Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 25 - SCHOOL BASED SERVICES › Attachment A

Current through June 17, 2024
INTRODUCTION
This Nebraska Education-Based Medicaid Administrative Claiming (NEBMAC)
	 Guide is effective for the quarter beginning September 1, 2017. All Nebraska
	 public school districts and Educational Service Units (ESU's) are eligible to
	 participate in the NEBMAC program. Effective June 1, 2017, Nebraska
	 transitioned the NEBMAC program to a competitively procured statewide
	 contractor for purposes of program administration in coordination and under the
	 direction of HHS. Additional changes are now being presented to accommodate the
	 state moving to a cost based reporting methodology for its direct service
	 program which results in some changes to the time study process as outlined in
	 this document.
The school setting provides a unique opportunity to enroll eligible
	 children in the Medicaid program and to assist children who are already
	 enrolled in Medicaid to access the benefits available to them. Medicaid offers
	 reimbursement for both the provision of covered medical services and for the
	 costs of administrative activities such as outreach which support the Medicaid
	 program.
The purpose of the Nebraska Education-Based Medicaid Administrative
	 Claiming Guide (referred to hereafter as the "Guide") is to inform schools and
	 other interested parties on the appropriate methods for claiming reimbursement
	 for the costs of Medicaid administrative activities performed in the school
	 setting.
The specific purpose of this Guide is to:
* Help schools and ESU's prepare appropriate claims for administrative
	 costs under the Medicaid program;
* Ensure that the Medicaid program pays only for appropriate
	 school-based administrative activities and that such activities are carried out
	 effectively and efficiently;
* Protect the fiscal integrity of the Medicaid program by providing a
	 clear articulation of the requirements for school-based administrative
	 claiming;
* Help ensure consistency in the application of federal administrative
	 claiming requirements and adherence to the provisions of the Centers for
	 Medicare & Medicaid Services' (CMS) "
Medicaid School-Based
	 Administrative Claiming Guide
";
* Promote the flexibility afforded in the implementation of the
	 Medicaid program;
* Assist in the implementation of operational and oversight functions;
	 and
* Provide technical assistance for the intended audience.
Contemporary schools are engaged in a variety of activities that would
	 not traditionally be thought of as education. In carrying out the mission of
	 meeting the educational needs of their students, schools find themselves
	 delivering many different services to students that help ensure that students
	 come to school healthy and ready to learn and that students can benefit from
	 instructional services.
Expenditures for direct school-based health services that are within
	 the scope of Medicaid coverage and furnished to Medicaid eligible children may
	 be claimed as "medical assistance" and are not within the scope of the
	 administrative claims discussed in this guide (See Section II - Medicaid in the
	 School Setting). Expenditures for administrative activities in support of these
	 school-based services including outreach and coordination may be claimed as
	 costs of administering the Nebraska Medical Assistance Program. These claims
	 are the subject of this Guide. The Guide is intended to help public school
	 districts and Educational Service Units (ESU's) better understand when Medicaid
	 reimbursement can be obtained for the administrative costs of school-based
	 health services and how to prepare and submit appropriate claims for
	 FFP.
At the national level, CMS reviews and assesses states' administrative
	 claiming programs in accordance with applicable federal Medicaid law and
	 regulations. CMS provides technical assistance to [Nebraska] DHHS to ensure
	 ongoing integrity of the administrative claiming process. The development and
	 implementation of the NEBMAC program is a collaborative process, as
	 appropriate, involving the relevant entities: school districts, Educational
	 Service Units, [Nebraska] DHHS, Nebraska Department of Education (NDE) and the
	 federal government. [Nebraska] DHHS is responsible for the operation of
	 Nebraska's Medicaid program so it is important for schools ESU's, and the
	 Nebraska Department of Education to work closely with [Nebraska] DHHS for
	 policy and technical assistance. This collaboration will help to ensure
	 compliance with administrative claiming requirements. [Nebraska] DHHS is
	 responsible for ensuring that applicable policies are applied uniformly
	 throughout the state and that claims are submitted to CMS in conformance with
	 such requirements.
The Medicaid program provides significant state operational and
	 programmatic flexibility under federal regulation and oversight but federal
	 Medicaid requirements only provide a framework for state Medicaid programs.
	 Nebraska establishes and administers its Medicaid program within this
	 framework. Therefore, even though federal Medicaid requirements are
	 administered by CMS, schools need to contact and work through [Nebraska]
	 DHHS.
The NEBMAC Program Coordinator, an employee of DHHS, provides oversight
	 of the NEBMAC program and helps to ensure compliance with all local and federal
	 regulations. The Program Specialist duties include, but are not limited
	 to:
Training/Compliance
* Respond to requests for information from Local Education Agencies and
	 ESUs.
* Maintain and disseminate all NEBMAC training materials, including the
	 approved NEBMAC Claiming Guide.
* Ensure all policies and procedures related to the administration of
	 the NEBMAC program are in compliance with state and federal guidelines.
* Provide guidance on proper coding to DHHS contractor and supply
	 necessary training materials as requested.
* Attend training sessions with DHHS contractor, provide any updates to
	 the program and answer questions.
Claim Review
* Review claims for completeness
* Verify all necessary supporting documentation is included and/or
	 available for review
* Verification of the quarterly Participant List
* Submission and certification of MAC financial cost reporting
* Review of applied Indirect Cost Rate and Medicaid Eligibility
	 Rate
* Submission and review of individual district claims
* Review claims to ensure that all claimed expenses are
	 allowable
* Notify school districts of any errors and return or adjust claims
	 accordingly
Time Study Review
* Review the Random Moment Time Study (RMTS) compliance rate, ensuring
	 each school district achieves the 85% participation level as required by
	 CMS.
* Send a letter of warning to any school district not achieving the
	 minimum compliance level.
* Monitor the subsequent quarter to ensure compliance at the defined
	 standards.
* For non-compliant entities, DHHS may deny both current claims and may
	 prohibit the entity from claiming MAC expenses for the remainder of the fiscal
	 year.
The Program Specialist will randomly select 5% of the sampled responses
	 to ensure validity and appropriate coding.
For purposes of this methodology and throughout this Guide, several
	 different terms are used to describe school-related administrative claiming
	 units. This includes LEA's (local education agencies), "districts," "school
	 districts," and "Educational Service Units". Reference to any should be
	 considered reference to all unless some special meaning or rule applies to a
	 specific type of claiming unit.
MEDICAID IN THE SCHOOL SETTING
Medicaid is a critical source of health care coverage for children. The
	 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provision (also
	 known in Nebraska as HEALTH CHECK or Well-Child) is Medicaid's comprehensive
	 and preventive child health program for individuals under the age of 21. A
	 primary goal of HEALTH CHECK is to establish a medical home for each child. A
	 medical home is the primary care provider who manages a coordinated,
	 comprehensive, continuous health care program to address the child's primary
	 health needs. The medical home should provide or make arrangements for after-
	 hours care and coordinate the child's specialty needs. The medical home should
	 follow the screening periodicity schedule guidelines published by the American
	 Academy of Pediatrics and perform periodic screens when medically necessary.
	 The purpose of this Guide is to explain how Nebraska public school districts
	 and Educational Service Units can be involved in the HEALTH CHECK program as
	 administrative agents of the Medicaid Division and receive Medicaid
	 reimbursement for providing administrative outreach and services coordination
	 to students who are eligible or potentially eligible for Medicaid services.
	 This program allows Nebraska's schools to become an "administrative arm" of the
	 Medicaid agency through the assurance of health care coordination of
	 students.
Even when appropriate health care services exist within a community,
	 many beneficiaries of public health care programs do not readily access the
	 primary and preventive services they or their children need. Among the primary
	 reasons for the failure of persons to access services are:
(a) the child in need is not being recognized
  as eligible for Medicaid which could fund the services needed; and (b) there is
  no system operating, however informal, to ensure that the services needed are
  identified and provided. By providing administrative outreach and care
  coordination, school-staff work to erase the "barriers-to-access" that may
  exist. However, administrative care coordination does not include the full
  development, implementation and monitoring of a care- or treatment-plan for
  individual students. Other providers of [Nebraska] DHHS including managed care
  plans, managed care organizations and public health nurses are responsible for
  primary care planning and management in some areas of the state. School
  districts are expected to coordinate services with all [Nebraska] DHHS
  providers.
Many of the administrative activities discussed in this Guide that are
	 claimable to Medicaid are those associated with and in support of the provision
	 of medical services reimbursable under Medicaid. (See Section IV. c ). There
	 are other administrative activities not associated with covered Medicaid
	 medical services which may be covered in schools. These include Medicaid
	 outreach, facilitating Medicaid eligibility determinations, medical/Medicaid
	 related training and general administration (See Activity Codes, Section IV.
	 C).
Schools can provide a wide range of health care and related services to
	 their students which may or may not be reimbursable under the Medicaid program.
	 The services can be categorized as follows:
*
IDEA-related health
	 services
: The Individuals with Disabilities Education Act
	 (IDEA) was passed to "assure that all children with disabilities have available
	 to them"¦ a free appropriate public education (FAPE) which emphasizes
	 special education and related services designed to meet their individual
	 needs." IDEA authorizes federal funding to states for medical services provided
	 to children through a child's Individual Education Program (IEP) or
	 Individualized Family Service Plan (IFSP) including children who are covered
	 under Medicaid. In 1988, Section 1903(c) of the Act was amended to permit
	 Medicaid payment for medical services provided to Medicaid eligible children
	 under IDEA and included in the child's IEP/IFSP.
Nebraska is referred to as a "Birth-mandate State" since Nebraska
	 R.R.S. §
										79-1132 requires that special
	 education and related services are to be provided for infants and toddlers upon
	 verification of a disability (ies). An infant or toddler with disabilities is a
	 child, two years of age or younger, who needs early intervention (known in
	 Nebraska as Early Development Network) services because they are experiencing
	 developmental delays in one of the following areas: cognitive development;
	 physical development; communication development; social or emotional
	 development, adaptive development or has a diagnosed physical or mental
	 condition that has a high probability of resulting in developmental delay.
	 Services are provided through an IFSP) that is developed and implemented for
	 each infant or toddler who is determined to be eligible for early intervention
	 (EI) or Early Development Network (EDN) services. The plan is based on
	 multidisciplinary evaluation and any other relevant information. Provision of
	 these services "to meet the unique needs of the child" is done so at no cost to
	 the child or family and is to begin immediately upon verification of the
	 disability which may be as early as birth.
*
"Section 504" - related health services: Section
	 504 of the Rehabilitation Act of 1973 requires
local
	 school districts to provide or pay for certain services to make education
	 accessible to children with disabilities. These services may include health
	 care services similar to those covered by IDEA and Medicaid. These services are
	 typically described in a Section 504 plan and are provided free of charge to
	 eligible individuals.
*
General health care
	 services
: These services are typically mandated by the
	 school district or state and include health care screenings, vision exams,
	 hearing tests, a scoliosis exam, et cetera and provided free of charge to all
	 students. Services provided by the school nurse (e.g., attending to a child's
	 sore throat, dispensing medicine, etc.) may also fall into this category. These
	 general health care services often resemble EPSDT/Health Check/Well-Child
	 services.
Federal matching funds are available under Medicaid for the cost of
	 administrative activities that directly support efforts to identify and enroll
	 potentially eligible persons into Medicaid and that directly support the
	 provision of medical services covered under the Nebraska Medical Assistance
	 Program (NMAP/Medicaid). To the extent that school employees perform
	 administrative activities that are in support of the Nebraska Medicaid Program,
	 federal reimbursement may be available.
While schools are legally liable to provide IDEA-related health
	 services at no cost to eligible students, Medicaid reimbursement is available
	 for these services because Section 1903(c) of the Act requires Medicaid to be
	 primary to the U.S. Department of Education for payment of the health-related
	 services provided under IDEA.
The direct medical services are paid by the Nebraska Medical Assistance
	 Program (NMAP/Medicaid) and referred to as "Medicaid in Public Schools" (MIPS).
	 Currently, Occupational Therapy (OT), Physical Therapy (PT) and Speech/Language
	 Pathology/Therapy (SLP/ST) related services are claimed for reimbursement by
	 public school districts, with an intended expansion of services effective
	 September 1, 2017 to include Nursing Services, Vision Services, Mental and
	 Substance Abuse Services, Personal Assistance Services and Transportation
	 Services. Associated costs are excluded from any calculation of administrative
	 costs and the administrative claim.
As prescribed in the Medicare Catastrophic Coverage Act [of 1988]
	 (MCCA), Medicaid covers these direct services only under the following
	 conditions:
* Services are identified in the child's Individual Education Program
	 (IEP) or Individualized Family Service Plan (IFSP) to meet the his/her unique
	 needs as required to provide a Free Appropriate Public Education (FAPE);
* Services are medically necessary and included in a Medicaid covered
	 category (speech therapy, physical therapy, etc.);
* Services are included in Nebraska's plan or available under EPSDT;
	 and
* Medical services are only claimed for those provided to Medicaid
	 eligible students.
AGREEMENTS
A.
General
Any public school district or Educational Service Unit (ESU) may
	 participate in Medicaid administrative claiming (NEBMAC). School districts and
	 ESU's receiving payment for Medicaid administrative activities being performed
	 in the school setting are acting as agents for the Nebraska Department of
	 Health and Human Services. Such activities may be paid under Medicaid only if
	 they are necessary for the proper and efficient administration of the Nebraska
	 Medicaid Program. Both ESU's and public school districts may claim related
	 costs as long as the costs are allowable according to the NEBMAC Guide.
	 Additionally, claimed costs must be incurred by the participating entity and
	 all other elements of a proper claim must be present.
In Nebraska, DHHS is the only entity that may submit claims to CMS in
	 order to receive FFP for allowable Medicaid costs. This requirement
	 necessitates that every participating agency be covered, either directly or
	 indirectly, through an intergovernmental agreement which describes and defines
	 the relationship between public school districts/Educational Service Units
	 conducting claimable activities, [Nebraska] DHHS and NDE. Such
	 intergovernmental agreements must be in place in order to claim federal
	 matching funds.
As of the beginning (September 1) of the 2017-18 school fiscal year,
	 all participating public school districts and ESU's will participate in the
	 NEBMAC program utilizing HHS' competitively procured statewide contractor for
	 purposes of program administration in coordination and under the direction of
	 HHS.
ESUs may provide contracted service providers to their member
	 districts, and in some instances the same provider may work in several
	 districts and the ESU. For purposes of the NEBMAC Program and to avoid
	 duplication of staff reporting, ESU contracted providers may only be included
	 once on the ESUs list of staff eligible to participate in the NEBMAC program.
	 ESU's making administrative claims shall use an average of their member school
	 districts' Medicaid eligibility rates weighted for enrollment but may only
	 include their own cost-pool expenditures in order to calculate claims pursuant
	 to this methodology.
Each public school district and ESU participating in Medicaid
	 administrative claiming shall separately maintain the financial accounting
	 records in accordance with the [United States] Office of Management and Budget
	 (OMB) requirements and standards 2 CFR Part 225 ) for purposes of
	 audits.
PRINCIPLES OF ADMINISTRATIVE CLAIMING
A.
General
ESU, school or school district employees perform administrative
	 activities that directly support the Medicaid program. Some or all of the costs
	 of these administrative activities may be reimbursable under Medicaid. However,
	 an appropriate claiming mechanism must be used. The random moment time study
	 (RMTS) is used for identifying and categorizing Medicaid administrative
	 activities and direct service activities performed by employees. The time-study
	 also serves as the basis for developing claims for the costs of administrative
	 activities that may be properly reimbursed under Medicaid/NEBMAC. (See Section
	 V. b ), and is used in the calculation of MIPS Cost Settlements The time-study,
	 including the activity codes, represent the actual duties and responsibilities
	 of participating ESU, school and school district employees, consistent with the
	 operational principles discussed below (See Section IV. c for activity
	 codes).
Effective September 1, 2017, activity codes listed in Section IV shall
	 be used. No alteration of the activity codes is acceptable.
B.
Operational
  Principles
1.
Proper
  and Efficient Administration
According to the federal statute, in order for the cost of any
	 activities to be allowable and reimbursable under Medicaid, activities must be
	 necessary for the proper and efficient administration of the plan (referring to
	 the Medicaid state plan) and the costs must be reasonable and necessary.
The principle of being necessary for the proper and efficient
	 administration of the Medicaid state plan was applied in developing time-study
	 activity codes. For example, outreach activities are considered to be in
	 support of the Medicaid program if they are in regard to explaining Medicaid
	 requirements. By contrast, outreach with respect to explaining the requirements
	 of education programs or other program requirements are not in support of the
	 Medicaid program and must be accounted for separately.
2.
Claiming for Allowable Activities
  Only
Medicaid can only pay for administrative expenditures related to, or in
	 support of health care services that are included in the state Medicaid plan or
	 services which are reimbursed under Medicaid for Medicaid eligible individuals.
	 For example, where school employees assist a Medicaid-eligible child to obtain
	 medical services that are included in the child's IEP or IFSP, if the provider
	 furnishing the medical services is not participating in Nebraska's Medicaid
	 program or is not part of a managed care organization (MCO) participating in
	 Nebraska's Medicaid program, FFP is not available for the services;
	 furthermore, FFP is not available for the administrative activities to assist
	 the child in accessing such services. These activities are not claimable
	 because they are not considered in support of the operation of the Medicaid
	 state plan (even if the services are included in Nebraska's Medicaid
	 program).
3.
Capture
  100 Percent of Time
In order to ascertain the portion of time and activities that are
	 related to administering the Medicaid program, DHHS must approve the allocation
	 methodology. Effective September 1, 2013, the approved allocation methodology
	 for Nebraska LEAs is the use of Random Moment Time Studies (RMTS).
To participate in the statewide NEBMAC and MIPS Cost Settlement
	 programs, an LEA or ESC must require certain district staff to participate in a
	 quarterly RMTS time study that covers the period for which claimed
	 administrative and direct service activities were performed. This time study in
	 turn, provides the basis for calculating amounts owed to the districts for
	 these activities.
While many school district staff participate in administrative
	 activities that are eligible for reimbursement by Medicaid, most do so only for
	 a portion of their normal workday and at varying intervals. The time study
	 allows LEA staff to document what they were doing during their sampled moment
	 and determine what portion of the day was spent on Medicaid-covered activities.
	 Details on how to conduct the time study are discussed in Section V, Claiming
	 Issues, of this guide.
In order to ensure that all of the time-study participants are
	 appropriately reflected in the timestudy, staff classifications and associated
	 supporting documentation (such as position descriptions) for time-study
	 participants have been reviewed and considered in developing the time-study
	 activity codes. This ensures that the unique responsibilities and functions
	 performed by participants, as well as special factors and programs applicable
	 to the participating ESU's, schools or school districts are accounted for and
	 included in the time-study codes. As these codes were formulated, they were
	 compared against staff classifications and supporting position descriptions to
	 ensure that all functions being performed are identified and incorporated into
	 the codes. (See also Section V. a Documentation.)
4.
Parallel Coding Structure: Medicaid
  and Non-Medicaid Codes for Each Activity
The time-study activity codes must capture all of the activities
	 performed by the time-study participants as indicated by Principle 2 and
	 distinguish Medicaid activities from similar activities that are not Medicaid
	 reimbursable. For example, a school employee who provides referrals for both
	 Medicaid and non-Medicaid programs needs to appropriately allocate his or her
	 time between these programs. This can be accomplished through the use of
	 "parallel" timestudy activity codes. In the above example, a time-study would
	 include an activity code such as "Non-Medicaid Outreach" and its parallel code
	 "Medicaid Outreach" (See Codes 1.a and 1.b in Section IV. c ) or "Referrals to
	 Non-Medicaid Enrolled Providers and Referral, Coordination and Monitoring of
	 Non-Medicaid Services" and a parallel code such as "Referral, Coordination and
	 Monitoring of Medical Services to Medicaid Enrolled Providers" (see Codes 8.a
	 and 8.b in Section IV. c ). Using a parallel coding structure ensures that the
	 time-study captures 100 percent of the time spent on referrals and allocates it
	 to the appropriate program. As noted in Section V. b .5, all staff in the
	 sample universe are to be trained on proper coding procedures including
	 reporting activities under the parallel codes before sampling begins.
5.
Duplicate Payments
Federal, state and local governmental resources should be expended in
	 the most cost-effective manner possible. In determining the administrative
	 costs that are reimbursable under Medicaid, duplicate payments are
not
allowable. That is, districts may not claim FFP for the costs
	 of allowable administrative activities that have been or should have been
	 reimbursed through an alternative mechanism or funding source. Just as DHHS
	 must provide assurances to CMS and of non-duplication through its
	 administrative claims and the claiming process, districts must provide like
	 assurances to [Nebraska] DHHS. Furthermore, in no case should a school district
	 or ESU claim or be paid more than the actual cost of that program or claiming
	 unit including state, local and federal funds.
Examples of activities for which the costs may not be claimable as
	 Medicaid administration due to the potential for duplicate payments:
* An activity that has been or will be paid as a medical assistance
	 service or as a service of another non-Medicaid program (See Section IV. b
	 Principle 6 on performing direct services vs. administrative
	 activities);
* An activity that is included as part of a managed care rate and is
	 reimbursed by the managed care organization.
It is important to distinguish between duplicate payments for the same
	 activity and the inefficient use of resources which may result in the
	 unnecessary performance of an activity more than once.
Coordination of activities is intended to mitigate the duplicate
	 performance of services or administrative activities and is discussed in
	 Principle 6 (Coordination of Activities).
There are many situations in which a Medicaid-eligible child with
	 special needs receives IEP or IFSP services from the school and well child,
	 primary, preventive and acute care services from a managed care organization
	 (MCO). MCO services can be provided at a school-based, school-linked clinic,
	 doctor's office or elsewhere. In those situations where the same
	 Medicaid-eligible child receives IEP or IFSP services from both a school and an
	 MCO, Nebraska makes concerted efforts to ensure that Medicaid is not paying for
	 the same services twice, once to the MCO and again to the school.
Any mechanism under which managed care rates are set and adjusted
	 addresses the activities and services being furnished in the school
	 setting.
6.
Coordination of Activities
In addition to avoiding duplicate payments as discussed above in
	 Principle 5, duplicate performance of activities must also be avoided. Under
	 Principle 1, allowable administrative activities must be necessary "for the
	 proper and efficient administration of the Nebraska Medicaid Program as well as
	 for the operation of all governmental programs. Therefore, it is important that
	 the school not perform activities that are already being offered or should be
	 provided by other entities or through other programs. As appropriate,
	 [Nebraska] DHHS, schools carefully coordinates efforts of NDE, providers,
	 community and non-profit organizations and other entities related to the
	 activities performed.
All agencies and persons involved must take whatever steps are
	 necessary to ensure that appropriate coordination occurs among providers. These
	 assurances are included in language implementing Medicaid managed care
	 contracts. In addition, schools are required under IDEA to provide services
	 listed in a child's IEP or IFSP. Therefore, Medicaid managed care contracts
	 contain provisions that specifically exclude these services from the capitation
	 rate paid to cover the costs of providing other medical services to Medicaid
	 eligible children.
The following are examples of activities that are or need to be
	 coordinated:
*
Activities performed by an MCO for Medicaid enrollees
	 such as case management functions
. To avoid duplication of these
	 functions by school personnel, coordination mechanisms are established between
	 the school and appropriate entities, such as the MCO and [Nebraska]
	 DHHS.
*
Payment rate setting mechanism
. [Nebraska]
	 DHHS and schools coordinate their activities, payments to providers, third
	 party payers and rate setting mechanisms to ensure that duplicate payments are
	 not made and that medical services and administrative activities are provided
	 as efficiently and effectively as possible. For example, MCO payment rates are
	 adjusted to reflect the activities and services being furnished in the school
	 setting.
*
An activity that is provided/conducted by another
	 governmental component
. For example, it is not necessary for
	 EPSDT educational materials, such as pamphlets and flyers which have already
	 been developed by [Nebraska] DHHS to also be developed by schools. It would be
	 inefficient in the allocation of Medicaid program and school resources to do
	 so. In order to avoid this, ESU's and school districts/schools coordinate and
	 consult with [Nebraska] DHHS to determine the appropriate activities related to
	 EPSDT and the availability of existing materials.
7.
Performing Direct Services v.
  Administrative Activities
School employees often perform both direct services (e.g., medical,
	 vocational or social services, teaching) and administrative activities (e.g.,
	 outreach or care coordination). The timestudy and activity codes capture and
	 clearly distinguish direct services from administrative activities. Direct
	 services like those addressed by Nebraska's MIPS program have different funding
	 sources, claiming mechanisms and documentation requirements related to each
	 program or type of activity and therefore should not be claimed as an
	 administrative expense. The RMTS activity codes are designed to capture all
	 administrative activities and direct services that may be performed in the
	 school but only some of those activities are reimbursable under Medicaid. The
	 time-study methodology identifies costs of medical and other direct services
	 like OT, PT and SLP. Proper application of the time-study methodology will
	 ensure that those costs are not included in claims for Medicaid administrative
	 activities.
The activity codes used in the time-study distinguish between different
	 types of activities and direct services as well as their respective funding
	 sources. For example, as indicated in the activity code system in Subsection C,
	 Medicaid program outreach is to be reported under Code 1.b, education program
	 outreach under Code 1.a, Direct Medical services under Code 4.a and 4.b, and
	 educational services under Code 3.
As indicated in Principle 4, payments for allowable Medicaid
	 administrative activities must not duplicate payments that have been or should
	 have been included as part of direct medical services, capitation rate or
	 through some other state or federal program as specified in 2 CFR Part 225 . It
	 is the school district's and ESU's responsibility to ensure there is no
	 duplication in a claim prior to submitting a claim to [Nebraska] DHHS.
Activities that are considered integral to or an extension of the
	 specified covered service are included in the rate set for the direct service
	 and therefore, should not be claimed as an administrative expense. For example,
	 when a school provides medical services such as OT, PT and/or SLP,
	 practitioners (therapists) should not bill separately for the cost of a
	 referral as an administrative expense through MIPS or any other Public
	 Assistance (PA) program. These activities are properly paid as part of the
	 medical service/therapy and reimbursed at the Federal Medical Assistance
	 Percentage (FMAP), nor may these activities be claimed as an additional cost
	 through administrative case management which is defined below.
a.
Case Management as
  Administration
The federal State Medicaid Manual (SMM) Section 4302 identifies certain
	 activities that may be properly claimed as
administrative
case
	 management. An allowable administrative cost must be directly related to
	 Nebraska's State [Medicaid] Plan or waiver service and be necessary for the
	 "proper and efficient administration of the state plan."
Some examples of administrative case management services addressed at
	 SMM Section 4302.2 (G)(2), are:
* Medicaid eligibility determinations and redeterminations;
* Medicaid intake processing;
* Medicaid preadmission screening for inpatient care;
* Prior authorization for Medicaid services;
* Utilization review; and
* Medicaid outreach.
As indicated in the SMM, CMS and [Nebraska] DHHS may make
	 determinations regarding whether or not other activities are necessary for the
	 proper and efficient administration of the state plan. Examples of activities
	 that are performed in a school-based setting may be found in the time-study
	 activity codes included in Section IV. c of this Guide.
While some case management activities may fall within the scope of both
	 administrative and targeted case management, claims may not be made for the
	 same costs both as targeted case management and administrative case management
	 per the duplicate payment provision discussed above.
b.
Case Management as a
  Service
Federal Sections 1905(a) (19) and 1915(g) (2) of the Act (42 United
	 States Code (U.S.C.) 1396d (a) (19) and
	 42 U.S.C.
	 1396n(g) (2), respectively)
	 define case management (CM), also referred to as services coordination (SC), as
	 services which will assist an individual eligible under the state [Medicaid]
	 plan in gaining access to needed medical, social, educational and other
	 services. Case management services are referred to as targeted case management
	 (TCM) services when the services are not furnished in accordance with
	 requirements pertaining to state wideness or comparability. TCM services are
	 included in the NMAP/Medicaid as an optional service. This flexibility enables
	 Nebraska to target case management services to specific classes of individuals
	 and/or to individuals residing in specified areas. If a child is receiving TCM
	 through the school or through another provider, extra care must be taken to
	 ensure that there is no duplication of services or payment. All TCM should be
	 reported under Activity "4, Direct Medical Services" in Section IV. c .
c.
Allocable
  Share of Costs
i.
Medicaid Eligibility Rate (MER)
Many school-based medical activities are provided both to Medicaid and
	 nonMedicaid eligible students. Therefore, costs applicable to these activities
	 must be allocated to both groups. This allocation of costs involves the
	 determination and application of the proportional share of Medicaid students to
	 the total number of students. Development of the proportional Medicaid share,
	 which is sometimes referred to as the Medicaid Eligibility Rate (MER), Medicaid
	 percentage, allocable share or discount rate, should relate to and be based on
	 the claiming unit (the entity submitting the claim). [Nebraska] DHHS and the
	 NDE work with the schools and ESU's to determine the MER for the claiming
	 unit.
Annually, districts are required by State statute to submit to NDE,
	 student information as of the last Friday in September. Beginning in the fall
	 of 2005, NDE began annually capturing names, dates of birth, and gender data
	 for their Nebraska Staff and Student Record System (NSSRS). A file of Medicaid
	 eligible recipients is then compared to NDE's file (by school district) in
	 order to identify the number of Medicaid eligible students in each district.
	 Dividing the number of matches identified for each district by the total number
	 of students in each district results in the proportional Medicaid share for
	 each district for that school year (Sep-Aug).
In order to determine the MER for participating ESU's, total number of
	 matches identified for all districts within the ESU is divided by the total
	 number of students in all districts within the ESU. The result is the
	 proportional Medicaid share for that ESU.
The proportional Medicaid share is then applied to the total costs of a
	 specific activity for which the claiming unit is submitting claims for FFP.
	 This process is necessary to ensure that only the costs related to Medicaid
	 eligible children are claimed to Medicaid. Note that not all activities are
	 subject to the proportional Medicaid share. Activities such as outreach and
	 facilitating eligibility determinations are not discounted at all while others
	 are totally unallowable and therefore discounted in total (100%).
ii.
Provider Participation
  Rate
Through the use of time-studies that contain specific activity codes,
	 costs of school personnel are distributed to certain activities (time-study
	 codes) to determine the administrative cost allocable to the Medicaid program.
	 The participation rate is based on the four (4) criteria listed below and the
	 universe of activity codes used in the time-study as a group must capture the
	 following categories of costs:
(1)
Unallowable
- the activity is unallowable as administration under
  the Medicaid program;
(2)
100% Medicaid Share
- the activity is solely attributable to the
  Medicaid program and as such is not subject to the application of the Medicaid
  share percentage. This is sometimes referred to as "not discounted";
(3)
Proportional Medicaid Share
- the activity is allowable as administration under the Medicaid program
  but the allocable share of costs must be determined by applying the percentage
  of the Medicaid eligible population or MER for each school district or ESU
  included in the time-study This is sometimes referred to as "discounted";
  or
(4)
Reallocated Activities
- those activities that are reallocated across other codes based on the
  percentage of time spent on allowable/unallowable administrative activities.
OMB 2 CFR Part 200 - Super Circular states that "a cost is allocable to
	 a particular cost objective if the goods or services involved are chargeable or
	 assignable to such cost objective
in accordance with relative benefits
	 received"
(emphasis added). To establish the proportional Medicaid
	 share, Medicaid eligible students must be determined and counted for each
	 school/school district or ESU that is submitting a claim. This number serves as
	 the numerator in a fraction with the denominator being the total number of
	 students in the same entity. This fractional value is the MER and is then
	 applied to the total costs applicable to the proportional Medicaid share
	 time-codes to determine the costs applicable to Medicaid administrative
	 activities. Note that the number of those Medicaid eligible and the total
	 number of students must be identified for the same time period. For example,
	 total enrollment at the opening of school in August compared with Medicaid
	 enrollment in November may not be used. Section 7.a above further describes the
	 MER as it is calculated for Nebraska School Districts and ESU's. See IV.7.a for
	 further explanation of Nebraska's method of gathering information for MER
	 calculations.
Click
	 here to view
In the following example, administrative claims are developed on a
	 school district basis. The purpose of applying a proportional Medicaid share is
	 to determine the amount to be allocated between Medicaid and non-Medicaid
	 students. The following example establishes how much of the costs related to
	 the activity should be allocated to Medicaid. The amount of federal financial
	 participation rate is currently 50% for all allowable administrative services.
	 This percentage is used to determine the appropriate claim based on the
	 activity costs that are allocable to Medicaid.
Example of Medicaid share:
* Gross Claimable Amount = $1,500
* Number of Medicaid Students in District = 1,000
* Number of Total Students in District = 5,000
* Activity = Referral, Coordination and Monitoring of
				  Medicaid Services (Proportional Medicaid /50 Percent Federal Financial
				  Participation)
* Medicaid Share Factor: Number of Medicaid Students
				  District
÷
Total Students in District
=
1,000/5,000
=
20 percent
* Gross Claimable Amount
$1,500
* Medicaid Share Rate (20 percent)
x .20
$300
* FFP Rate (50 percent)
x .50
* Net Claimable Amount
$
150
For example, an administrative activity may involve: "Referring
	 students for necessary medical health, mental health or substance abuse
	 services covered by Medicaid." While the activity may be intended to benefit
	 only Medicaid students, medical referrals would affect services provided to
	 both Medicaid and nonMedicaid students. That is, both groups would benefit from
	 the activity and therefore the costs associated with such referral activities
	 must be allocated accordingly.
The allocation of costs applies to activities that are performed with
	 respect to a population of children that includes Medicaid and
	 non-Medicaid-eligible children such as referral and monitoring of services.
	 Specifically, children with an IEP may have medical (Medicaid covered) services
	 included in their IEP's. Some of these children may be eligible for Medicaid
	 and some may not. When the IEP coordinator performs administrative activities
	 such as referral and monitoring of services for such children, they typically
	 do not know who is and who is not eligible for Medicaid. For that reason, a
	 Medicaid percentage is applied to the time spent on this activity to determine
	 the proportion of the time that is allowable as a Medicaid administrative
	 activity.
For outreach activities that are performed to identify potentially
	 Medicaid eligible students and enroll them in the Medicaid program, schools do
	 not need to determine which of these students are later determined eligible or
	 which students apply for the program. Discounting is not applicable for this
	 type of activity.
8.
Enhanced FFP Rates
Claiming for Translation and Interpretation
	 Services
CMS policy permits reimbursement at the standard 50% federal
	 matching rate for translation/interpretation activities that are claimed as an
	 administrative expense, so long as they are not included and paid for as part
	 of the rate for direct services. With the enactment of CHIPRA in 2009, States
	 were given the option to claim a higher matching rate for
	 translation/interpretation services (75% under Medicaid; 75% or the State's
	 enhanced FMAP + 5%, whichever is higher, under CHIP) that are claimed as
	 administration and are related to enrollment, retention and use of services
	 under Medicaid and CHIP for certain populations.
9.
Individual Education Program (IEP)
  and Individualized Family Service Plan (IFSP) Activities
Section 411 (k) (13) of the Medicare Catastrophic Coverage Act [of
	 1988] (MCCA) (Public Law (P.L.) 100-360) amended Section 1903(c) of the Act
	 (42 U.S.C.
	 1396b(c)) to permit Medicaid
	 payment for services provided to children under the Individuals with
	 Disabilities Education Act (IDEA) through an Individual Education Program
	 (IEP). IDEA provisions require school staff to perform a number of
	 education-related activities that can generally be characterized as ChildFind,
	 evaluation (initial), reevaluation and development of an IEP (See also Appendix
	 A). Nebraska schools have a responsibility to develop and implement an
	 Individualized Family Service Plan (IFSP) for each infant or toddler who has a
	 verified disability and is thereby determined to be eligible for early
	 intervention (IDEA "Part C") services. Likewise, schools are responsible for
	 developing and implementing an IEP for each child from three (3) to 21 who has
	 a verified disability and is thereby determined to be eligible for "Part B"
	 Special Education services. See
IDEA-related health services
in Section II (Medicaid in the School Setting) for additional
	 information.
IDEA related activities conducted by school staff are briefly described
	 below:
ChildFind
: All children with disabilities
	 residing in the state who are in need of special education and related services
	 must be identified, located and evaluated.
Initial Evaluations and Reevaluation
: Before
	 special education and related services are provided, an initial evaluation must
	 be conducted by the responsible public school district (usually the resident
	 district) in order to determine whether a child has a disability and their
	 special/specific educational needs. A re-evaluation is a determination as to
	 whether the child continues to be disabled and is performed in regards to the
	 continuation of the educational needs of the child. These evaluations are
	 usually initiated by the Student Assistance Team (SAT) and performed by a
	 Multidisciplinary [evaluation] team (MDT) as outlined in NDE's "
Regulations and Standards for Special Education
	 Programs
." More commonly known in Nebraska as "Rule 51," these
	 regulations may be found at Title 92 Nebraska Administrative Code (NAC) Chapter
	 51.
Individual Education Program (IEP
): IEP's are
	 addressed in Appendix A to the Guide.
Individualized Family Service Plan (IFSP)
:
	 IFSP's are addressed in Appendix A to the Guide.
Schools conduct activities listed above for the purpose of fulfilling
	 education-related services as mandated by IDEA. As such, associated costs of
	 these activities are not allowable as administrative costs covered by the
	 Medicaid program. In developing and reporting under the time-study activity
	 codes, education-related activities must be clearly identified and
	 distinguished as non-Medicaid activities. In general, these activities could be
	 reported under time-study Codes 1.a, 2.a or 3 in Subsection c .
It is important to distinguish ChildFind activities from Medicaid
	 outreach for the purpose of claiming FFP under Medicaid. In accordance with
	 IDEA, schools conduct ChildFind activities to identify children with
	 disabilities who need special education and related services. Regardless of
	 whether the ChildFind activities result in finding eligible children for whom
	 an IEP or IFSP is developed, ChildFind costs are not allowed under Medicaid as
	 administration. This type of outreach can be distinguished from outreach to
	 identify children who might be eligible for Medicaid; such Medicaid outreach
	 activities are allowable.
Various education-related statutes obligate schools to furnish or make
	 payment for services provided in the school setting for which Medicaid payment
	 is not available. Section 1903(c) of the Act clarifies that Medicaid payment is
	 available for medical services contained in a child's IEP or IFSP established
	 under IDEA so long as the child is eligible and the services are otherwise
	 reimbursable under Medicaid but no other education-related statutes obligate
	 Medicaid payment. For example, Section 504 of the Rehabilitation Act of 1973
	 requires local school districts to provide or pay for certain services to make
	 education accessible to children with impairments; these services are described
	 in a Section 504 plan. The 1903(c) exception is very specific and does not
	 extend to services provided pursuant to a Section 504 plan. Education agencies
	 such as school districts are required to pay for Section 504 services and there
	 is no provision to make the education agencies secondary to Medicaid.
	 Consequentially, federal Medicaid funds are not available for these
	 services.
IDEA is described further in Appendix A to this Guide.
10.
Review and Approval of Program and
  Codes by CMS
CMS reviews claims made by [Nebraska] DHHS, particularly in situations
	 involving the establishment of a new program in the state such as a
	 school-based administrative claiming program in order to determine the
	 allowability of such claims for federal matching funds. Furthermore, as
	 discussed below and in Section V. d on Cost Allocation Plans, [United States]
	 DHHS's Division of Cost Allocation (DCA), in coordination and consultation with
	 CMS, is required to approve public assistance cost allocation plans (CAP's).
	 CAP's must incorporate, by reference, time-study and cost allocation
	 methodology adopted by [Nebraska] DHHS for schools to develop and document
	 claims submitted to [Nebraska] DHHS.
Federal regulations (42 CFR 433.34) require that a
	 single state agency have an approved public assistance CAP under the Medicaid
	 state plan and on file with [United States] DHHS that meets certain regulatory
	 requirements (Subpart E of 45 CFR Part 95 ). In Nebraska, that single state
	 agency is [Nebraska] DHHS. As indicated in Subpart E of 45 CFR Part 95 and
	 referenced in 2CFR Part 225 , Attachment D, a state's public assistance CAP is
	 an official document which describes the procedures that the state uses in
	 identifying, measuring and allocating state agency costs incurred in support of
	 all programs administered or supervised by the state such as Temporary
	 Assistance for Needy Families (TANF), Medicaid, Food Stamps, Child Support
	 Enforcement (CSE), adoption assistance, Foster Care and Social Service Block
	 Grant (SSBG).
Furthermore, there are certain items that must be in the public
	 assistance CAP which [Nebraska] DHHS must submit before providing FFP to school
	 districts for administrative claiming. The public assistance CAP makes explicit
	 reference to the methodologies, claiming mechanisms, interagency agreements and
	 other relevant issues pertinent to the allocation of costs and submission of
	 claims by LEA's, (school districts and ESU's).
[Nebraska] DHSS works with its regional CMS office in Kansas City, on
	 an ongoing basis to assure a proper and accurate Cost Allocation Plan is in
	 place and is properly applied as described above and further required by
	 [United States] DHHS's CMS.
The required elements of public assistance CAP's are further discussed
	 in the Cost Allocation Plan section of the Guide (Section V. d ) as is the
	 review and approval process for such plans.
C.
Activity Codes:
  Descriptions and Examples
1.
Introduction
When staff perform duties related to the proper administration of
	 Nebraska's Medicaid program (NMAP), federal funds (FFP) may be accessed for the
	 costs of providing these administrative services. To identify the cost of
	 providing these administrative services and direct services, time-studies of
	 must be conducted. The time-study identifies the time spent on the Medicaid
	 administrative activities that are allowable and reimbursable under the
	 Medicaid program. Effective September 1, 2017, coding scheme/activity codes as
	 listed below must be used and may not be modified.
The indicators below, which follow each Code, provide the application
	 of the FFP rate, 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 do
	 not include references to rates of FFP, proportional or total Medicaid or
	 whether such codes are allowable or unallowable under Medicaid.
a.
Application of FFP
  rate
50 percent Refers to an activity that is allowable as administration
	 under the Medicaid program and claimable at 50 percent.
75 percent Refers to the Enhanced FFP rate allowable under the
	 Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA),
	 Public Law No. 111-3, enacted on February 4, 2009 for translation or
	 interpretation services.
b.
Unallowable Activities
U Refers to an activity that is unallowable as administration under the
	 Medicaid program and therefore claimable only at zero (0) percent. This is
	 regardless of whether or not the population served includes Medicaid eligible
	 individuals.
c.
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 allocable share of
	 costs must be determined by the application of the proportional Medicaid share
	 (Medicaid Eligibility Rate). The Medicaid share is determined as the ratio of
	 Medicaid eligible students to total students.
d.
Reallocated
  Activities
R Refers to those general administrative activities performed by
	 time-study participants which must be reallocated across other activity codes
	 on a pro rata basis. These reallocated activities are reported under Code 9,
	 "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 indirect cost rate.
Staff should document time spent on each of the following coded
	 activities:
Code
Activity
Reimbursement
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 Service not on IEP
U
CODE 4.b
Direct Medical Service on an IEP
U
CODE 5.a
Transportation for Non-Medicaid Service
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 Services
PM/50 Percent FFP
CODE 8.a
Non-Medical/Non-Medicaid Related Training
U
CODE 8.b
Medical/Medicaid Related Training
PM/50 Percent FFP
CODE 9.a
Referral, Coordination and Monitoring of NonMedicaid
				  Services
U
CODE 9.b
Referral, Coordination and Monitoring of Medicaid
				  Services
PM/50 Percent FFP
CODE 10
General Administration
R
CODE 11
Non Paid, Non Work
N/A
The following activity codes represent a set of activity categories
	 including administrative and direct services that are used and adapted to
	 reflect Nebraska's specific program titles, etc. These codes were developed in
	 accordance with the principles discussed in other sections of this Guide and
	 must be used by schools effective September 1, 20017.
TIME STUDY CODE DESCRIPTIONS
1A.
Non-Medicaid Outreach - U
All participating time-study participants should use this code when
	 performing activities that inform individuals about their eligibility for
non-Medicaid
social, vocational and outreach programs (including
	 special education) and how to access them; describing the range of benefits and
	 how to obtain them. Both written and oral methods may be used. Includes 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. Providing information related to the
  applications for non-Medicaid programs. (e.g., foster care family coordination,
  WIC referrals, local shelters, emergency food assistance, day care, and
  indigent programs).
3. Scheduling
  and promoting activities that educate individuals about the benefits of healthy
  life styles and practices.
4.
  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.).
5. Conducting campaigns that encourage
  persons to access social, educational, legal or other services not covered by
  Medicaid.
6. Assisting in early
  identification of children with special medical/dental/mental health needs
  through various child find activities. (e.g., contacting a nurse to communicate
  the child's needs, completing observations on students to determine needs,
  etc.).
7. Outreach activities in
  support of programs that are 100 percent funded by state general
  revenue.
8. Developing outreach
  materials such as brochures or handbooks for these programs.
9. Making arrangements with presenters of
  health education programs.
10.
  Parent conferences on truancy, drugs, gangs, etc.
1B.
Medicaid Outreach - TM/50 Percent
  FFP
School staff should use this code when performing activities that
	 inform eligible or potentially eligible individuals about Medicaid and how to
	 access the program. Such activities include providing information to parents of
	 potentially eligible children on how to apply for Medicaid or information on
	 how to reenroll children who are already eligible and whose eligibility is soon
	 to expire. Education about Medicaid may only be conducted for the populations
	 served by the school districts, i.e., students and their parents or
	 guardians.
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
  ESPDT 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 New Mexico Human Services Department Medical
  Assistance Division (HSD/MAD), the Medicaid agency). As appropriate, school
  developed education materials should have prior approval of the
  HSD/MAD.
3. Distributing literature
  about the benefits, eligibility requirements, and availability of the Medicaid
  program, including EPSDT.
4.
  Assisting HSD/MAD to fulfill the education 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) 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.
2A.
Facilitating
  Application for Non-Medicaid Programs - U
This code should be used by school staff when informing an individual
	 or family about
nonMedicaid
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.
1. Explaining the eligibility process for
  non-Medicaid programs, including IDEA.
2. Assisting the individual or family
  collect/gather information and documents for the nonMedicaid program
  application (e.g., foster care family coordination, WIC referrals, local
  shelters, emergency food assistance, day care, Indigent programs
  etc.).
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.
2B.
Facilitating Medicaid Eligibility Determination - TM/50 Percent
School staff should use this code when assisting an individual with the
	 Medicaid eligibility process. Includes related paperwork, clerical activities,
	 or staff travel required to perform these activities. This activity does not
	 include the actual determination of Medicaid eligibility.
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, 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 Income Support Division 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.
3.
School Related and Educational Activities - U
This code should be used for school-related activities, including
	 social services, educational services, teaching services, employment and job
	 training, and other activities that are not Medicaid-related. These activities
	 include the development, coordination, and monitoring of a student's education
	 plan. Includes related paperwork, clerical activities, or staff travel required
	 to perform these activities.
1.
  Providing classroom instruction (including lesson planning).
2. Testing, correcting papers.
3. Developing, coordinating, and monitoring
  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 actual IEP meetings with the parents, except for the
  development of the medical component, e.g., the individualized treatment plan,
  of the IEP. (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.
4A.
Direct Medical Services, Not Covered as IDEA/IEP Service - U
This code should be selected when school district staff are providing
	 direct client care services that are not IDEA and/or not IEP services. This
	 code includes the provision of all non-IDEA/IEP medical services reimbursed
	 through Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
	 services. 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 non-IDEA and/or non-IEP direct client care services as
	 follows:
1. Medical Screenings
  (including scoliosis), Vision Screenings, Hearing Screenings, Dental
  Screenings, EPSDT Screenings, and nurse consults for non-Direct Service
  services;
2. Administering first
  aid;
3. Administering medication
  other than those medications outlined in the IEP as direct client care nursing
  services under the Direct Service program, e.g., providing
  immunizations;
4. Making referrals
  for and/or coordinating medical or physical examinations and necessary medical
  evaluations not covered as direct client care services under the Direct Service
  Program, as a result of a direct medical service;
4B.
Direct Medical Services, Covered as
  IDEA/IEP Service - U
This code will be assigned when school district staff (employees or
	 contracted staff) provides direct client services as covered services delivered
	 by school districts under the Direct Service Program. 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 of the actual
	 direct client services (when the student may not be present), for example,
	 paperwork, or staff travel directly related to the direct client services.
	 Examples of activities reported under this code, include IDEA/IEP direct client
	 services with the Student/Client present:
1. Audiologist services, including evaluation
  and therapy services (only if included in the student's IEP);
2. Physical Therapy services, including
  evaluation and therapy services (only if included in the student's
  IEP);
3. Occupational Therapy
  services, including evaluation and therapy services (only if included in the
  student's IEP);
4. Speech Language
  Pathology Therapy services, including evaluation and therapy services (only if
  included in the student's IEP);
5.
  Counseling Services, including counseling, evaluation, and therapy services
  (only if included in the student's IEP);
6. Nutritional Assessments and Counseling
  (only if included in the student's IEP);
7. 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. Medicaid administration would not include those that
  are provided to the entire student population, i.e. administration of aspirin,
  but are specifically those called for in the IEP;
8. Case Management Services, including
  medical/functional assessments and developing a comprehensive plan of care;
  and
9. Specialized Transportation
  Services (only if included in the student's IEP).
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.
5A.
Transportation for Non-Medicaid Programs - U
School district employees 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. Includes
	 related paperwork, clerical activities or staff travel required to perform
	 these activities.
1. Scheduling or
  arranging transportation to social, vocational, and/or educational programs and
  activities.
5B.
Transportation-Related Activities in Support of Medicaid-Covered Services
  - PM/50 Percent FFP
School district employees 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
	 costs of the transportation (bus fare, taxi fare, etc.), but rather the
	 administrative activities involved in providing transportation. Includes
	 related paperwork, clerical activities or staff travel required to perform
	 these activities. See Section VI for a more detailed and thorough discussion of
	 Medicaid transportation policy.
1.
  Scheduling or arranging transportation to Medicaid covered services.
6A.
Non-Medicaid Translation
  -
School employees who provide translation services for non-Medicaid
	 activities should use this code. Includes related paperwork, clerical
	 activities or staff travel required to perform these activities.
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, 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.
6B.
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,
	 translation must be provided either by separate units or separate employees
	 performing solely translation functions for the school, and it must facilitate
	 access to Medicaid covered services. School employees who provide Medicaid
	 translation services should use this code. Includes related paperwork, clerical
	 activities or staff travel required to perform these activities.
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. This includes alternative
  languages, Braille, sign language and translation due to illiteracy.
2. Developing translation materials that
  assist individuals to access and understand necessary care or treatment covered
  by Medicaid.
7A.
Program Planning, Policy Development and Interagency Coordination Related
  to Non-Medical Services - U
School staff should use this code when performing activities associated
	 with developing strategies to improve the coordination and delivery of
	 non-medical services to school age children. Non-medical services may include
	 social services, educational services, vocational services, and state or state
	 education mandated child health screenings provided to the general school
	 population. Employees who position description includes program planning,
	 policy development, and interagency coordination may use this code. If schools
	 so choose, they may be explicit in the position descriptions with respect to
	 the specific functions. Includes related paperwork, clerical activities or
	 staff travel required to perform these activities.
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 nonmedical
  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.
7B.
Program Planning, Policy
  Development and Interagency Coordination Related to Medical Services - PM/50
  Percent FFP
This code should be used by school staff when performing activities
	 associated with the development of strategies to improve the coordination and
	 delivery of medical/dental/mental health services to school age children and
	 adolescents, and when performing collaborative activities with other agencies
	 and/or providers. Employees who position description includes program planning,
	 policy development, and interagency coordination may use this code. If schools
	 so choose, they may be explicit in the position descriptions with respect to
	 the 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 9B. Includes related
	 paperwork, clerical activities or staff travel required to perform these
	 activities.
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 eligibles, 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
  HSD/MAD and Medicaid managed care organizations, 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 HSD/MAD 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 organizations, which will
  provide services to targeted population groups.
15. Coordinating with interagency committees
  to identify and promote recipients' access to Medicaid EPSDT
  services.
8A.
Non-Medical/Non-Medicaid Related Training - U
School staff should use this code when coordinating, conducting, or
	 participating in training events and seminars for outreach staff regarding the
	 benefit of the programs other than the Medicaid program. For example, training
	 may include how to assist families to access the services of education
	 programs, and how to more effectively refer students for those services.
	 Includes related paperwork, clerical activities, or staff travel required to
	 perform these activities.
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.
8B.
Medical/Medicaid Related Training -
  PM/50 Percent FFP
School staff should use this code when coordinating, conducting, or
	 participating in training events and seminars for Medicaid training staff
	 regarding the benefits of medical/Medicaid related services, how to assist
	 families to access such services, and how to more effectively refer students
	 for services. Include related paperwork, clerical activities, or staff travel
	 required to perform these activities.
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, screening and referral of
  students with special health needs to such services (e.g., Medicaid EPSDT
  services). (This is distinguished from IDEA child find programs.)
3. Participating in training on Medicaid
  school-based direct services and administrative requirements.
9A.
Referral, Coordination
  & Monitoring of Non-Medicaid Services - U
School staff should use this code when making referrals for,
	 coordinating, and/or monitoring the delivery of non-Medicaid covered services
	 or the delivery of non-medical services, such as educational services. Includes
	 related paperwork, clerical activities or staff travel required to perform
	 these activities.
1. Making referrals
  for and coordinating access to social and educational services such as child
  care, employment, job training, and housing.
2. Making referrals for, coordinating, and/or
  monitoring the delivery of state education agency mandated child health screens
  (e.g., vision, hearing, scoliosis).
3. Making referrals for, coordinating, and
  monitoring the delivery of scholastic, vocational, and other non-health related
  examinations.
4. Making referrals
  for, coordinating, and monitoring the delivery of services that are provided to
  all students in the school.
5.
  Gathering any information that may be required in advance of these non-Medicaid
  related referrals.
6. Participating
  in a meeting/discussion to coordinate or review a student's need for
  scholastic, vocational, and non-health related services not covered by
  Medicaid.
7. Monitoring and
  evaluating the non-medical components of the individualized plan as
  appropriate.
9B.
Referral, Coordination and Monitoring of Medicaid Services - PM/50
  Percent FFP
School staff should use this code when making referrals for,
	 coordinating, and/or monitoring the delivery of medical (Medicaid covered)
	 services. Referral, coordination and monitoring activities related to services
	 in an IEP are reported in this code. Activities that are part of a direct
	 service are not claimable as an administrative activity. Furthermore,
	 activities that are an integral part of or an extension of a direct medical
	 service, e.g., patient follow-up, patient assessment, patient counseling,
	 patient education, patient consultation, and billing activities, should be
	 reported under Code 4A/4B, Direct Medical Services. Includes related paperwork,
	 clerical activities, or staff travel necessary to perform these
	 activities.
1. Identifying and
  referring adolescents who may be in need of Medicaid family planning
  services.
2. Making referrals for
  and/or coordinating medical or physical examinations and necessary
  medical/dental/mental health evaluations.
3. Making referrals for and/or scheduling
  EPSDT screens, periodic screens, and appropriate immunization but not referrals
  for state-mandated health screening or other primary and preventive services
  provided free of charge to all students.
4. Referring students for necessary medical
  health, mental health, or substance abuse services covered by
  Medicaid.
5. Arranging for any
  Medicaid covered medical/dental/mental health diagnostic or treatment services
  that may be required as the result of a specifically identified
  medical/dental/mental health need.
6. Gathering any information that may be
  required in advance of medical/dental/mental health referrals.
7. Participating in a meeting/discussion to
  coordinate or review a student's needs for health related services covered by
  Medicaid.
8. Providing follow-up
  contact to ensure that a child has received the prescribed
  medical/dental/mental health services covered by Medicaid.
9. Coordinating the delivery of community
  based medical/dental/mental health services for a child with special/severe
  health care needs.
10. Coordinating
  the completion of the prescribed services, termination of services, and the
  referral of the child to other Medicaid service providers as may be required to
  provide continuity of care.
11.
  Providing information to other staff on the child's related
  medical/dental/mental health services and plans.
12. Monitoring and evaluating the Medicaid
  service components of the IEP as appropriate.
13. Coordinating medical/dental/mental health
  service provision with managed care plans as appropriate.
10.
General Administration - R
1. Taking lunch, breaks, leave, or other paid
  time not at work.
2. Establishing
  goals and objectives of health-related programs as part of the school's annual
  or multi-year plan.
3. Reviewing
  school or district procedures and rules.
4. Attending or facilitating school or unit
  staff meetings, training, or board meetings.
5. Performing administrative or clerical
  activities related to general building or district functions or
  operations.
6. Providing general
  supervision of staff, including supervision of student teachers or classroom
  volunteers, and evaluation of employee performance.
7. Reviewing technical literature and
  research articles.
8. Other general
  administrative activities of a similar nature as listed above that cannot be
  specifically identified under other activity codes.
11.
Not-Paid/Not-Worked - R
Non-paid time/non-work time is time during the school work day for
	 which a participant in the time study is not working AND is not being
	 compensated. Examples of activities reported under this code:
1. Part-time/Contracted staff whose sampled
  moment occurs during non-scheduled work hours.
2. Staff member takes an unpaid day off
  during the sampled moment
3.
  Non-paid sick time.
4. Non-paid
  leaves of absence.
5. No longer
  employed by the program
CLAIMING ISSUES
A.
Documentation
The time-study methodology and instructions, as well as the cost
	 allocation requirements issued to the schools stipulate the documentation
	 schools and ESU's must maintain to support claims submitted to [Nebraska] DHHS.
	 The documentation for administrative activities must clearly demonstrate that
	 the activities/services directly support the administration of the Medicaid
	 program. In accordance with federal statutes, state regulations and the
	 Nebraska Medicaid plan, claimants (school districts, and ESU's) are required to
	 maintain/retain adequate source documentation to support all Medicaid payments
	 for administrative claiming. The basis for this requirement can be found in
	 federal statute and regulations. See Section 1902(a)(4) of the Act and
	 42 CFR
	 431.17 as well as
	 45 CFR
	 74.53 and
	 42 CFR 433.32(a) requiring source
	 documentation to support accounting records and
	 45 CFR
	 74.20 and
	 42 CFR 433.32(b-c) regarding the
	 retention period for records. The administrative claiming records must be made
	 available for review by state and federal staff or their designees upon request
	 during normal working hours (Section 1902(a)(4) of the Act implemented at
	 42 CFR
	 431.17) . It is the district's responsibility
	 to ensure that claims submitted are in conformance with the applicable policies
	 and in conformance with such requirements.
Documentation maintained in support of administrative claims must be
	 sufficiently detailed to permit DHHS or CMS to determine whether the activities
	 are necessary for the proper and efficient administration of the state plan.
	 Simply checking a box on a time-study form does not facilitate independent
	 validation of the sample results.
In the past, federal agencies have generally accepted minimal
	 documentation of time-study random moment sampling. However, circumstances
	 under which school-based administrative activities are sampled for purposes of
	 FFP under the Medicaid program differ from other time-study and random moment
	 sampling. In other instances, costs to be distributed are generally federally
	 reimbursable and the results of the sample only determine the percentage of the
	 costs that are directed to each federal program. When sampling is conducted to
	 determine federal financial participation under the Medicaid program for the
	 costs of school-based administrative activities, a vast majority of the costs
	 are not federally reimbursable. Therefore, it is critically important for
	 additional documentation to be maintained in order to verify the
	 appropriateness of claims in terms of allowability and allocability and to
	 limit the risk of erroneous claiming.
The burden of proof and validation of time-study sample results remains
	 the responsibility of the schools/ESU. To meet this requirement, the RMTS
	 survey
include space
for a brief narrative description of the
	 Medicaid activity, function or task being performed.
Additional guidance regarding documentation for compensation of salary
	 and wages is found in OMB 2 CFR Part 200 - Super Circular OMB 2 CFR Part 200 -
	 Super Circular makes a distinction between documentation of costs and the
	 methods/ mechanisms for allocating such costs. While costs must be documented
	 at least on a monthly basis, time-studies which are conducted for purposes of
	 allocating costs can occur on a quarterly basis or some other statistically
	 valid time frame. ASMB C-10, U.S. Department of Health and Human Services'
	 implementation guide for OMB 2 CFR Part 225 , provides further guidance on the
	 requirements and circumstances dictating the frequency of time and effort
	 reporting. Other principles related to documentation and documentation
	 requirements that apply in addition to the above requirements are:
- The documentation related to salaries and wages, including personnel
	 activity reports, is required;
- Accounting records should be supported by source documentation such
	 as canceled checks, electronic funds transfers, paid bills, payrolls, contract
	 and sub grant award documents;
- The documentation related to foster care payments and administrative
	 costs is required;
- Case management services based on time-studies are an acceptable form
	 of documentation for a given period;
- Costs must be verified as being incurred in a particular federal
	 program;
- Undocumented personnel costs are not allowed; and
- Adequate documentation for labor costs is required.
Position descriptions can be useful as supporting documentation for
	 staff participating in timestudies. However, position or job descriptions are
	 often generic and may indicate that "other administrative duties" are included
	 without providing a definition for those administrative functions. In many
	 cases, these "other administrative duties" may be understood to include the
	 performance of Medicaid related activities and the completion of time-studies.
	 In that regard, it may be helpful, though it is not required, to include in the
	 time-study participants' position descriptions further explanation or
	 documentation of the Medicaid related activities performed, particularly if the
	 position descriptions do not reflect any aspect of the performance of such
	 activities. However, schools are not required to modify job descriptions in
	 order to incorporate time-study activities. Furthermore, CMS does not require
	 position descriptions to be maintained for staff who are not participating in
	 the school-based administrative claiming program.
B.
Components of the Random
  Moment /Time-Studies
1.
Random Moment Sampling Methodology
To determine the proportion of claims for administrative activities in
	 support of the NEBMAC program, proportion of claims for direct service
	 activities, and the proper allocation of costs, DHHS utilizes a Random Moment
	 Time Study (RMTS) time study methodology that is monitored and administered at
	 the state level by DHHS staff and its selected contractor. Details concerning
	 the RMTS process and the individuals who may participate are described
	 below.
2.
Time Study
  Participants
Any LEA or ESU staff member who spends part of their working time
	 performing program-related administrative or direct service activities, and
	 meets the eligibility criteria, is eligible for inclusion in one of two cost
	 pools for purposes of the time study.
When a district constructs the list of staff that is included in the
	 time study, it determines first whether the individuals in those positions
	 perform administrative and/or direct service activities that support the NEBMAC
	 and MIPS programs and then includes them in the appropriate category. Each
	 category of staff will fall into one of two mutually exclusive cost pools. The
	 purpose of two cost pools is to group staff into "like" categories.
* Cost Pool 1 is made up of direct service/therapy personnel and is the
	 same listing of providers currently in the State plan.
* Cost Pool 2 is made up of staff involved in administrative activities
	 rather than direct service activities. Staff that are 100% federally funded
	 should be excluded from participation in the program, e.g. staff whose salary
	 and benefits are paid entirely from IDEA or other federal funds.
The following categories of staff have been identified as appropriate
	 participants for the time studies. All staff will be reported into one of two
	 cost pools: "Cost Pool 1" or "Cost Pool 2". The two cost pools are mutually
	 exclusive, i.e., no staff should be included in both pools. The following
	 provides an overview of the eligible categories in each cost pool.
The MSBS program includes a number of direct medical services, also
	 known as Direct Services that may include: physical, occupational, speech
	 therapies, etc. These services are reimbursable by Medicaid if they are
	 determined to be medically necessary in accordance with Medicaid policy, are
	 part of the Medicaid-eligible recipient's IEP or IFSP for the treatment of an
	 identified medical condition, and are provided by a qualified professional.
	 Staff that fall under this description and are involved in these types of
	 activities are included in Cost Pool 1.
In addition, school staff may be involved in administrative services in
	 support of the Medicaid Program although they are not involved in the provision
	 of direct services or direct-service providers. These activities may include,
	 but are not limited to: Medicaid outreach; facilitating Medicaid eligibility
	 determinations; translations related to Medicaid services; program planning,
	 policy development, and interagency coordination related to medical services;
	 medical/Medicaid-related training; referral, coordination, and monitoring of
	 Medicaid services; and scheduling referrals for medical services. Staff that
	 fall under this description are considered "non-Direct Service" providers and
	 are included in Cost Pool 2.
3.
Sample Universe
A basic step in the development of an approvable time-study is the
	 determination of the sample universe. That is, school district staff/person(s)
	 who will participate in (be sampled under) the time-study. All staff will be
	 reported into one of two cost pools: "Cost Pool 1" or "Cost Pool 2", and the
	 following provides an overview of the eligible categories in each cost
	 pool.
4.
Cost Pool
  1
Staff that participate in administrative activities and are eligible to
	 submit claims for the Direct Service (DS) Program are included in Cost Pool 1.
	 The RMTS Study will also be utilized to determine Direct Service cost
	 reimbursement. Cost Pool 1 staff includes:
Occupational Therapist, Licensed
Occupational Therapy Asst, Licensed
Occupational Therapy Paraprofessional (Supervised)
Physical Therapist, Licensed
Physical Therapy Assistant, Licensed
Physical Therapy Paraprofessional (Supervised)
Physician
Psychologist, Provisionally Licensed
Psychologist, Licensed
Independent Mental Health Practitioner, Licensed (LIMHP)
Mental Health Practitioner, Licensed (LMHP)
Mental Health Practitioner, Provisionally Licensed (PLMHP)
Alcohol and Drug Counselor, Licensed (LADC)
Alcohol and Drug Counselor, Provisionally Licensed
Behavioral Analyst, Board Certified
Behavioral Analyst Assistant, Board Certified
Behavioral Technician, Registered
Registered Nurse (RN), Licensed
Practical Nurse (LPN), Licensed
Health Technician (Supervised)
Health Paraprofessional (Supervised)
Audiologist, Licensed
Speech Pathologist, Licensed
Speech Pathologist, Medicaid Enrolled
Speech Paraprofessional (Supervised)
Personal Assistant Service Provider
Optometrist, Licensed
Ophthalmologist, Licensed
5.
Cost Pool 2
Staff included in Cost Pool 2 are non-Direct Service personnel that are
	 involved in administrative activities. In addition to the categories listed
	 below, if an LEA or ESU identifies a staff member who typically or potentially
	 performs allowable Medicaid administrative functions: the district may seek
	 permission from the DHHS Program Manager to include those additional staff
	 members.
Aides
Bilingual Specialist
Counselor
Diagnostician
Interpreter
Orientation and Mobility Specialist
Principal/Asst Principal
Program Specialist
Special Education Administrator/Asst
Special Education Teacher
Student Services Personnel
Social Worker, Bachelors Level (BSW)
Social Worker, Masters Level (MSW)
Medicaid administrative activities may be performed by school employees
	 who also provide direct medical services (e.g., nurses, physical therapists,
	 educational staff such as the Director of Exceptional Student Education and
	 teachers' aides). However, if the costs of such staff are completely offset,
	 there would be no purpose to include them in the sample universe. That is, only
	 staff for whom some costs remain after any applicable offsets should be
	 included in the time-study. For example, if federal funding sources or third
	 party payors other than Medicaid meet 100 percent of the costs of social
	 workers, there would be no reason to include such workers in the time-study and
	 they must be excluded from participation. Furthermore, due to the offset, costs
	 of such staff would also not be included in the costs to be allocated.
It may also be appropriate to exclude certain other workers from the
	 study. For example, medical staff hired by the schools as contractors and
	 reimbursed on a fixed fee basis such as audiologists paid a set amount for each
	 hearing test performed and others who do not perform any other administrative
	 activities should not be included in the time-study. Such workers should not be
	 included in the sample universe and therefore their costs would be excluded
	 from the base to be allocated.
Allocation of certain costs required to be funded by sources other than
	 the Medicaid program may need to be offset from Medicaid costs or may be
	 precluded from allocation to the Medicaid program. However, school staff whose
	 salary costs are not entirely met by one or more federal grant(s) may be
	 eligible to be included in the sample. Thus, if funds from an educational grant
	 pay only a percentage of the individual's costs, that person can be sampled as
	 long as the costs are offset by the funds from the educational grant. Also, any
	 matching funds required by the educational grant should be excluded. In
	 addition, staff members such as physical therapy aides may need to be included
	 in the sample universe and not simply allocated based on the activities of
	 associated professionals (e.g., physical therapists).
If a time-study participant's salary is funded by local public school
	 dollars, staff can be included in the sample universe. If third party funds
	 only partially cover the salary, staff can be included in the time-study but
	 such amounts need to be applied in offsetting the claims made under the
	 Medicaid program. The determination of which employees should be included in
	 the sample universe and which costs of such employees should be included in the
	 cost-pool and the conditions associated with the funding source must all be
	 considered in determining the universe of participants for the
	 time-study.
A list of the job titles of school staff who participate in Medicaid
	 administrative activities and therefore would be included in the sample
	 universe should be maintained.
6.
Sampling
Once compiled statewide, each cost pool is sampled to identify
	 participants in the RMTS time study. The sample is selected from each statewide
	 cost pool, along with the total number of eligible time study moments for the
	 quarter. Using a statistically valid random sampling technique, the desired
	 number of random moments is selected from the total pool of moments. Next, each
	 randomly selected moment is matched up using a statistically valid random
	 sampling technique, with an individual from the total pool of
	 participants.
Each time the selection of a moment and the selection of a name occurs,
	 both the minute and the name are returned to the overall sample pool to be
	 available for selection again. In other words, the random selection process is
	 done with replacement so that each moment and each person are available to be
	 selected each time a selection occurs. This step guarantees the randomness of
	 the selection process.
Each selected moment is defined as a specific one-minute unit of a
	 specific day from the total pool of time study moments and is assigned to a
	 specific time study participant. Each moment selected from the pool is included
	 in the time study and coded according to the documentation submitted by the
	 employee.
7.
Process
  for Participating in the RMS Time Study
The RMS time study model is used to measure the percentage of time
	 school district staff spends in performance of Medicaid administrative and
	 direct service activities by sampling and assessing the activities of a
	 randomly selected cross-section of individuals included in Cost Pool 1 and Cost
	 Pool 2. These individuals are queried at random over a billing quarter about
	 their activities during a specified moment on a certain date. The results of
	 these queries are then tallied and averaged for the quarter; these averages
	 total the reimbursable amount that each school district is eligible to receive
	 for that quarter. The sampling period is defined as the same three-month period
	 comprising each quarter of the federal calendar.
To participate in the state-administered RMS, the steps outlined below
	 are followed:
1. Identify total pool of
  time study participants
2. Identify
  total pool of time study moments
3.
  Randomly select moments and then randomly match each moment to a
  participant
4. Notify selected
  participants about their selection
5. Complete time study coding
8.
Identify Total Pool of Time Study
  Participants
Prior to the beginning of each quarter, participating LEAs and ESUs
	 submit a staff roster (Participant List) providing a comprehensive list of
	 staff eligible to participate in the RMS time study.
This list may include vacant positions that are planned to be filled
	 during the reporting quarter. If a vacant position is filled during the
	 quarter, the individual will complete the time study (if sampled), and actual
	 costs incurred for the position during the quarter are eligible to be reported.
	 If a vacant position is not filled during the quarter, then any sampled time
	 study moments are coded to Code 11 "Not Worked/Not Paid" and no costs are
	 eligible to be reported. If a position becomes vacated during the quarter and
	 is later filled with a direct replacement, the direct replacement will complete
	 the time study (if sampled), and the proportional costs incurred for both the
	 original participant and direct replacement are eligible to be reported. If the
	 vacated position is not filled during the quarter, then any sampled time study
	 moments are coded to Code 11 "Not Worked/Not Paid" and only those proportional
	 costs eligible during the period staff received compensation can be
	 reported.
The list of names is subsequently grouped into job categories (that
	 describe their job function), and from that list all job categories are
	 assigned into one of two "cost pools" as previously defined. Once the roster of
	 eligible staff is submitted it cannot be updated or changed once the RMTS
	 period begins.
9.
Identify Total Pool of Time Study Moments
The sampling period is defined as the three-month period comprising
	 each quarter of the state Fiscal Year calendar. The following are the quarters
	 followed for the Administrative Claiming program and a time study is performed
	 for each of the quarters, except for the June 1 - August 31 quarter (summer
	 quarter):
* September 1 - November 31
* December 1 - February 28
* March 1 - May 31
* June 1 - August 31
The total pool of "moments" within the time study is represented by
	 calculating the number of working days in the sample period, times the number
	 of work hours of each day, times the number of minutes per hour, and times the
	 number of participants within the time study. The total pool of moments for the
	 quarter is reduced by the exclusion of weekends, holidays and hours during
	 which employees are not scheduled to work. Standard working hours are
	 determined by DHHS, provided to the contractor, and consistently applied across
	 the LEAs and ESUs.
10.
Randomly Select Moments and Randomly Match Each Moment to a
  Participant
Once compiled statewide, each cost pool is sampled to
  identify participants in the RMTS time study. The sample is selected from each
  statewide cost pool, along with the total number of eligible time study moments
  for the quarter. Using a statistically valid random sampling technique, the
  desired number of random moments is selected from the total pool of moments.
  Next, each randomly selected moment is matched up using a statistically valid
  random sampling technique, with an individual from the total pool of
  participants.
Each time the selection of a moment and the selection of a name occurs,
	 both the minute and the name are returned to the overall sample pool to be
	 available for selection again. In other words, the random selection process is
	 done with replacement so that each moment and each person are available to be
	 selected each time a selection occurs. This step guarantees the randomness of
	 the selection process.
Each selected moment is defined as a specific one-minute unit of a
	 specific day from the total pool of time study moments and is assigned to a
	 specific time study participant. Each moment selected from the pool is included
	 in the time study and coded according to the documentation submitted by the
	 employee.
11.
Sampling Requirements
In order to achieve statistical validity, maintain program efficiencies
	 and reduce unnecessary district administrative burden an efficient sampling
	 methodology will be used.
CMS policy permits a 5% precision level for random moment time study
	 results that are used to claim MAC expenditures, as stated in the CMS May 2003
	 Medicaid School-Based Administrative Claiming Guide. However, CMS policy
	 requires a higher 2% precision level for medical assistance (MAP) expenditures
	 claimed under the cost based reporting methodology for its Direct Service
	 Program. As a result, the following sampling methodology is defined for each
	 Cost Pool.
12.
Sampling Methodology - Cost Pool 1 (Direct Service & Administrative
  Providers)
Statistical calculations show that a minimum sample of 2401 completed
	 moments each quarter, per cost pool, is adequate to obtain this precision when
	 the total pool of moments is greater than 3,839,197. Additional moments are
	 selected each quarter to account for any invalid moments. Invalid moments are
	 moments not returned or inaccurately coded.
The following formula is used to calculate the number of moments
	 sampled for each time study cost pool:
Click
	 here to view
Click
	 here to view
Click
	 here to view
The following table shows the sample sizes necessary to assure
	 statistical validity at a 95% confidence level and tolerable error level of 2%.
	 Additional moments will be selected to account for unusable moments, as
	 previously defined. An over sample of 15% will be used to account for unusable
	 moments.
N=
Sample Size Required
Sample Size plus 15% Oversample
100,000
2345
2697
200,000
2373
2729
300,000
2382
2739
400,000
2387
2743
500,000
2390
2745
750,000
2393
2752
1,000,000
2395
2754
3,000,000
2399
2759
>3,839,197
2401
2761
13.
Sampling Methodology - Cost Pool 2 (Administrative Services Providers
  Only)
CMS policy permits a 5% precision level for random moment time study
	 results that are used to claim MAC expenditures, as stated in the CMS May 2003
	 Medicaid School-Based Administrative Claiming Guide. The RMTS sampling
	 methodology for Cost Pool 2 must meet federal reporting and documentation
	 requirements, and is designed to permit a level of precision of +/- 5% (five
	 percent) with a 95% (ninety-five percent) confidence level for activities.
	 Calculations show that a minimum sample of 385 completed moments each quarter
	 is adequate to obtain this precision when the total pool of moments is greater
	 than 222,639. Additional moments of a 15% oversample should be selected each
	 quarter to account for any lost moments (observations that cannot be used for
	 analysis, i.e., incomplete moments or moments selected for staff no longer at
	 the district, etc.).
Moments not returned by the school district will not be included in the
	 database unless the return rate for valid moments is less than 85%. If the
	 statewide return rate of valid moments is less than 85%, all non-returned
	 moments will be included and coded as non-Medicaid.
To assure that districts are properly returning sample moments,
	 districts' return percentages for each quarter will be analyzed. If an
	 individual district has non-returns greater than 15% and greater than five (5)
	 sampled moments for a quarter, HHS may take appropriate action using sanctions,
	 which may include but not be limited to conducting more frequent monitoring
	 reviews, eliminating the school district's claimed portion of federal funds, or
	 ultimately, termination of the school district's participation.
Nebraska requires a state-wide response for the time-study survey of at
	 least 85%. Moments that have been inaccurately coded shall be returned to the
	 district/ESU for correction and every effort shall be made to obtain the
	 corrected valid moment from the district/ESU. Moments not returned or not
	 accurately completed and subsequently resubmitted shall not be included in the
	 data base. If the return rate of valid moments is less than 85%, non-returned
	 moments shall be included and coded as non-allowable until an 85% compliance
	 rate is obtained. To ensure that enough moments are received to have a
	 statistically valid sample, a minimum of 15% oversampling should be used.
	 Districts/ESU must submit completed moments within five (5) working days after
	 the sampled moment. To assure that districts/ESU's are properly returning
	 sample moments, return percentages for each quarter shall be analyzed (See Item
	 7 below for further Validation requirements).
The State shall be notified of any district/ESU that has non-returns
	 greater than 15% and more than five (5) moments for a quarter. The State in
	 turn will issue a warning in writing to the district/ESU requesting that a
	 corrective action plan be submitted to the State within thirty (30) days of the
	 warning letter. The plan should detail the district/ESU's methodology for
	 increasing its response rate. If the district/ESU has a non-response rate
	 greater than 15% for two (2) successive time-study periods, it will not be able
	 to participate for the entire fiscal year (Sep-Aug) and must return any payment
	 made for the defaulted fiscal year.
14.
Treatment of Summer Period
The summer period is distinguished from the regular school year and
	 refers to the period between the end of one regular school year and the
	 beginning of the next regular school year. In general, a time-study is
	 developed and conducted with respect to a particular period and must represent
	 and incorporate the actual activities performed during that period. The
	 timestudy mechanism and the associated application are then used to allocate
	 the costs associated with the activities performed during the period.
Costs incurred during a summer period may relate to costs and
	 activities associated with the regular school year and therefore, sometimes
	 special treatment is necessary. The summer (break) period refers to the period
	 between the end of one regular school year and the beginning of the next
	 regular school year. Often, in the school setting, costs related to the regular
	 school year are connected to the summer period. That is, salaries/benefits may
	 continue to be paid to time-study participants during the months of the summer
	 period even though the costs of these continuing salary payments during the
	 summer represent and reflect activities actually performed during the regular
	 school year.
The time-study methodology for addressing the summer period must
	 reflect the practices of the applicable claiming unit related to the summer
	 period. The treatment of continued salary and related costs that are actually
	 paid during the summer but which reflect and represent activities actually
	 performed during the regular school year must be distinguished from the
	 treatment of salary and related costs that are paid during the summer and
	 reflect activities actually performed during the summer. For example, a
	 time-study performed during the summer period would not be appropriate to use
	 for purposes of allocating those salary costs paid during the summer period if
	 such costs represent activities actually performed during the regular school
	 year. In that regard, time-studies performed during the regular school year
	 would represent and be appropriate for allocating the costs of the continued
	 salary payment from the regular school year that are paid during the
	 summer.
As indicated, results of time-studies performed during the regular
	 school year would be applied to allocate the associated salary costs paid
	 during the summer. In general, this is acceptable if administrative activities
	 are not actually performed during the summer break but salaries reflecting
	 activities performed during the regular school year are prorated over the year
	 and paid during the summer break. However, if activities are actually performed
	 during the summer period, application of the results of time-studies from the
	 regular school year would not accurately reflect the costs associated with the
	 summer period activities. In those cases, timestudies would also need to be
	 conducted with respect to summer periods.
In Nebraska, school staff members are often paid for a nine-month
	 school year but their salaries paid over 12 months. Sampling during the 9
	 months, therefore, identifies activity related to salaries better than a sample
	 over the 12-month period. In lieu of using the standard time-study concept
	 during the fourth (summer - June, July, August) quarter, school districts may
	 use an average of the time-study results from the preceding three (3) quarters.
	 The fourth quarter encompasses the summer months when a systematic sampling
	 would find few school staff at work. This sampling average will be applied to
	 the fourth fiscal quarter's financial information to formulate the
	 claim.
15.
Time-Study
  Documentation
As with all administrative costs that are related to time-study
	 activities, there must be documentation of the costs for which FFP will be
	 claimed under Medicaid. Documentation to be retained must support and include
	 the following: sample universe determination, sample selection, sample results,
	 sampling forms, cost data for each school district and summary sheets showing
	 how each school district's claim was compiled. All claims by the LEA's and
	 schools are summarized and submitted to
DHHS
for
	 payment. The individual sample sheets may or may not be kept locally. Sometimes
	 individual sheets are maintained locally while summary records are maintained
	 at a central location.
[Nebraska] DHHS allows operational flexibility for validating the
	 results of time-studies related to administrative activities. For example,
	 administrative claims could be compared to parallel claims for direct services
	 under Medicaid. However, regardless of the validation mechanism that is
	 employed, appropriate documentation supporting claims must be maintained and
	 available for audit purposes. DHHS and CMS work together to develop an
	 acceptable validation mechanism.
16.
Training for Staffing
  Time-study
All staff in the sample universe should be adequately trained before
	 completing a sampled moment. Periodic staff education is essential for proper
	 administration of the Medicaid EPSDT and NEBMAC programs. All district staff
	 should become aware of the EPSDT program and its health benefits to eligible
	 students through district-wide in-service awareness programs.
Without proper NEBMAC program training, data collected and used to
	 generate billable charges will have little, if any, validity or reliability.
	 Absent such, districts could not substantiate their charges and some or all
	 funds paid would likely be disallowed and recouped. The procedures recommended
	 herein and those which are to be included in the methodology are intended to
	 assure the development of a complete, valid and reliable record of employee
	 time and effort regarding program billings.
The objective of training staff for participation in the RMTS is to
	 teach the:
1. Goals and overview of
  the NEBMAC program;
2. Instructions
  regarding the accurate completion of the RMTS time survey; and Importance of
  the accuracy of the participants' documentation to the district's overall
  effort.
It is important that the cost-pool staff realize what NEBMAC, outreach
	 to children and wellness education means to them. Training should prepare the
	 sampled participant to understand the purpose of the time-study and to be able
	 to accurately document their activity during their sampled moment. Staff should
	 know the difference between health related and other activities. Professional
	 staff must understand the distinctions between the performance of
	 administrative activities and direct medical services.
Time study participants are notified via email to participate in the
	 time study and of their sampled moment. Sampled participants will be notified
	 of their sampled moment no earlier than forty-eight (48) hours prior to their
	 sampled moment. At the prescribed moment, each sampled participant is asked to
	 record and submit his/her activity for that particular moment. The sampled
	 moment has a three (3) day response window. After the three (3) day response
	 time has expired, the participant's login will not work and they will no longer
	 be able to respond to the time study.
All staff training materials used by school districts must be approved
	 by [Nebraska] DHHS prior to use for compliance with State methodology. Failure
	 to do so may invalidate claims. Notification of training sessions must be made
	 by the school district or consultant to DHHS in advance of training so that
	 Agency staff may observe.
17.
Monitoring Process
Each school district or its contractor/consultant must maintain
	 separate audit files for each quarter billed. The following documentation is
	 required:
* Completed RMTS surveys;
* A copy of the summary of time-study compliance;
* School location and costs paid for each group member in the cost-pool
	 master list, employees and contracted personnel;
* Upon request of the auditor, contracts of contracted
	 employees;
* Any computations or allocations used in reimbursement calculations
	 and written explanations;
* A detailed listing of all revenues offset by the claim by
	 source;
* Copies of training materials given to staff;
* Names of attendees and instructors for the training session given for
	 that quarter;
* A completed quarterly claim; and
* Organizational charts, job descriptions or other documents
	 establishing supervisory relationships
must be available for
	 audit.
The above listed audit files should be retained by each school district
	 for a period of five (5) years after the quarterly claim is filed with DHHS
	 unless an ongoing audit or resolution of an audit exception in process. This
	 data is essential to conducting periodic audits of billings. Lack of such
	 documentation may lead to the disallowance of costs by DHHS and the school
	 district or ESU could be forced to repay such costs.
18.
Validation Process
In order to ensure that the time-study results are valid, the sampling
	 methodology must be monitored for each participating school district and ESU.
	 Yearly, sampling of claims of participating entities should be selected for
	 review to verify time-study activities, statistics and claiming activities.
	 Such reviews will include examination of calculations of time-study documents,
	 processes and claim documents, and should involve 10% of the time study sample.
	 DHHS employees or its agent may conduct these reviews. School districts will be
	 notified in advance of any planned site visits in connection with
	 reviews.
For each claim submitted for payment, DHHS also validates the claim
	 calculations and the application of Medicaid Eligibility and indirect cost
	 rates.
C.
Offset of Revenues
Certain revenues must offset allocation costs in order to reduce the
	 total amount of costs in which the federal government will participate. To the
	 extent the funding sources have paid or would pay for the costs at issue,
	 federal Medicaid funding is not available and the costs must be removed from
	 total costs (See OMB 2 CFR Part 225, Attachment A, Part C., Item 4.a.). The
	 following include some of the revenue-offset categories which must be applied
	 in developing the net costs:
* All federal funds:
* All state expenditures which have been previously matched by the
	 federal government including but not limited to Medicaid funds for medical
	 assistance such as the payment rate for services under fee-for-service;
* Insurance and other fees collected from non-governmental sources must
	 be offset against claims for Medicaid funds;
* All applicable credits must be offset against claims for Medicaid
	 funds. Applicable credits refer to those receipts or reduction of expenditure
	 type transactions that offset or reduce expense items allocable to federal
	 awards as direct or indirect costs;
* A program may not claim any federal match for administrative
	 activities if its total cost has already been paid by the revenue sources
	 above. A government program may not be reimbursed in excess of its actual
	 costs, i.e., make a profit.
* The administrative costs incurred by DHHS to administer the School
	 Based Admin program are: salaries, benefits, operating costs, and allocated
	 costs (per the Nebraska Cost Allocation Plan). These costs are reported on the
	 CMS-64.10 Base Line 29.
* DHHS will refund 50% of that fee to CMS and will be reported on form
	 CMS 64-10 Base, Line 19.
* DHHS will subtract the amount received for the 3% fee from the total
	 paid to the schools as a cost allocation adjustment and report the net amount
	 CMS 64.10 Base form, Line 19. This will occur each quarter as part of the
	 normal cost allocation adjustment process prior to running the final cost
	 allocation module (distribution) in Enterprise One (NIS).
D.
Cost Allocation
  Plans
Requirements for the development, documentation, submission,
	 negotiation and approval of public assistance cost allocation plans are set
	 forth in Subpart E of 45 CFR Part 95 and ASMB C-10. All administrative costs
	 (direct and indirect) are normally charged to federal awards by implementing
	 the public assistance cost allocation plan (CAP). OMB 2 CFR Part 225, Cost
	 Principles for State, Local and Indian Tribal Governments - Attachment D -
	 extends these requirements to all federal agencies whose programs, including
	 Medicaid, are administered by a state public assistance agency. 2CFR Part 225
	 policy is that state public assistance agencies will develop, document and
	 implement and the federal government will review, negotiate and approve public
	 assistance CAP's.
In accordance with the federal regulations indicated above and 2 CFR
	 Part 225, a public assistance CAP must be amended and approved by the Division
	 of Cost Allocation (DCA) within DHHS before FFP is available for administrative
	 claims in the Medicaid program. In this regard, public assistance CAP's must
	 provide, in accordance with the approved interagency agreements, for
	 reimbursement of the administrative activities performed in the school setting
	 and for which claims will be made by the LEA's, school districts and schools to
	 DHHS The public assistance CAP must make explicit reference to the
	 methodologies, claiming mechanisms, interagency agreements and other relevant
	 issues that will be used by the LEA's, school districts and schools for making
	 such claims and appropriately allocating costs. CMS does not have direct
	 authority for approval of the public assistance CAP's. That is the purview of
	 the DCA. However, CMS works directly with the DCA in the public assistance CAP
	 review and approval process. Under this process the DCA will not approve such
	 public assistance CAP's without CMS review and approval of the methodologies
	 referenced in the public assistance CAP. Therefore, referenced elements must be
	 reviewed and approved by CMS before implementation of the school-based
	 administrative claiming program and before the claiming of FFP.
See also Section IV. b Principle 11 titled "Review and Approval of
	 Program and Codes by CMS."
The school-based administrative claiming program must be supported by a
	 system that has the capability to isolate the costs directly related to the
	 support of the Medicaid program from all other costs incurred by the school and
	 that will ultimately be claimed by DHHS as administration. Such costs must
	 comply with the cost allocation principles described in
	 2 CFR Part
	 225 which requires that costs be "necessary
	 and reasonable" and "allocable" to the Medicaid program. Claims for the school
	 district's indirect costs are only allowable when the entity has an approved
	 indirect cost rate issued by the cognizant agency and costs are claimed in
	 accordance with the rate
E.
Administrative Claiming Implementation
  Plan
The implementation plan includes the following elements:
*
Treatment of Indirect Costs:
Indirect costs may be claimed at the restricted or nonrestricted indirect cost
	 rate approved by the cognizant agency responsible for approving such rates.
	 With respect to school-based administrative costs, "cognizant agency" is the
	 U.S. Department of Education or its delegate. In Nebraska, the cognizant agency
	 is the Nebraska Department of Education. NDE's School Finance and
	 Organizational Services section annually calculates indirect cost rates for
	 each local education agency (districts and Educational Service Units), and
	 submits the cost allocation plan to the U.S. Department of Education for
	 approval. Once approved, restricted and unrestricted indirect cost rates are
	 available at
http://www.education.ne.gov/fos/ASPX/IndirectCost/Default.aspx
.
	 The school district must certify that costs claimed as direct costs do not
	 duplicate those costs reimbursed through application of the indirect cost
	 rate.
*
Certified Public Expenditures
:
	 Administrative payments for school-based services will be made utilizing
	 certified public expenditures (CPE) to satisfy the state match requirements
	 under Medicaid. There are sufficient
local
funds to match
	 Title XIX expenditures and the funds are not already being used to match
	 federal funds of other federal programs or being reimbursed by other federal
	 grants.
*
Description of Current Administrative Activities
	 Paid by Medicaid
: Administrative case management will
	 usually not include the full development, implementation and monitoring of a
	 care or treatment plan for individual students. Other contractors/providers of
	 DHHS, including managed care plans, managed care organizations and public
	 health nurses are responsible for the primary care planning and management in
	 some areas of the state. School districts will be made aware of the existence
	 of such contractors/providers in their areas and are expected to coordinate
	 with them.
*
Time-study Plan
: The
	 implementation plan includes details regarding the sampling methodology for
	 selecting time-study participants including the types of job classifications
	 eligible to be sampled, selection of time-study moments and provisions for
	 applying a 95 percent or higher confidence level or some other statistically
	 valid measure to the timestudy.
F.
Timely Filing
  Requirements:
Medicaid law requires that DHHS file a claim for FFP within a two-year
	 period that begins on the first day of the calendar quarter immediately
	 following the quarter in which the expenditure was made by the school district
	 or ESU. Federal regulations indicate that a state agency's expenditure for
	 administration is considered to have been made in the quarter the payment was
	 actually made by DHHS. Therefore, we ask that school districts and ESU's file
	 their claims within fifteen (15) months of the end of the quarter activities
	 are/were provided.
G.
State Law Requirements
The OMB 2 CFR Part 200 - Super Circular states: "To be allowable under
	 federal grants, costs must meet the following criteria ....be authorized or not
	 prohibited under state or local laws and regulations." Thus, FFP for
	 school-based services and administrative outreach claims are not available if
	 school districts and ESU's are not in compliance with state statutes. If there
	 is a question of whether the school district or ESU is in violation of state
	 law, a legal opinion should be sought.
H.
Provider
  Agreements
In order for a school or an ESU to participate as a provider of
	 services and receive FFP through the Medicaid program for those services, it
	 must have an intergovernmental agreement with the state. The basis and
	 authority for this requirement can be found at Sections 1902(a)(4),
	 1902(a)(27), 1902(a)(57) and 1902(58) of the Act and implementing regulations
	 at 42 CFR
	 431.107. Schools do not need to be Medicaid
	 providers in order to participate in Medicaid administrative claiming but there
	 are some administrative activities that schools will not be eligible to receive
	 FFP for unless they have a provider agreement. For example, a school or
	 claiming unit that has an agreement with DHHS to claim administrative costs can
	 provide and receive FFP for, Medicaid outreach activities regardless of whether
	 the school participates as a provider in the Medicaid program. However, if the
	 school does not participate as a provider in the Medicaid program, it cannot
	 bill Medicaid for the cost of direct medical services provided by school staff
	 (e.g., physical therapists). Furthermore, since the Medicaid program would not
	 reimburse for any of the services provided by the school due to its lack of a
	 provider agreement, costs of administrative activities in support of those
	 services such as referrals by the school would not be reimbursable under
	 Medicaid as administration.
I.
Transportation as
  Administration
School-based administration claimed in Nebraska does not include actual
	 transportation costs.
APPENDIX A - General Federal Overview of the Medicaid and IDEA
	 Programs and the Applicability of School-based Administrative Claiming to these
	 Programs
A number of federal, state and local programs operate in the school
	 setting, only some of which may focus on traditional education goals.
	 Interaction and overlap among these programs often provide numerous benefits to
	 children, although sometimes with an additional burden in administrative
	 complexity on the part of program administrators. The following section
	 contains a brief overview of the Medicaid program as it operates in the school
	 environment and the Individuals with Disabilities Education Act (IDEA). These
	 two (2) federal programs, Medicaid and IDEA, with distinct and separate
	 statutory authorities, are closely linked in the school setting even though
	 their underlying purposes and perspectives differ. In order to understand the
	 procedures for claiming school-based administrative expenditures under
	 Medicaid, it is important to consider both Medicaid and Education
	 perspectives.
A.
Medicaid
1.
Medicaid's Role In School-Based
  Health Services Programs
Schools have been at the forefront in developing and implementing
	 programs to increase access to medical services for children. CMS has long
	 recognized that school-based health services play an important role in ensuring
	 that children and adolescents receive needed health care in a setting that is
	 appropriate while ensuring that there is minimum disruption in the educational
	 process.
In 1988, Medicaid's role in supporting school-based health care was
	 greatly expanded by the enactment of the MCCA, P.L.
				  100-360. It clarified in Medicaid statute that the Medicaid program is
	 primary to the IDEA program in paying for the costs of direct medical services
	 provided to Medicaid-eligible children with special health care needs
	 identified pursuant to IDEA. Each child eligible under IDEA must have an IEP or
	 IFSP which includes a statement of the special education and related services
	 to be provided to or on behalf of the child. These services include needed
	 school-based services that are considered medical services by Medicaid that may
	 be covered under the Medicaid program.
Many school-based health programs deliver a broad range of services
	 that are covered by Medicaid affording access to care for children who might
	 otherwise go without needed services. For Medicaid to cover school-based
	 services they must be primarily medical and not educational in nature. The
	 services must be provided by a qualified Medicaid provider to children in
	 families that meet Medicaid income eligibility requirements and they must be
	 considered medically necessary for the child. The services may include:
* routine and preventive screenings and examinations;
* diagnosis and treatment of acute, uncomplicated problems;
* monitoring and treatment of chronic medical conditions; and
* provision of medical services to children with disabilities under
	 IDEA.
Administrative activities in support of services that are not included
	 in an IEP or IFSP and that are provided to Medicaid children in schools are
	 usually not Medicaid coverable because most of these services are generally
	 provided free of charge to non-Medicaid children. Such services include primary
	 and preventive services provided by nurses or other qualified professionals in
	 the school setting such as dispensing medication, attending to acute
	 non-emergent problems (sore throat, earache, etc.), well-child examinations and
	 vision and hearing screenings. (Free-Care and TPL are addressed in Section IV.
	 b Principle 12. and Section V. j of the Guide.)
2.
Early and Periodic Screening,
  Diagnosis and Treatment (EPSDT)
The Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
	 program is Medicaid's comprehensive and preventive children's health program
	 that emphasizes the early assessment of children's health care needs through
	 periodic examinations. EPSDT is a unique benefit in Medicaid because the scope
	 of required services can be broader than what is otherwise included under a
	 state's general Medicaid state plan. EPSDT is a required state plan service
	 that by statute includes any necessary coverable services under Section 1905(a)
	 of the Social Security Act (the Act) (42 U.S.C. 1396d) whether or not
	 those services are covered under the state plan. While the EPSDT program may be
	 known by other, more descriptive names in different states (i.e., Well Child
	 Care, Health Check, KIDMED), basic elements are similar in order to meet
	 federal requirements. Still, states have considerable discretion in
	 administering their EPSDT programs as long as they comply with federal
	 requirements. In many states schools play a large role in many EPSDT
	 activities, particularly with respect to outreach, screening, diagnosis and
	 treatment. In Nebraska, EPSDT services are referred to as "Health
	 Check."
a.
EPSDT
  Screening
Schools often deliver screening services that comport with EPSDT
	 requirements. Screenings include: a comprehensive health and developmental
	 history, a comprehensive unclothed physical exam, appropriate immunizations and
	 laboratory tests. Health education and anticipatory guidance are also an
	 integral part of an initial or periodic screen.
b.
EPSDT
  Treatment
The EPSDT program requires a state Medicaid agency to cover necessary
	 health care, diagnostic services and treatment that is within the federal
	 Medicaid framework to "correct and ameliorate" defects and physical and mental
	 illnesses and conditions discovered by screening, whether or not those services
	 are otherwise available under the state plan to individuals, age 21 and older.
	 While EPSDT has tremendous potential for increasing health care services
	 provided to the eligible population, certain restrictions apply. In order for
	 Medicaid to pay for a medical service provided to a child or adolescent, any
	 service must meet a number of federal coverage requirements. The services must
	 be described under a service category referenced in Section 1905(a) of the Act
	 (42 U.S.C.
	 1396d) , it must be medically necessary and
	 it must be provided by a qualified Medicaid provider. In the school, just as in
	 any other setting, federal policies on FFP in the Medicaid program must be
	 followed with respect to the 1988 legislation which revised Section 1903(c) of
	 the Act (42 U.S.C.
	 1396b(c)) regarding IDEA,
	 free-care exclusion rule and third party liability.
(Free-Care and third party liability are addressed in Section IV. b
	 Principle 12 and Section V. j of the Guide.)
c.
EPSDT Administrative
  Claiming
The EPSDT administrative requirements found in Section 1902(a)(43) of
	 the Act (42 U.S.C.
	 1396a(a)(43)) are part of
	 the legal basis and authority for obtaining FFP for administrative costs
	 associated with health care provided in or by schools. The following
	 administrative activities are a required part of any state's EPSDT
	 program:
* informing Medicaid eligible individuals about the availability of
	 EPSDT services;
* providing or arranging for the provision of EPSDT screening
	 services;
* arranging for (directly or through referral to appropriate providers
	 or agencies) needed corrective and ameliorative treatment;
* assisting families identifying and choosing Medicaid providers;
	 and
* conducting follow-up to ensure children receive needed diagnosis and
	 treatment.
The EPSDT requirement to inform children and families of the
	 availability of EPSDT services is done at the time of enrollment and
	 periodically thereafter as necessary.
3.
Children's Health Insurance Program
  (CHIP)
The State Children's Health Insurance Program (CHIP) specified under
	 Title XXI of the Act enables states to provide health insurance to children in
	 families with incomes too high to qualify for the Medicaid program but too low
	 to afford private health insurance. CHIP coverage is provided by states through
	 separate Title XXI state child health programs, Title XXI Medicaid expansions
	 or a combination of both. Nebraska's CHIP program is a Medicaid expansion. All
	 states have approved CHIP plans and receive enhanced federal matching payments
	 for CHIP expenditures up to a fixed state CHIP allotment that varies on a
	 federal fiscal year basis. States may spend up to 10 percent of their total
	 annual CHIP expenditures (federal and state) on non-benefit activities
	 including: outreach conducted to identify and enroll children in CHIP;
	 administration costs; health services initiatives and other child health
	 assistance.
Outreach activities related to a state's separate Title XXI CHIP
	 program are funded under the state's available Title XXI CHIP allotments.
	 However, outreach activities provided with respect to a CHIP-related Medicaid
	 expansion are funded at the state's option either from the state's CHIP
	 allotment or from regular Medicaid funding. Joint outreach efforts for Medicaid
	 and CHIP may similarly be matched by either Medicaid or CHIP. Under the
	 provisions of OMB 2 CFR Part 225 and associated regulations, costs that are
	 common to more than one (1) program are generally allocated to the related
	 programs in accordance with the relative benefits received by each program.
	 However, CHIP statute(s) provide for an exception to this general cost
	 allocation principle, allowing states some flexibility in claiming FFP for
	 outreach activities. Detailed guidance on these state options is available on
	 the CMS CHIP web site:
http://www.insurekidsnow.gov/index.html
Nebraska's outreach efforts are not administered through CHIP (Title XXI) but
	 instead funded by its Title XIX (NMAP/Medicaid) program.
B.
Individuals
  with Disabilities Education Act (IDEA)
1.
Purpose of IDEA
The Individuals with Disabilities Education Improvement Act (IDEA) of
	 2004 ( P.L.
				  108446 / 20 USC
	 1400) is the most recent version of this
	 important federal special education law. IDEA was passed to "assure that all
	 children with disabilities have available to them"¦ a free appropriate
	 public education which emphasizes special education and related services
	 designed to meet their individual needs." Specific principles in IDEA
	 include:
* Free Appropriate Public Education (FAPE);
* Appropriate evaluation;
* Individualized Family Service Plan (IFSP) for infants and toddlers
	 (B-2);
* Individual Education Program (IEP) for students with verified
	 disabilities (3-21);
* Least restrictive environment;
* Parent and student participation in decision-making; and
* Procedural safeguards.
In the context of IDEA, "Free Appropriate Public Education" means that
	 special education and related services that meet the standards of the state
	 education agency are provided to children with disabilities at public expense
	 under public supervision and direction and without charge. The public school
	 system must serve disabled children by responding to their individual needs,
	 regardless of the nature or severity of their disabilities.
* "Special education" is defined at 34 Code of Federal Regulations
	 (CFR) 300.26 to mean specially designed instruction which meets the unique
	 needs of the child and includes instruction conducted in the classroom, in the
	 home, in hospitals, in institutions, in other settings and instruction in
	 physical education.
* "Related services" are defined at
	 34 CFR
	 300.34 as "transportation and such
	 developmental, corrective and other supportive services as are required to
	 assist a child with a disability to benefit from special education." "Related
	 Services include:
i. Counseling
  services;
ii. Early identification
  and assessment of disabilities;
iii. Interpreting services;
iv. Medical services for diagnostic and
  evaluation purposes;
v.
  Occupational therapy;
vi.
  Orientation and mobility services;
vii. Parent counseling and
  training;
viii. Physical
  therapy;
ix. Psychological
  services;
x. Recreation;
xi. Rehabilitation counseling
  services;
xii. School health
  services;
xiii. School nurse
  services;
xiv. Social work services
  in schools; and
xv. Speech-language
  pathology and audiology services.
Not all of the special education and related services required by the
	 IDEA are within the scope of the federal Medicaid program. Only medically
	 necessary IDEA services that are described in the definition of "medical
	 assistance" can be covered as Medicaid services when furnished by qualified
	 participating Medicaid providers.
IDEA authorizes federal funding to states for related services provided
	 to children through a child's Individualized Family Service Plan (IFSP) or
	 Individual Education Program (IEP) including those that are referred to and
	 covered as medical services under Medicaid. Section 411(k) (13) of the Medicare
	 Catastrophic Coverage Act of 1988, P.L.
				  100-360, amended Section 1903(c) of the Act to permit Medicaid payment
	 for medical services provided to children under IDEA through a child's IFSP or
	 IEP. This amendment was enacted to require Medicaid to be primary to the
	 Department of Education for payment of the health-related services provided
	 under IDEA. Medicaid covers services included in an IFSP or IEP under the
	 following conditions:
* The services are medically necessary and included in a Medicaid
	 covered category (speech therapy, physical therapy, etc.);
* All other federal and state Medicaid regulations are followed
	 including those for provider qualifications, comparability of services and the
	 amount, duration and scope provisions; and
* The services are included in the state's plan or available under
	 EPSDT. Further discussion of school based medical services can be found in the
	 guidance document, "Medicaid and School Health: A Technical Assistance Guide,"
	 issued by CMS in August 1997.
2.
ChildFind
Part B, Section 612 (a)(3) of IDEA provides for the identification,
	 location and evaluation of children with disabilities within the state and
	 mandates that a "practical" method be developed and implemented to determine
	 which children with disabilities should be provided services. A state is only
	 eligible for funding under IDEA if the state demonstrates that it meets certain
	 conditions including conducting "ChildFind" activities, as defined in IDEA.
	 These "ChildFind" activities are undertaken to identify children in need of
	 special education and related services. Medicaid is
not
responsible for covering or paying for "ChildFind" or other activities that
	 fulfill education mandates. While ChildFind activities are not claimable as
	 Medicaid administration, there are related activities such as Medicaid outreach
	 which are allowable.
Activities performed for purposes of the Medicaid program such as
	 informing potential eligible children and their families about Medicaid, how to
	 access the program and facilitating the Medicaid application process are
	 included as Medicaid outreach. In contrast, ChildFind is specifically mandated
	 in IDEA and includes activities carried out for educational purposes.
	 Therefore, distinction is made between the educational activities such as
	 ChildFind and Medicaid outreach for purposes of claiming in Medicaid. (See
	 Section IV. b Principle 10 for further information on ChildFind.)
3.
Evaluation and
  Assessment Activities
Part B, Section 614 of IDEA outlines the evaluation process for
	 determining if a child has a disability as defined in Section 602 and
	 determining the educational needs of the child. This section focuses on
	 appropriate evaluation principles and provides protection from unnecessary,
	 costly or inappropriate assessment activities. The evaluation and assessment
	 are conducted to determine if the child has a disability and if the child's
	 particular disability affects the student's educational performance; evaluation
	 and assessment must provide relevant information that directly assists the
	 school in determining the educational needs of the child. Re-evaluation must be
	 accomplished at least every three (3) years for an IEP. These evaluations are
	 conducted, in part, to determine a child's health related needs for purposes of
	 the IEP. (See Section IV. b Principle 10 for further information on IEP-related
	 medical evaluations and assessments.)
4.
Individual Education Program
  (IEP)
For those Nebraska children identified and determined to be disabled in
	 accordance with Section 602 of IDEA, an IEP must be developed by a team of
	 individuals as defined in Section 614. In the case of a child with a
	 disability, age Birth through two (2) years, under certain conditions, an
	 Individualized Family Service Plan (IFSP) may be developed to serve as an IEP.
	 The IEP is statutorily defined as a written statement for each child with a
	 disability that, among other elements, includes:
* A statement of the child's present levels of educational
	 performance;
* A statement of measurable annual goals including benchmarks or short
	 term objectives;
* A statement of the special education and related services and
	 supplementary aids and services to be provided to the child or on behalf of the
	 child and a statement of the program modifications or supports for school
	 personnel that will be provided for the child;
* An explanation of the extent, if any, to which the child will not
	 participate with nondisabled children in the regular class and in the
	 activities described above;
* A statement of any individual modifications in the administration of
	 state or district-wide assessments of student achievement needed for the child
	 to participate in the assessment;
* The projected date for the beginning of services and modifications
	 and the anticipated frequency, location and duration of services and
	 modifications;
* For children age 14 or younger, if appropriate, a statement of
	 transition service needs;
* For children beginning at age 16 or younger, if appropriate, a
	 statement of needed transition services for the student;
* A statement of the child's progress toward annual goals and how the
	 child's parents will be informed of the progress toward the annual goals;
	 and
* Transfer of rights statement.
The phases of the IEP process are generally described as
	 follows:
a.
Pre-IEP
Pre-IEP activities include "ChildFind" activities designed to identify
	 children in need of evaluation and assessment activities performed to determine
	 if the child has a disability as defined by Section 602 of the IDEA and to
	 determine the educational needs of the child. There are no claimable
	 administrative expenditures under Medicaid associated with these pre-IEP
	 activities. Medicaid does not pay for the IEP team meetings or for costs
	 related to attendance at those meetings by medical professionals. However, if a
	 state has opted to include targeted case management in its Medicaid plan as a
	 service, Medicaid may be able to pay for the activities of the child's case
	 manager/services coordinator.
b.
Development of
  IEP
The development of an IEP is a requirement of IDEA with the primary
	 purpose being to facilitate the child's education. Medicaid does not pay for
	 the administrative activities associated with the development of the IEP
	 because it is an education requirement. Once the IEP is established and
	 implemented, however, Medicaid may pay for administrative activities that are
	 directly related to the provision of those Medicaid covered services identified
	 in the IEP and are furnished to Medicaid eligible children.
The IEP is developed by a team of individuals, including:
* The child's parents;
* At least one of the child's regular education teachers and/or one
	 special education teacher or provider;
* A representative of the school district who is knowledgeable about
	 specific curriculum;
* An individual who can interpret the instructional implications of
	 evaluation results;
* Other individuals, at the discretion of the parents or the school
	 district who have knowledge or special expertise regarding the child;
	 and
* The child with the disability, whenever appropriate.
IDEA further specifies that in the development of the IEP, strengths of
	 the child, concerns of the parents for enhancing the education of their child
	 and the results of the initial or most recent evaluation of the child are to be
	 considered. Special factors, such as behavior issues, language limitations,
	 accommodations for visual or hearing impairments and the need for assistive
	 technology devices/services must also be considered in the development of the
	 IEP.
c.
Review/Revision of IEP
The school district is mandated to review the IEP periodically but not
	 less than annually and if needed, to revise the program to address any lack of
	 expected progress toward individually defined goals or to address the results
	 of a re-evaluation of the child. The IEP can be revised at any time if the
	 child is not making expected progress or if new factors arise.
These activities are for the purpose of fulfilling education-related
	 mandates under IDEA. As such, associated costs of these activities are not
	 allowable as administrative costs under the Medicaid program.
A more detailed discussion of IEP's and the IDEA can be found in
	 Section IV.
d.
Individualized Family Service Plan (IFSP)
By Statute, Nebraska is a "birth mandate state." This means that school
	 districts are responsible for the "special education" services required to meet
	 the unique developmental needs of the infant or toddler from the point in time
	 when the child's developmental disability is verified through processes
	 prescribed in IDEA and further defined by the Nebraska Department of
	 Education's "Regulations and Standards for Special Education Programs (Title 92
	 Nebraska Administrative Code Chapter 51).
For each infant and toddler (under 3 years of age) determined to be
	 disabled in accordance with Section 602 of IDEA, an IFSP must be developed in
	 accordance with Section 636 of the Act. The IFSP shall be in writing and
	 contain:
* A statement of the child's present levels of physical development,
	 cognitive development and adaptive development, based on objective
	 criteria;
* A statement of the family's resources, priorities and concerns
	 relating to enhancing the development of the family's infant or toddler with a
	 disability;
* A statement of measurable results or outcomes expected to be achieved
	 for the infant or toddler and the family;
* A statement of the specific early intervention services based on
	 peer-reviewed research to the extent practicable and necessary to meet the
	 unique needs of the infant or toddler and the family;
* A statement of the natural environments in which early intervention
	 (Early Development Network in Nebraska) services will appropriately be
	 provided;
* Projected dates for initiation of services and anticipated length,
	 duration and frequency of services;
* Identification of the services coordinator who will be responsible
	 for the implementation of the plan and coordination of other agencies and
	 persons including transition services; and
* Steps to be taken to support the transition of the toddler with a
	 disability to preschool or other appropriate services.
The phases of the IFSP process are generally described as
	 follows:
e.
Pre-IFSP
Pre-IFSP activities include "ChildFind" activities designed to identify
	 infants and toddlers in need of evaluation and assessment activities performed
	 to determine if the child has a disability as defined by Section 602 of the
	 IDEA and to determine the developmental needs of the infant or toddler and
	 their family. There are no claimable administrative expenditures under Medicaid
	 associated with these pre-IFSP activities. Medicaid does not pay for the IFSP
	 team meetings or for costs related to attendance at those meetings by medical
	 professionals. However, if a state has opted to include targeted case
	 management in its Medicaid plan as a service, Medicaid may be able to pay for
	 the activities of the child's case manager/services coordinator.
f.
Development
  of IFSP
For states like Nebraska who choose to participate, development of an
	 IFSP is a requirement of IDEA with the primary purpose being to facilitate the
	 infant or toddler's development, to minimize their potential for developmental
	 delay and to recognize the significant brain development that occurs during a
	 child's first three (3) years of life. Medicaid does not pay for the
	 administrative activities associated with the development of the IFSP because
	 it is an education requirement. Once the IFSP is established and implemented,
	 however, Medicaid may pay for administrative activities that are directly
	 related to the provision of those Medicaid covered services identified in the
	 IFSP and are furnished to Medicaid eligible children.
The IFSP is a written plan developed by a multidisciplinary team
	 including the parents as required by Section 636 of IDEA.
IDEA further specifies that in the development of the IFSP, strengths
	 of the child, concerns of the parents for enhancing the development of their
	 infant or toddler and the results of the initial or most recent evaluation of
	 the child are to be considered. Special factors, such as behavior issues,
	 language limitations, accommodations for visual or hearing impairments and the
	 need for assistive technology devices/services must also be considered in the
	 development of the IFSP.
g.
Review/Revision of IFSP
The IFSP is to be evaluated once a year and the family shall be
	 provided a review of the plan at six (6) month intervals or more often where
	 appropriate based on the infant or toddler and family need(s). The IFSP can be
	 revised at any time if the child is not making expected progress or if new
	 factors arise.
These activities are for the purpose of fulfilling mandates under IDEA.
	 As such, associated costs of these activities are not allowable as
	 administrative costs under the Medicaid program.
APPENDIX B - CLAIM PROCESS/PROCEDURES
A.
General
Claim preparation requires that the proper training has occurred of
	 sampled staff that random moment time study (RMTS) surveys were completed
	 correctly and the resulting data was accumulated without error. Salary and
	 benefit information for those staff must be correct. The percentage of Medicaid
	 enrolled and potentially eligible students must be accurate.
Claims are prepared once per quarter for that full quarter and must be
	 submitted to [Nebraska] DHHS within one year after the end of each quarter.
	 Claim quarters are defined as follows:
First (Fall quarter): September 1 to November 30
Second (Winter quarter): December 1, to February 28/29
Third (Spring quarter): March 1, to May 31
Fourth (Summer quarter): June 1, to August 31
B.
Data
  Elements
1. Time-study
  Average: Percentage derived by dividing the amount of time determined in the
  time-study by the total work time for personnel in the sample
  cost-pool.
2. Total Personnel
  Related Costs: Total salaries, benefits and other allowable costs incurred
  during the quarter for those personnel in the cost-pool.
3. The federally approved cost allocation
  plan used to determine the non-restricted indirect cost rate, by which salaries
  and benefits are multiplied. The product of this reflects the "overhead"
  administrative expenses required to support the related personnel. NDE is the
  cognizant agency for indirect cost rates for all public school districts and
  ESU's in Nebraska.
4. The Medicaid
  Eligibility Rate [MER] calculated for the school district or ESU.
C.
Claim
  Calculation
Claim calculations will be formatted based on a claim template provided
	 by DHHS' vendor for the school districts and ESU's. Submittal of the invoice
	 and related information must contain all information required by
	 DHHS.