Centers for Medicare and Medicaid Services (CMS) Comments on California Department of Health Care Services (DHCS) School-Based Medi-Cal Administrative Activities (SMAA) proposal submitted 10/12/2013

Disclaimer:  Please note that these comments are intended merely to facilitate further discussion and should be not be construed as comprehensive or final.  CMS reserves the right to request additional changes in order to meet federal Medicaid claiming requirements.  The requested changes should be included in a track changes version as well as the submission of the training materials.

1. Training materials - Please include the following information in the training materials as indicated below:
• Please provide a sample set of instructions as well as an example of a LEC/LGA/LEA invoice including instructions to show how the claiming unit will complete the invoice and the steps in the process. Be sure to include the rollout plans for training each of the school districts, etc.
• Please explain how salary costs are reallocated for general administration as well as  for paid time off.
• Please include a description of the non-salary costs and an explanation in the training materials and where these costs are captured in the invoice.
2. Time Survey Methodology description page 6-1 - Please include in the description that the goal is to capture 100% of time, etc.
3. RMTS vs. Paper-based, Pg. 6-1 - It appears the State is proposing for possibly several vendors, etc. to put together either a “paper-based” worker log or RMTS for school based by claiming unit, etc.  On pg. 6-1 of the implementation plan, it states “a manual paper-based option for claiming units that do not have access to electronic information systems (EIS) will be accepted.” CMS requires that the statewide program be consistent across all contractors, LEAs and LGAs whether they’re using a worker log and/or RMTS. The paper-based option should be a last resort and we suggest that all school districts have the capacity to participate in one of the electronic systems that are being developed.
4. Paper-based option - How will the State ensure the statistical validity of the paper-based option/ worker log for SMAA? See comment above.
5. Consistency across claiming units - CMS is requesting DHCS provide  assurances that the new Plan will be  implemented consistently across the State.  Please describe how DHCS will ensure this consistency in their oversight and monitoring of this program.
6. Closing Rosters, Page 6-7 - Please indicate when the rosters are closed to adding new participants before the beginning of each quarter. This information should be included in the Plan and when a moment is no longer available to a participant.
7. Quality Assurance, Page 6-18 - Please expand upon the description of the quality assurance process review to be conducted locally, by LECs, LEAs or LGA, etc as well as by DHCS.
8. Claiming Unit Grid, Section 7, Page 7-2 - Please indicate in this section of the Plan when the time study closes and counties are no longer able to add new participants. Please provide additional explanation regarding the claiming unit function grid.  Please explain how DHCS’ review of the grid provides sufficient information for DHCS to determine that the activities the claiming unit intends to submit claims for are necessary for the proper and efficient administration of the State plan.
9. County contract language - The State will be responsible to integrate any approved changes into the county contract language and require the LECs/LGAs/LEAs to do the same.
10. Personal Services Contractor, Page 3-5 - Please explain these non-employee entities and what services and administration will be performed by these individuals.  Please explain the participation fee to be paid to cover additional costs for administration of this program.
11. Sample MAA Invoice- Appendix B - The State had previously provided an LEC sample MAA invoice template that will be submitted to DHCS. Will this same template be used by all claiming units? Are the RMTS MAA Invoices proposed significantly different?  Please explain any notable differences and provide the training materials related to this invoice.
12. Enhanced Matching for SPMP - Please confirm the State will NOT claim time spent at the enhanced matching rate of 75% for SPMP activity in the school-based claiming time study as SPMP is not allowed in the school setting as indicated in the 2003 Medicaid School-Based Administrative claiming guide.
13. Duplication of Payment, Page 4-4 - the State says “LECs/LGAs may not claim FFP for costs of allowable administrative activities that have been or should have been reimbursed through an alternative mechanism or funding source.”  What internal controls are to be implemented to ensure that there are no duplicate payments as well as duplication of costs claimed for medical services and/or administration?  Will the same claiming entity that provides direct services participate in the time study to assure there is no duplication between medical related services and school based administration?
14. Internal Controls - What new internal controls will be implemented to ensure compliance with 42 CFR Section 433.15(b)(7) and OMB Circular A-87?  How does DHCS determine that the issues identified in the Financial Management review are addressed including:
• Are all of the activities being proposed (or actually performed) by the LEA needed to properly administer the state plan?
• Are the time survey results and vendor fees reasonable and don’t exceed the 15% limit?
• Are other direct charges included on the invoice also reasonable?
15. State Assurances - The State is responsible to provide assurances that they are meeting the requirements of the 2003 Medicaid School-Based Administrative claiming guide. Please review the guide in its entirety to make sure all of the requested information such as MOUs, interagency agreements, etc. are provided to CMS in the final submission.
16. LEAs - Please explain why the State believes colleges and universities should continue to be allowed to participate in school MAA.  Why does the State believe colleges and universities’ claiming are necessary for the efficient administration of the Medicaid State Plan? It is CMS’s recommendation that colleges and universities be eliminated from the program.
17. LEAs, Section 4, Page 4-6 - How will the State ensure against duplication of payments regarding LEA Medi-Cal billing option and SMAA since other entities within the State are also providing administrative activities.  Therefore, the State will need to describe the other programs operated by DHCS that deliver administration in the school setting and their relationship to this program to ensure that there is no duplication of effort. A matrix or chart format is suggested.  Please explain how DHCS ensures that no costs are duplicated between SMAA and LEA services since providers are allowed to participate in both programs and different cost allocation methodologies are used. The State needs to provide assurances that they will have consistent cost allocation practices.
18. Code 12 translation 50 percent FFP - Is the State aware of the enhanced matching rate for Medi-Cal translation services?
19. Code 10 non-medical transportation - For Code 10, how will the State ensure against duplication of payment for both arranging and providing the actual transportation service?  Please include a description of the differences.
20. Cost Pools - Based on the implementation plan there are four Cost Pools (CP) including CP #1 direct service staff who conduct both direct services and administrative claiming activities, CP#2  administrative claiming staff, CP#3  Non-MAA costs not included in the claim, and CP#4 allocated costs.  Please confirm that the direct services providers listed in Cost Pool #1 are in the CA approved SPA.
21. RMTS Training materials - staff training for coders need to get an overview of school based admin and services and the different activities provided that are both educational and Medicaid- related provided in the school setting.
22. RMTS training - Please include a slide or two on completing the time study and reporting instances/examples where activities are being miscoded. Please include additional examples of Medi-Cal vs. non-Medi-Cal activities and whether school staff will receive this training as well as the coders to distinguish how to complete the RMTS.
23. RMTS Training Code 8:  Please provide additional examples of allowable and unallowable activities for referral and coordination to be included.  Please include an example of the unallowable activity for staff who participate in IEP meetings since this is an educational related activity.
24. Consistency - Please review the LAUSD and the CMAA Plans including the training materials to ensure consistency across each of the claiming entities within and across the State.
25. Vendor fee schedule Section 4, Page 4-3/4-4 – The vendor fee section should be clarified to clearly indicate that even the per person vendor fee contracts will be subject to the aggregate 15% limit.  The wording in the second bullet implies this is only for flat fee contracts.
26. Record Retention Section 8, Page 8-1 – The record retention requirement for local claiming units may not cover the full time required by federal regulations for DHCS to maintain documentation for claims submitted to CMS.