to be returned to the schools through the claiming process.

The purpose of this guide is to outline a comprehensive approach and time study for use with both administrative and FFS cost claiming.

Interagency Participation Agreement

Each LEA participating in MAC must sign a LEA Assurances and Application for Certification.

This agreement, included as Appendix 1, identifies each party’s responsibilities and must be signed before DMAHS can request federal reimbursement. The address for submission of a signed agreement is:

Receiving School Monitoring/SEMI DOE, Office of Special Education Programs

P.O. Box 500 100 Riverview Plaza, Building 100

Trenton, NJ 08625-0500

After the DMAHS signature is affixed, a signed copy will be returned to the LEA.

MAC Reimbursement

Federal Medicaid reimbursement under the MAC program will be made to LEAs implementing a program that meets the requirements in this guide.

Description of Current Administrative Activities Paid by Medicaid

Several New Jersey state and local agencies are performing administrative services for the New Jersey Medicaid population and receiving Federal reimbursement for services which may be similar to those being considered for reimbursement in the school setting. Although local health departments, early intervention networks, etc. are performing outreach and referral for Medicaid eligibility activities, these activities are not addressing the needs pertinent to the Medicaid eligib le school population for school-based services. The additional activities performed at the school site are needed by the DMAHS to ensure that all children are appropriately referred for Medicaid eligibility determinations and, if Medicaid eligible, are linked to medically necessary Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

Coordination of Activities

LEA staff must not knowingly perform activities that are already being offered or provided by DMAHS, the New Jersey Department of Education (DOE), or other entities providing outreach, referral and assistance to Medicaid eligible and potentially eligible children and their families. The LEAs should constantly strive to become knowledgeable of Medicaid and health care resources in their communities and develop mechanisms to coordinate activities.

Examples of activities that should be coordinated include activities such as primary care case management or disease management. To avoid duplication of these functions, school personnel should, when needed, develop coordination mechanisms between the LEAs and the appropriate entities, and DMAHS. Activities provided/conducted by another governmental component should also be coordinated. For example, it is not necessary for EPSDT educational materials, such as pamphlets and flyers that have already been developed by DMAHS, to be redeveloped by schools. LEAs should coordinate and consult with the DMAHS to determine the appropriate activities related to EPSDT and to determine the availability of existing materials. Information on coordination activities and resources will be provided to the LEAs during training events.

LEA STAFF ACTIVITIES INCLUDED UNDER

MEDICAID ADMINISTRATIVE CLAIMING

As stated previously in this guide, some of the activities routinely performed by LEAs are activit ie s that could be eligible for Medicaid reimbursement under the MAC program. The purposes of this chapter are to: define LEA activities that are included in MAC time studies; and specify which activities are Medicaid reimbursable. The following chapter defines the type of school staff members eligible to have their activities claimed by LEAs as MAC reimbursable activities. It is important to note that 100% of LEA staff time is considered during MAC time studies but only certain staff activities are actually eligible for Medicaid reimbursement, as defined in this chapter.

LEA Job Activities

The New Jersey DMAHS has adopted the parallel coding structure recommended by CMS as stipulated in the revised May 2003 CMS Administrative Claiming Guide. This coding structure will be applied to all MAC claims filed commencing October 1, 2011. Each MAC activity is assigned a numeric or a combination numeric/alpha code. These codes are used on time study forms for the purpose of determining the percentage of LEA staff time spent on each activity. Some activities, which are ineligible for MAC reimbursement, such as direct health care services billed under the SEMI program, are included in the list because all job activities must be considered when time sampling is conducted. Thus they are designed to capture reimbursable and non-reimbursable MAC activities.

MAC Activities List

The major categories of MAC activities are:

CODE 1.a. Non-Medicaid Outreach

CODE 1.b. Medicaid Outreach

CODE 2.a. Facilitating Application for Non-Medicaid Programs

CODE 2.b. Facilitating Medicaid Eligibility Determination

CODE 3. School Related and Educational Activities

CODE 4.a Direct Medical Services – Not Covered as IDEA/IEP Services

CODE 4.b. Direct Medical Services – Covered as IDEA/IEP Services

CODE 4.c. Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as IDEA/IEP service

CODE 5.a. Transportation for Non-Medicaid Services

CODE 5.b. Transportation-Related Activities in Support of Medicaid

Covered Services

CODE 6.a. Non-Medicaid Translation

CODE 6.b. Translation Related to Medicaid Services

CODE 7.a. Program Planning, Policy Development, and Interagency

Coordination Related to Non-Medical Services

CODE 7.b. Program Planning, Policy Development and Interagency

Coordination Related to Medical/Medicaid Services

CODE 8.a. Non-Medical/Medicaid Training

CODE 8.b. Medical/Medicaid Related Training

CODE 9.a. Referral, Coordination, and Monitoring of Non-Medicaid

Services

CODE 9.b. Referral, Coordination, and Monitoring of Medicaid Services

CODE 10. General Administration

CODE 11. Not Scheduled to Work

Definition of LEA Job Activities

Detailed definitions of each of the categories of job activities used in the MAC program are contained later in this document. This information should be made available to staff involved with the time study process. Medicaid does not pay for administrative expenditures related to, or in support of, services that are not included in New Jersey’s State Medicaid plan or services which are not reimbursed under Medicaid. However, EPSDT services must be offered to a child whether or not New Jersey has included such services in its State Medicaid plan. Administrat ive expenditures related to, or in support of EPSDT are reimbursable under Medicaid.

Charter Schools

Administrative claiming is allowed for charter schools on the same basis as individual public schools if the charter school has a contract with the LEA in which it is located and includes administrative activities. Charter Schools are funded through state and local funds. They are considered “public schools” and therefore are eligible to Certify Public

Expenditures (CPE).

MAC Interface with the Special Education Medicaid Initiative (SEMI) Program

The Special Education Medicaid Initiative (SEMI) Program provides reimbursement for only Medicaid eligible students with SEMI services referenced in their Individualized Education Programs (IEPs). MAC activities and reimbursement are not limited to IEP students or services. Student Medicaid eligibility status is not captured during the time study process. If an LEA is enrolled as a SEMI provider and is billing Medicaid for covered services, the same services will not be reimbursed under the MAC program.

The program and time study have been designed to capture data for both the MAC and SEMI programs. The activity codes utilized in the time study have been designed to ensure that there is no duplication of reimbursement between the two programs.

Allocable Share of Costs

Since many school-based medical activities are provided to both Medicaid and non-Medicaid eligible students, the time applicable to these activities must be allocated to both groups. Once time is allocated to the appropriate activity codes, costs are then associated with those codes and some of the costs must be discounted by the Medicaid percentage. Discounting involves the determination of a proportional share of Medicaid students to the total students and the total costs applicable to a specific activity in a particular school or LEA. Development of the proportional Medicaid share (also referred to as the Medicaid percentage) should relate to the Medicaid eligibility rate in the LEA submitting the claim. Claims will be developed on an LEA-wide basis based upon a statewide pool of staff that is sampled. Through the use of time studies which contain specific activity codes, the cost of school personnel is distributed to certain activit ie s (time study codes) to determine the administrative cost allocable to the Medicaid program. The IEP Ratio will be utilized to allocate the proportional Medicaid share for the Cost Settlement of the SEMI program annually. The Medicaid Eligibility ratio (MER) applies to the MAC program.

Unallowable Activities:

This refers to an activity which is unallowable as administration under the Medicaid program, regardless of whether or not the population served includes Medicaid eligible individuals.

Application of Medicaid Share:

Total Medicaid refers to an activity which is 100 percent allowable as administration under the

Medicaid program.

Proportional Medicaid refers to an activity which is allowable as administration under the Medicaid program, but for which the allocable share of costs must be determined by the application of the proportional Medicaid share (the Medicaid percentage). The Medicaid share is determined as the ratio of Medicaid eligible students to total students and is referred to as the Medicaid Eligibil ity Rate (MER) applies to the MAC program. The IEP ratio is defined as the ratio of Medicaid Eligib le Special Education Students with a SEMI billable service on the IEP to total Special Education

Students with a SEMI billable service on the IEP.

Reallocated Activities:

Refers to those general administrative activities performed by time study participants which must be reallocated across the other claimable and non-claimable activity codes on a pro rata basis.

These reallocated activities are reported under Code 10, General Administration.

MEDICAID ADMINISTRATIVE CLAIMING PROGRAM

TIME STUDY ACTIVITIES

When staff members perform duties related to the proper administration of New Jersey’s Medicaid program, federal funds may be drawn as reimbursement for the federal share of the costs of providing these administrative services. To identify the cost of providing these services, a time study of staff must be conducted. The time study identifies the time and subsequent costs spent on Medicaid administrative activities that are allowable and reimbursable under the Medicaid program. Only staff included in the sample universe will be eligible to have costs reported during the financial collection process.

Staff Activity and Codes – the indicators below, which follow each Code, provide the application of the Federal Financial Participation (FFP) rate, the allowability or non-allowability designation, and the proportional Medicaid share status of the Code. In order to maintain coding objectivity by time study participants, time study sheets used by employees should not include references to rates of FFP, proportional or total Medicaid, or whether such codes are allowable, or unallowable under

Medicaid.

Application of FFP rate

50 percent Refers to an activity that is allowable as administration under the

Medicaid program and claimable at the 50 percent non-enhanced FFP rate.

75 percent Refers to an activity that is allowable as administration under the Medicaid program and claimable at the 75 percent enhanced FFP rate.

Unallowable Activities

U Refers to an activity that is unallowable as administration under the

Medicaid program. This is regardless of whether or not the population served includes Medicaid eligible individuals.

Application of Medicaid Share

TM (Total Medicaid) refers to an activity that is 100 percent allowable as administration under the Medicaid program.

PM (Proportional Medicaid) Refers to an activity which is allowable as administration under the Medicaid program, but for which the allowable share of costs must be determined by the application of the proportional Medicaid share (the Medicaid eligibility rate

(MER) or the IEP Ratio). The Medicaid share is then determined by applying the MER or the IEP Ratio to the appropriate student populations.

Reallocated Activities

R Refers to those general administrative activities performed by time study participants which must be reallocated across the other activity codes on a pro rata basis. These reallocated activities are reported under Code 10, General Administration. Note that certain functions, such as payroll, maintaining inventories, developing budgets, executive direction, etc., are considered overhead and, therefore, are only allowable through the application of an approved unrestricted indirect cost rate.

Uniform Codes

Staff should document time spent on each of the following coded activities:

CODE 1.a. Non-Medicaid Outreach –U CODE 1.b. Medicaid Outreach – TM/50 Percent FFP CODE 2.a. Facilitating Application for Non-Medicaid Programs U

CODE 2.b. Facilitating Medicaid Eligibility Determination – TM/50 Percent

FFP

CODE 3. School Related and Educational Activities – U CODE 4.a. Direct Medical Services – Not Covered as IDEA/IEP Services - U CODE 4.b. Direct Medical Services – Covered as IDEA/IEP Services - IEP

Ratio CODE 4.c. Direct Medical Services – Covered on a Medical Plan of Care, Not

Covered as IDEA/IEP service – MP Ratio CODE 5.a. Transportation for Non-Medicaid Services – U CODE 5.b. Transportation-Related Activities in Support of Medicaid Covered

Services – PM/50 Percent FFP CODE 6.a.Non-Medicaid Translation – U

CODE 6.b. Translation Related to Medicaid Services – PM/75 Percent FFP CODE 7.a. Program Planning, Policy Development, and Interagency

Coordination Related to Non-Medical Services – U

CODE 7.b. Program Planning, Policy Development and Interagency Coordination Related to Medical/Medicaid Services – PM/50

Percent FFP CODE 8.a. Non-Medical/Medicaid Training – U CODE 8.b. Medical/Medicaid Related Training – PM/50 Percent FFP

CODE 9.a. Referral, Coordination, and Monitoring of Non-Medicaid Services

– U

CODE 9.b. Referral, Coordination, and Monitoring of Medicaid Services – PM/50 Percent FFP

CODE 10. General Administration – R

CODE 11. Not Scheduled to Work- Not Included in the distribution or invalid.

Medicaid Covered Services

The purpose of the MAC program is to ensure access of eligible individuals to Medicaid services. The following list identifies the services covered under the SEMI program.

Audiology

Counseling

Nursing

Nutrition

Orientation and Mobility

Occupational Therapy

Physical Therapy

Speech Therapy

The following activity codes, as approved by CMS, have been adopted for usage in the MAC program.

Code 1.a. - Non-Medicaid Outreach –U

This code should be used by all LEA staff when performing activities that inform individuals about non-Medicaid social, vocational, and educational programs (including special education) and how to access them; describing the range of benefits covered under these non-Medicaid social, vocational and educational programs and how to obtain them. Both written and oral methods may be used. Include related paperwork, clerical activities or staff travel required to perform these activities.

1. Informing families about wellness programs and how to access these programs.

2. Scheduling and promoting activities that educate individuals about the benefits of healthy life-styles and practices.

3. Conducting general health education programs or campaigns that address life-style changes in the general population (e.g., dental prevention, anti-smoking, alcohol reduction, etc.).

4. Conducting outreach campaigns that encourage persons to access social, educational, legal or other services not covered by Medicaid.

5. Assisting in early identification of children with special medical/dental/mental health needs through various child find activities.

6. Outreach activities in support of programs that are 100 percent funded by state general revenue.

7. Developing outreach materials such as brochures or handbooks for these programs.

8. Distributing outreach materials regarding the benefits and availability of these programs.

Code 1.b. - Medicaid Outreach– TM/50 percent FFP

LEA staff should use this code when performing activities that inform eligible or potentially eligible individuals about Medicaid and how to access it. Activities include bringing potential eligible individuals into the Medicaid system for the purpose of determining eligibility and arranging for the provision of Medicaid services. LEAs may only conduct outreach for the populations served by their affiliated schools, i.e., students and their parents or guardians.

Examples include:

1. Informing Medicaid eligible and potential Medicaid eligible children and families about the benefits and availability of services provided by Medicaid (including preventive treatment, and screening) including services provided through the EPSDT program.

2. Developing and/or compiling materials to inform individuals about the Medicaid program (including EPSDT) and how and where to obtain those benefits. Note: This activity should not be used when Medicaid-related materials are already available to the schools (such as through the Medicaid agency). As appropriate, school developed outreach materials should have prior approval of the Medicaid agency.

3. Distributing literature about the benefits, eligibility requirements, and availability of the

Medicaid program, including EPSDT.

4. Assisting the Medicaid agency to fulfill the outreach objectives of the Medicaid program by informing individuals, students and their families about health resources available through the Medicaid program.

5. Providing information about Medicaid EPSDT screening (e.g., dental, vision) in schools that will help identify medical conditions that can be corrected or improved by services offered through the Medicaid program.

6. Contacting pregnant and parenting teenagers about the availability of Medicaid prenatal, and well baby care programs and services.

7. Providing information regarding Medicaid managed care programs and health plans to individuals and families and how to access that system.

8. Encouraging families to access medical/dental/mental health services provided by the

Medicaid program.

Activities which are not considered Medicaid outreach under any circumstances are: (1) general preventive health education programs or campaigns addressing lifestyle changes, and (2) outreach campaigns directed toward encouraging persons to access social, educational, legal or other services not covered by Medicaid.

Code 2.a. - Facilitating Application for Non-Medicaid Programs – U

LEA staff should use this code when informing an individual or family about programs such as

Temporary Assistance for Needy Families (TANF), Food Stamps, Women, Infants, and Children (WIC), day care, legal aid and other social or educational programs and referring them to the appropriate agency to make application. The following are examples:

1. Explaining the eligibility process for non-Medicaid programs, including IDEA.

2. Assisting the individual or family collect/gather information and documents for the non- Medicaid program application.

3. Assisting the individual or family in completing the application, including necessary translation activities.

4. Developing and verifying initial and continuing eligibility for the Free and Reduced

Lunch Program.

5. Developing and verifying initial and continuing eligibility for non-Medicaid programs.

6. Providing necessary forms and packaging all forms in preparation for the non-Medicaid eligibility determination.

Code 2.b. - Facilitating Medicaid Eligibility Determination-TM/50 percent FFP

LEA staff should use this code when assisting an individual in becoming eligible for Medicaid.

Include related paperwork, clerical activities or staff travel required to perform these activitie s.

This activity does not include the actual determination of Medicaid eligibility. Examples include :

1. Verifying an individual’s current Medicaid eligibility status for purposes of the Medicaid eligibility process.

2. Explaining Medicaid eligibility rules and the Medicaid eligibility process to prospective applicants.

3. Assisting individuals or families to complete a Medicaid eligibility application.

4. Gathering information related to the application and eligibility determination for an individual, including resource information and third party liability (TPL) information, as a prelude to submitting a formal Medicaid application.

5. Providing necessary forms and packaging all forms in preparation for the Medicaid eligibility determination.

6. Referring an individual or family to the local Assistance Office to make application for

Medicaid benefits.

7. Assisting the individual or family in collecting/gathering required information and documents for the Medicaid application.

8. Participating as a Medicaid eligibility outreach outstation, but does not include determining eligibility.

Code 3. - School Related and Educational Activities – U

This code should be used for any other school related activities that are not health related, such as social services, educational services and teaching services; employment and job training. These activities include the development, coordination and monitoring of a student’s education plan.

Include related paperwork, clerical activities or staff travel required to perform these activitie s.

1. Providing classroom instruction (including lesson planning).

2. Testing, correcting papers.

3. Developing, coordinating, and monitoring the academic portion of the Individualized

Education Program (IEP) for a student, which includes ensuring annual reviews of the IEP are conducted, parental sign-offs are obtained, and the academic portion of the actual IEP meetings with the parents. (If appropriate, this would also refer to the same activities performed in support of an Individualized Family Service Plan (IFSP).)

4. Compiling attendance reports.

5. Performing activities that are specific to instructional, curriculum, and student-focused areas.

6. Reviewing the education record for students who are new to the school district.

7. Providing general supervision of students (e.g., playground, lunchroom).

8. Monitoring student academic achievement.

9. Providing individualized instruction (e.g., math concepts) to a special education student.

10. Conducting external relations related to school educational issues/matters.

11. Compiling report cards.

12. Carrying out discipline.

13. Performing clerical activities specific to instructional or curriculum areas.

14. Activities related to the educational aspects of meeting immunization requirements for school attendance.

15. Compiling, preparing, and reviewing reports on textbooks or attendance.

16. Enrolling new students or obtaining registration information.

17. Conferring with students or parents about discipline, academic matters or other school related issues.

18. Evaluating curriculum and instructional services, policies, and procedures.

19. Participating in or presenting training related to curriculum or instruction (e.g., language arts workshop, computer instruction).

20. Translating an academic test for a student.

CODE 4.a. - Direct Medical Services – Not Covered as IDEA/IEP Service (FFS – Non IEP)

- U

This code should be selected when LEA staff members (employees or contract staff) are providing direct client care services for which medical necessity has not been determined. This code includes pre and post activities associated with the actual delivery of the direct client care services, e.g., paperwork or staff travel required to perform these services.

Examples of activities reported under this code:

All non IDEA and/or non-IEP direct client care services as follows:

1. Providing health/mental health services.

2. Conducting medical/health assessments/evaluations and diagnostic testing and preparing related reports.

3. Providing personal aide services.

4. Performing developmental assessments.

5. Developing a treatment plan (medical plan of care) for a student if provided as a medical service.

6. Administering first aid

7. Making referrals for and/or coordinating medical or physical examinations and necessary medical evaluations as a result of a direct medical service.

CODE 4.b. - Direct Medical Services – Covered as IDEA/IEP Service (FFS – IEP) – IEP

Ratio

This code should be selected when LEA staff members (employees or contracted staff) provide direct client services as covered services delivered by LEAs under the FFS Program for students with an IEP/IFSP. These direct client services may be delivered to an individual and/or group in order to ameliorate a specific condition and are performed in the presence of the student(s). This code includes the provision of all IDEA/IEP medical (i.e. health-related) services. It also includes functions performed pre and post actual direct client services (when the student may not be present), for example, paperwork, or staff travel directly related to the direct client services.

All IDEA/IEP direct client services with the Student/Client present including:

1. Providing health/mental health services as covered in the student’s IEP.

2. Conducting medical/health assessments/evaluations and diagnostic testing and preparing related reports as covered in the student’s IEP.

The list of services corresponds to all of the services outlined in the State Plan. This includes:

1. Audiologist services including evaluation and therapy services (only if included in the student’s IEP).

2. Physical Therapy services and evaluations (only if included in the student’s IEP).

3. Occupational Therapy services and evaluations (only if included in the student’s IEP).

4. Speech Language Therapy services and evaluations (only if included in the student’s

IEP).

5. Counseling services, including therapy services (only if included in the student’s IEP).

6. Orientation and Mobility services and evaluations (only if included in the student’s IEP).

7. Nursing services and evaluations (only if included in the student’s IEP), including skilled nursing services on the IEP and time spent administering/monitoring medication only if it is included as part of an IEP and documented in the IEP.

8. Nutrition Services include the management and counseling for students on special diets for genetic metabolic disorders, prolonged illness, deficiency disorders or other complicated medical problems. Nutritional support through assessment and monitoring of the nutritiona l status, and teaching related to the dietary regimen.”

This code also includes pre and post time directly related to providing direct client care services when the student/client is not present. Examples of pre and post time activities when the student/client is not present include: time to complete all paperwork related to the specific direct client care service, such as preparation of progress notes, translation of session notes, review of evaluation testing/observation, planning activities for the therapy session, travel to/from the therapy session, or completion of billing activities.

General Examples that are considered pre and post time:

1. Pre and post activities associated with physical therapy services, for example, time to build a customized standing frame for a student or time to modify a student’s wheelchair desk for improved freedom of movement for the client.

2. Pre and post activities associated with speech language pathology services, for example, preparing lessons for a client to use with an augmentative communicative device or preparing worksheets for use in group therapy sessions.

3. Updating the medical/health-related service goals and objectives of the IEP.

4. Travel to the direct service/therapy.

5. Paperwork associated with the delivery of the direct care service, as long as the student/client is not present. Such paperwork could include the preparation of progress notes, translation of session notes, or completion of billing activities.

6. Interpretation of the evaluation results and/or preparation of written evaluations, when student/client is not present. (Assessment services are billed for testing time when the student is present, for interpretation time when the student is not present, and for report writing when the student is not present.)

CODE 4.c. - Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as

IDEA/IEP service – MP Ratio

This code should be selected when LEA staff members (employees or contracted staff) provide direct client services as covered services delivered by LEAs under the FFS Program when documented on a Medical Plan other than an IEP/IFSP or for services in which medical necessity has been determined. These direct client services may be delivered to an individual and/or group in order to ameliorate a specific condition and are performed in the presence of the student(s). This code includes the provision of medical (i.e. health-related) services outlined on a medical plan other than an IEP/IFSP or for which medical necessity has been determined. It also includes functions performed pre and post actual direct client services (when the student may not be present), for example, paperwork, or staff travel directly related to the direct client services.

All Medical Plan direct client services with the Student/Client present including:

1. Providing health/mental health services as covered in the student’s medical plan other than an IEP/IFSP.

2. Conducting medical/health assessments/evaluations and diagnostic testing and preparing related reports as covered in the student’s medical plan other than an IEP/IFSP.

3. Services for which medical necessity has been determined.

The list of services corresponds to all of the services outlined in the State Plan. This includes:

1. Audiologist services including evaluation and therapy services (only if included in the student’s medical plan).

2. Physical Therapy services and evaluations (only if included in the student’s medical plan).

3. Occupational Therapy services and evaluations (only if included in the student’s medical plan).

4. Speech Language Therapy services and evaluations (only if included in the student’s medical plan).

5. Counseling services, including therapy services (only if included in the student’s medical plan or when medical necessity has been determined).

6. Orientation and Mobility services and evaluations (only if included in the student’s medical plan).

7. Nursing services and evaluations (only if medical necessity has been determined includ ing skilled nursing services on the medical plan and time spent administering/monitor ing medication only if it is included as part of a medical plan of care and documented in the plan of care.)

8. Nutrition Services include the management and counseling for students on special diets for genetic metabolic disorders, prolonged illness, deficiency disorders or other complicated medical problems. Nutritional support through assessment and monitor ing of the nutritiona l status, and teaching related to the dietary regimen.”

9. All EPSDT covered services such as screenings, immunizations, etc. or services in which medical necessity has been determined.

This code also includes pre and post time directly related to providing direct client care services when the student/client is not present. Examples of pre and post time activities when the student/client is not present include: time to complete all paperwork related to the specific direct client care service, such as preparation of progress notes, translation of session notes, review of evaluation testing/observation, planning activities for the therapy session, travel to/from the therapy session, or completion of billing activities.

General Examples that are considered pre and post time:

1. Pre and post activities associated with physical therapy services, for example, time to build a customized standing frame for a student or time to modify a student’s wheelchair desk for improved freedom of movement for the client.

2. Pre and post activities associated with speech language pathology services, for example, preparing lessons for a client to use with an augmentative communicative device or preparing worksheets for use in group therapy sessions.

3. Updating the medical/health-related service goals and objectives of the medical plan of care.

4. Travel to the direct service/therapy.

5. Paperwork associated with the delivery of the direct care service, as long as the student/client is not present. Such paperwork could include the preparation of progress notes, translation of session notes, or completion of billing activities.

6. Interpretation of the evaluation results and/or preparation of written evaluations, when student/client is not present. (Assessment services are billed for testing time when the student is present, for interpretation time when the student is not present, and for report writing when the student is not present.)

Code 5.a. - Transportation for Non-Medicaid Services – U

LEA staff should use this code when assisting an individual to obtain transportation to services not covered by Medicaid, or accompanying the individual to services not covered by Medicaid.

Include related paperwork, clerical activities or staff travel required to perform these activity.

1. Scheduling or arranging transportation to social, vocational, and/or educational programs and activities.

Code 5.b. - Transportation related to Medicaid Services – PM/50 percent FFP

LEA staff should use this code when assisting an individual to obtain transportation to services covered by Medicaid. This does not include the provision of the actual transportation service or the direct cost of the transportation, but rather the administrative activities involved in providing transportation. Include related paperwork, clerical activities or staff travel required to perform these activities. An example is:

1. Scheduling or arranging transportation to Medicaid covered services.

Note: Staff that may arrange transportation that may be included in the RMTS include, but are not limited to, Program Administrators, Special Education Support or other staff at the district who are responsible for arranging specialized transportation for students to receive medical services.

However, job titles of staff that provide these types of services vary by district.

Code 6.a. - Non-Medicaid Translation – U

LEA staff should use this code when providing translation services related to social, vocational or education programs and activities as an activity separate from the activities referenced in other codes. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples include:

1. Arranging for or providing translation services (oral or signing services) that assist the individual to access and understand social, educational, and vocational services.

2. Arranging for or providing translation services (oral or signing services) that assist the individual to access and understand state education or state-mandated health screenings

(e.g., vision, hearing, and scoliosis) and general health education outreach campaigns intended for the student population.

3. Developing translation materials that assist individuals to access and understand social, educational, and vocational services.

Code 6.b. - Translation Related to Medicaid Services-PM/75 percent FFP

Translation may be allowable as an administrative activity if it is not included and paid for as part of a medical assistance service. However, it must be provided by separate units or separate employees performing solely translation functions for the LEA and it must facilitate access to

Medicaid covered services.

This code should be used by LEA employees who provide translation services related to Medicaid covered services as an activity separate from the activities referenced in other codes. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples include:

1. Arranging for or providing translation services (oral and signing) that assist the individual to access and understand necessary care or treatment covered by Medicaid.

2. Developing translation materials that assist individuals to access and understand necessary care or treatment covered by Medicaid.

3. Providing translation services (oral and signing) that assist the individual to access and understand necessary care or treatment covered by Medicaid.

4. Developing translated materials, including Braille transcriptions, that assist individuals to access and understand necessary care or treatment covered by Medicaid

5. Translation while the school nurse provides covered services to a student whose primary language is Vietnamese.

6. Sign language interpretation during provision of covered services to a deaf child.

7. Transcribing into Braille the fact sheet school nurses use to explain/practice steps/proper technique for using an inhaler.

8. Translation to help a school psychologist follow up with a student’s non-

English speaking parent on a mental health referral.

Code 7.a. - Program Planning, Policy Development and Interagency Coordination Related to Non-Medical Services – U

LEA staff should use this code when performing activities associated with the development of strategies to improve the coordination and delivery of non-medical/non-mental health services to school age children and when performing collaborative activities with other agencies. Non-medical services may include social, education and vocational services. Only employees whose position descriptions include program planning, policy development and interagency coordination should use this code. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples include:

1. Identifying gaps or duplication of non-medical services (e.g., social, vocational educational and state mandated general health care programs) to school age children and developing strategies to improve the delivery and coordination of these services.

2. Developing strategies to assess or increase the capacity of non-medical school programs.

3. Monitoring the non-medical delivery systems in schools.

4. Developing procedures for tracking families’ requests for assistance with non-medical services and the providers of such services.

5. Evaluating the need for non-medical services in relation to specific populations or geographic areas.

6. Analyzing non-medical data related to a specific program, population, or geographic area.

7. Working with other agencies providing non-medical services to improve the coordination and delivery of services and to improve collaboration around the early identification of non-medical problems.

8. Defining the relationship of each agency’s non-medical services to one another.

9. Developing advisory or work groups of professionals to provide consultation and advice regarding the delivery of non-medical services and state-mandated health screenings to the school populations.

10. Developing non-medical referral sources.

11. Coordinating with interagency committees to identify, promote and develop non-medical services in the school system.

Code 7.b. - Program Planning, Policy Development and Interagency Coordination Related to Medical Services-PM/50 percent FFP

This code should be used by LEA staff when performing activities associated with the development of strategies to improve the coordination and delivery of medical/dental/menta l health services to school age children, and when performing collaborative activities with other agencies and/or providers. Employees whose position descriptions include program planning, policy development and interagency coordination may use this code. However, it is a state option whether or not the position descriptions need to be explicit with respect to these specific functions.

This code refers to activities such as planning and developing procedures to track requests for services; the actual tracking of requests for Medicaid services would be coded under Code 9.b., Referral, Coordination and Monitoring of Medical Services. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples include:

1. Identifying gaps or duplication of medical/dental/mental services to school age children and developing strategies to improve the delivery and coordination of these services.

2. Developing strategies to assess or increase the capacity of school medical/dental/mental health programs.

3. Monitoring the medical/dental/mental health delivery systems in schools.

4. Developing procedures for tracking families’ requests for assistance with medical/dental/mental services and providers, including Medicaid. (This does not include the actual tracking of requests for Medicaid services.)

5. Evaluating the need for medical/dental/mental services in relation to specific populations or geographic areas.

6. Analyzing Medicaid data related to a specific program, population, or geographic area.

7. Working with other agencies and/or providers that provide medical/dental/mental services to improve the coordination and delivery of services, to expand access to specific populations of Medicaid eligible, and to increase provider participation and improve provider relations.

8. Working with other agencies and/or providers to improve collaboration around the early identification of medical/dental/mental problems.

9. Developing strategies to assess or increase the cost effectiveness of school medical/dental/mental health programs.

10. Defining the relationship of each agency’s Medicaid services to one another.

11. Working with Medicaid resources, such as the Medicaid agency and Medicaid managed care plans, to make good faith efforts to locate and develop EPSDT health services referral relationships.

12. Developing advisory or work groups of health professionals to provide consultation and advice regarding the delivery of health care services to the school populations.

13. Working with the Medicaid agency to identify, recruit and promote the enrollment of potential Medicaid providers.

14. Developing medical referral sources such as directories of Medicaid providers and managed care plans, which will provide services to targeted population groups, e.g., EPSDT children.

15. Coordinating with interagency committees to identify, promote and develop EPSDT services in the school system.

Code 8. a. - Non-Medical/Medicaid Training – U

This code should be used by LEA staff when coordinating, conducting or participating in training events and seminars for school-based services staff regarding the benefit of the programs other than the Medicaid program such as educational programs; for example, how to assist families to access the services of the relevant programs and how to more effectively refer students for those services.

Include related paperwork, clerical activities or staff travel required to perform these activitie s.

1. Participating in or coordinating training that improves the delivery of services for programs other than Medicaid.

2. Participating in or coordinating training that enhances IDEA child find programs.

Code 8.b. - Medical/Medicaid Specific Training – PM/50 percent FFP

This code should be used by LEA staff when coordinating, conducting or participating in training events and seminars for New Jersey DMAHS and MAC staff regarding the benefits of the

Medicaid program, how to assist families in accessing Medicaid services, and how to more effectively refer students for services. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples include:

1. Participating in or coordinating training that improves the delivery of medical/Medicaid related services.

2. Participating in or coordinating training that enhances early identification, intervention, and screening of students with special health needs…