1 Tex. Admin. Code § 355.8095

Current through Reg. 49, No. 45; November 8, 2024

Section 355.8095 - Medicaid Administrative Claiming Program

(a) Introduction. Medicaid Administrative Claiming (MAC) is a joint federal-state funded health care program which provides reimbursement for the costs of Medicaid administrative activities that refer eligible or potentially eligible Medicaid recipients to appropriate Medicaid and health-related services.

(b) Definitions. The following definitions apply when the terms are used in this section.

(1) CMS--Centers for Medicare & Medicaid Services. The federal agency within the United States Department of Health and Human Services responsible for overseeing and directing Medicare and Medicaid, or its successor.

(2) FFY--Federal fiscal year. Begins October 1 and ends September 30 of the following calendar year.

(3) Governmental entity--A state agency or a political subdivision of the state. A governmental entity includes a city, county, school district, special district, community mental health center, or other unit of government.

(4) HHSC--The Texas Health and Human Services Commission or its designee.

(5) MAC Financial Claim--The claim for reimbursement submitted to HHSC by a governmental entity each federal fiscal quarter.

(6) Participant--A governmental entity employee or contractor position, including a federally funded position, responsible for performing MAC activities in support of Medicaid or medical services as a weekly part of the position's job duties. These activities must directly support efforts to identify, enroll, and maintain Medicaid eligibility for eligible and potentially-eligible children and adults.

(7) PL--Participant list. A comprehensive list of all participants eligible for inclusion in the Random Moment Time Study, as defined in paragraph (9) of this subsection.

(8) QSI--Quarterly Summary Invoice. An invoice of costs reimbursable to a MAC participating governmental entity.

(9) RMTS--Random Moment Time Study. A federally-approved, statistical sampling technique administered by HHSC to identify the percentage of time that is reimbursable under the MAC program versus the percentage of time that is directly or indirectly related to covered services and other activities.

(10) STAIRS--State of Texas Automated Information Reporting System. HHSC's online application for submitting cost reports and accountability reports.

(c) Eligible providers. A governmental entity is eligible to be reimbursed for MAC activities if it meets the following criteria.

(1) It has entered into a written provider agreement with HHSC.

(2) It operates one of the following provider types or programs:

(A) Early Childhood Intervention (ECI);

(B) local health department (LHD);

(C) local mental health authority or local intellectual and developmental disability authority (MH/IDD authority);

(D) school district, public charter school, or state school (school district); or

(E) Aging and Disability Resource Center (ADRC).

(3) The provider or program is enrolled in Medicaid.

(d) Eligible activities.

(1) To be claimed through the MAC program, administrative activities must:

(A) directly support efforts to identify, enroll, and maintain Medicaid eligibility for eligible and potentially-eligible children and adults; and

(B) directly support the provision of services covered under the Texas Medicaid State Plan.

(2) The following activities have been identified by CMS as eligible for reimbursement:

(A) outreach;

(B) utilization review;

(C) eligibility determination;

(D) Medicaid referral, coordination, and monitoring;

(E) scheduling or arranging transportation to Medicaid covered services;

(F) translation services;

(G) program planning;

(H) development and interagency coordination;

(I) training;

(J) provider relations; and

(K) activities that determine a consumer's need for direct medical care.

(e) Governmental Entity's Responsibilities.

(1) Designated contacts. A governmental entity that participates in MAC must:

(A) designate an employee to serve as an RMTS contact who:

(i) ensures that the entity's PL is verified and updated quarterly;

(ii) attends the RMTS training required in paragraph (2) of this subsection;

(iii) provides RMTS training to sampled participants;

(iv) provides ongoing technical assistance to entity participants;

(v) ensures entity compliance with 85 percent required time study response rate; and

(vi) ensures all contact information recorded in STAIRS is current and accurate; and

(B) designate an employee to serve as a MAC financial contact who:

(i) serves as the main point of contact between the entity and HHSC for all MAC financial-related issues;

(ii) maintains the accuracy of all contacts in STAIRS;

(iii) communicates with all key stakeholders to ensure all participants claimed engaged in eligible activities during the claiming period on a weekly basis;

(iv) attends the MAC financial training required in paragraph (3) of this subsection;

(v) certifies the accuracy of the MAC Financial Claim and the availability of matching funds;

(vi) ensures that the QSI is signed by an entity employee with signature authority and is notarized; and

(vii) ensures that all supporting documentation described in paragraph (4) of this subsection is maintained.

(2) RMTS training. Annual training conducted by HHSC is mandatory for all RMTS contacts who certify a PL for an entity.

(3) MAC financial training. HHSC provides annual training to participating governmental entities.

(A) Each primary MAC financial contact must attend and receive credit for training for each FFY in which the governmental entity chooses to participate.

(B) Training is provided for each FFY and is not retroactive.

(C) A governmental entity that does not have a trained MAC financial contact who is an employee of the entity is prohibited from submitting a MAC Financial Claim. Governmental entity-contracted vendors are not permitted to enter an entity's data into STAIRS for any entity that does not have a trained MAC financial contact who is an employee of the entity.

(4) Documentation. A governmental entity that participates in MAC must maintain documentation that supports the MAC activities performed by the entity and all costs submitted for reimbursement.

(A) A governmental entity must collect and maintain MAC participation documents in a readily-accessible location and format, including:

(i) financial data used to develop the expenditures and revenues for the claim calculations, including the state and local match used for certification;

(ii) copies of computations used to calculate financial costs;

(iii) all revenues offset from the claim, by source; and

(iv) all signed and certified QSIs.

(B) Participation documents must be maintained for a period of no less than three years. In the case of an audit during the first three retention years, the records must be retained three years after the close of the audit. A school district must retain participation documents for a period of no less than five years, but in the case of an audit during the first five retention years, the records must be retained five years after the close of the audit.

(f) Claim calculation.

(1) Preparers of MAC Financial Claims must apply the cost principles outlined in:

(A) 2 CFR Part 200 ; and

(B) § RSA 355.102 of this chapter (relating to General Principles of Allowable and Unallowable Costs), § RSA 355.103 of this chapter (relating to Specifications for Allowable and Unallowable Costs), § RSA 355.104 of this chapter (relating to Revenues); and § RSA 355.105 of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures).

(2) The costs allowable for submission through a MAC Financial Claim are:

(A) for an ECI, LHD, MH/IDD authority, ADRC, or school district:

(i) salary, payroll taxes, and benefits; and

(ii) contracted staff expenses; and

(B) for an ECI, LHD, MH/IDD authority, or ADRC:

(i) materials and supplies;

(ii) equipment and other allowable costs; and

(iii) expenses for administrative staff and administrative support staff excluded from the RMTS .

(3) HHSC reserves the right to retain five percent of the federal share of actual and reasonable costs for HHSC's own administrative costs.

(g) Claim submission.

(1) To claim reimbursement for eligible activities, eligible providers must:

(A) have an active written provider agreement with HHSC executed on or before the first day of the quarter in which reimbursement is being claimed;

(B) have participated in the HHSC-administered RMTS;

(C) have a MAC financial contact who is an entity employee and who has received credit for the MAC training for the FFY in which the governmental entity wishes to submit a claim;

(D) submit a certified PL for the quarter in which reimbursement is being claimed;

(E) submit a MAC Financial Claim; and

(F) submit a certified QSI.

(2) The MAC Financial Claim and other required documents are submitted to HHSC through STAIRS.

(h) Program specific requirements for school districts. Participating school districts must:

(1) have an approved MAC Program Operating Plan on file with the HHSC Provider Finance Department; and

(2) when contracting with a vendor for which the school district will be held accountable, incorporate the authorization to enter and certify the school district's quarterly financial information into the contract and provide the contract upon HHSC request.

1 Tex. Admin. Code § 355.8095

Adopted by Texas Register, Volume 43, Number 25, June 22, 2018, TexReg 4169, eff. 7/1/2018; Amended by Texas Register, Volume 47, Number 12, March 25, 2022, TexReg 1617, eff. 4/3/2022