Diversifying AAA/ADRCs Funding Streams:

How states and their local partners can draw down federal Medicaid Administrative

Match for ADRC/NWD Systems

July 30, 2017 n4a Conference

Agenda • What is the value of Medicaid Claiming?

– For the ADRC/NWD System/for my organization

• How is this done? – Implementation Process and Steps – Maryland & Hawaii’s Medicaid Claiming Infrastructure

• How to get buy in? – State Leadership Perspective – Colorado’s Planning Experience

• What’s Happening Now? • ACL Support and Resources

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What is Medicaid Claiming? • Administrative Medicaid Claiming (aka Federal

Financial Participation (FFP)) is a way in which Medicaid reimburses agencies doing work that supports Medicaid programs.

• This is not a fee-for-service; agencies are not paid per activity.

• FFP reimbursement is calculated based on the results of a time study or daily time documentation

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• Strengthens the case for State and local funding: – Local money goes twice as far – Demonstrates that the ADRC/NWD network is a core

infrastructure supporting the Medicaid program

• Ongoing source of funding: – Once approved, funding will continue – Medicaid claiming covers about 40% of costs for

Wisconsin’s ADRC/NWD

• Does not require major changes to regular operations

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What is the Value?

Claiming and Reimbursement Process

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Operating agency adds all participating staff into "cost

pool"

Operating agency runs time studies to capture

staff time

Local sites submit quarterly documentation of actual

expenditures to operating agency

Operating agency calculates the Medicaid %, documents costs

within the cost pool, and requests reimbursement from

state Medicaid

State Medicaid agency submits claiming report,

receives federal funds, and allocates funds to

operating agency for disbursement

Maryland’s Medicaid Claiming • Maryland uses a random moment time study (RMTS)

methodology – Staff code activity at a randomly selected time

• Less burdensome, more accurate reporting compared to 100% time tracking

• Uses a web-based RMTS software system – Automatically generates the samples each quarter

• Adapted codes that correspond to staff work – Level 1 Screen – Person Centered Counseling – Coordination of services with individuals at risk of Medicaid spend-down

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2500 samples generated per quarter

150 staff total

Statewide Average for State Fiscal Year 2017: Medicaid Claimable

Percent = 47.65%

Total Claiming Reimbursement = $3,303,000

Maryland’s Claiming Totals

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Deborah Stone-Walls Maui AAA, Hawaii

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Hawaii’s Steps for Implementing Medicaid Claiming

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Simply put….

Identify the work that we do

Tease out if the activities are related to Medicaid

Document time spent on Medicaid activities

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Medicaid Claiming Codes • Codes should support operations • Ordered to make choice of code

clearer • Negotiated with direct staff • Training on the coding process • Random Moments pilots—Survey

Monkey • Analysis/testing of codes • Provides estimates of claimable time

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1. Reimbursed by another source

2. Medicaid Choice Counseling

3. Call Log/Intake

4. Facilitating Program Applications

5. Assessment/Support Plan Development

6. Referral, Coordination, & Monitoring

7. Outreach

8. Training or Program Admin.

9. General Admin.

10. Other

Pilot Testing

Conduct Pilot A

• Evaluate codes during pilot

• 3 weeks • Update

codes

Conduct Pilot B

• Develop cost and time estimates

• Establish a baseline

• 3 weeks

Implement FFP

• State and Federal approval

• Ongoing time study

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Establishing the Cost Pool • Personnel: salaries, taxes, fringe for direct,

supervisory and support staff • Operations: Lease/rental, program activities,

printing/publications/advertisement, staff training, supplies, travel, etc.

• Equipment and motor vehicle costs • Report actual costs quarterly

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Getting Staff On Board

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1. Reimbursed Directly by

Another Source

3. Call Log/ Intake

5. Assessment /Support Plan Development

6. Referral, Coordination, or

Monitoring7. Outreach

8. Training or Program

Administration

9. General Administration 10. OtherNo No No No No

Code 1

Yes

Code 3

Yes

Medicaid an option?

Yes

Code 5a

Code 5b

Code 5c

Yes No

At risk for

spenddown&

institutionalization

Yes

Tied to a specific

program

Medicaid related

Yes

Code 7a Code 7b

Yes

Yes

Code 7c

No

No

Tied to a specific

program

Medicaid related

Yes

Code 8a Code 8b

Yes

Code 8c

No

No

Yes

Code 9

Yes

Code 10

Yes

Medicaid an option?

Code 6a

Code 6b

Code 6c

Yes No

At risk for

spenddown&

institutionalization

4. FacilitatingApplication

2. Quest Integration Choice

Counseling

Code 2

Yes

NoNoNo No

Yes

Medicaid related

Code 4a Code 4b

Yes No

Not Medicaid related

Medicaid related

General administration

Further evaluation required

What’s in it for me? Increase available funding to support activities and STAFF members

Decrease ongoing funding/employment anxiety and burnout

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Staff Training and Ongoing Monitoring

Engage ALL types of learners Staff trainings Training should have lots of examples and scenarios,

not just code definitions….practice, practice, practice FFP Time Study Guide Bi-weekly “quizzes” to keep code definitions fresh for

staff Ensures accuracy in coding

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Helpful Hints • Talk with other states to learn from their

experiences • Early collaboration between State and local

staff and preliminary mini-pilots can improve the accuracy of codes and need for further refinement

• Provide thorough training and develop mechanism for answering ongoing questions

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Helpful Hints, cont. • Set realistic goals for data collection and time

study duration – Smaller agencies may need more time to gather data

• Don’t over complicate!! Staff are already performing tasks; not looking to change day to day operations

• Collect complete costs for staff participating in FFP claiming (e.g., rent, utilities, etc.)

– The greater the associated costs, the higher the return

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Roger Auerbach Lewin Group

What does the ADRC/NWD System do for Medicaid?

• Outreach and consumer education • Intake, triage, application assistance • Planning for future needs – Person Centered

Counseling • Delaying or preventing Medicaid eligibility • Triage and screening to prevent Medicaid spend-

down, including diversion away from long-term institutionalization by providing resources and support in the community

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What’s in it for Medicaid?

• Reduce Medicaid costs by counseling individuals about non-Medicaid community services and developing person-centered plans

• Streamlining enrollment into Medicaid for services not provided by other programs

• Integrate and coordinate access to Medicaid services

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Developing Draft Codes, Testing and Approval

• Develop and pilot test draft codes • Evaluate and refine codes • Design a quality management process • Secure final Medicaid approval of the proposal • Develop an MOU • Receive approval from CMS

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Tim Cortez Colorado Department of Health Care Policy and Financing

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Colorado’s Background

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• ADRC grant awarded in 2005 • 16 ADRCs operating in Colorado • ADRCs are partially financed by the Older Coloradans

Act and may have local funds • Colorado received a NWD planning grant in 2014 and

the implementation grant in 2015 • The SUA requested approval to set aside a portion of

state general fund

Colorado Background, Cont.

• The SUA (CDHS) and Medicaid State Agency (HCPF) began engagement with the ADRCs in 2016

• PCG in 2017 developed time study codes and draft amendment for the Medicaid Cost Allocation Plan

– Currently in review by state staff • HZA modified the online time study platform to allow

ADRCs to respond to random time study surveys • ADRCs are currently piloting after initial pilot

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How Can I Position My Organization?

• Understand what contributions you make or can make to support the Medicaid Program

• Engage with state agencies to identify reimbursable activities and develop time study codes

• Participate in time study pilots • Understand your responsibilities for cost reporting

and participating in time study surveys

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Return on Investment

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• New funds for work ADRCs are already doing • Depends on a few factors:

– Availability of funds for state match – Amount of Medicaid related activities per quarter – Local funds available

• If the costs attributable to Medicaid outweigh the administrative strings, then probably a positive ROI.

State Level Agreements

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• MOU between State Medicaid Agency (HCPF) and State Unit on Aging (CDHS)

– SUA agrees amount of state funds to set aside – SUA submits report to HCPF requesting how much

FFP to cover program costs allocated by time – HCPF agrees to seek reimbursement and transfer

funds to SUA

Local Level Agreements

• Contracts between ADRC and SUA – ADRC submits ADRC cost reports to SUA – ADRC identifies staff to participate in Time Study

Surveys – ADRC agrees to carry out ADRC functions

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Ami Patel ACL

Currently Claiming

DC

HI

MD

DE

NJ CT

RI

MA

NH

VT

ME

MT

ID

CO

WY

NV

CA

NM AZ

MN

KS

TX

IA

IL

WI

TN

IN OH

MI

AL MS

AR

LA

GA

WV

PA

OR SD

ND

MO

OK

NE

NY

SC

NC

KY

FL

VA

AK

WA

Planning

11 states currently claiming for ADRC/NWD activities 13 in the planning phase

ADRC/NWD System Medicaid Claiming

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What’s Happening Now? • CMS recently issued the “No Wrong Door System Reference

Document for Medicaid Administrative Claiming Guidance” to assist NWD states with implementing Medicaid claiming.

• ACL Workbook and Guidance: - ACL has drafted a workbook that includes various tools and

guidance documents for states to use as they develop a claiming infrastructure. These tools include:

- PowerPoint presentations for engagement of NWD partners and stakeholders

- Cost simulator - Claiming code guidance - Cost allocation spreadsheets, and more

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Resources

https://nwd.acl.gov

https://www.medicaid.gov/medicaid/financing-and-reimbursement/admin-claiming/no-wrong-door/index.html

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Contacts

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Ami Patel ami.patel@acl.hhs.gov

Administration for Community Living

Deborah Stone-Walls, deborah.stone-walls@co.maui.hi.us

Maui, Hawaii Area Agency on Aging

The Lewin Group

Colorado Dept. of Health Care Policy and Financing

Tim Cortez Timothy.cortez@state.co.us

Roger Auerbach roger.auerbach@yahoo.com