Medicaid Administrative Claiming for Activities Performed by
State Long-Term Care Ombudsman Programs
Medicaid funding may be available for certain administrative costs related to activities performed by state Long-Term Care Ombudsman (LTCO) Programs that benefit the state’s Medicaid program. The information below is intended to provide more detailed guidance regarding claimable and non-claimable LTCO activities.
In order for Medicaid administrative funding to be available, the LTCO must have an interagency agreement or other contractual arrangement with the State Medicaid agency that is supported by an allocation methodology which divides LTCO costs among benefiting programs in accordance with the benefits received so that Medicaid only pays for its fair share. This methodology must be included in the State’s approved Public Assistance Cost Allocation Plan.
The following are some examples of LTCO activities that may be eligible for federal Medicaid administrative funding:
- Education and consultation to potential enrollees on Medicaid eligibility and facilitation of the enrollment process.
- Identifying and referring individuals who may be eligible for and in need of Medicaid services.
- Developing procedures for tracking and reporting consumer requests for assistance with obtaining medical/dental/mental/long-term care (including home and community based) services that are covered by Medicaid
- Consultation and advocacy to assist beneficiaries in transitioning from Medicare Part A coverage into the Medicaid nursing facility benefit.
- Direct case advocacy in transitioning individuals from private pay status into Medicaid funded nursing facility, home and community based services, or other Medicaid service categories.
- Identifying Medicaid-eligible residents who want to transition out of nursing home facilities and then connecting them with the appropriate local contact agency or other services to assist them in returning to the community.
- Identifying and reporting suspected instances of Medicaid fraud to federal and state agencies for investigation and action.
- Identifying gaps or duplication of medical/dental/mental/long-term care services to elders and individuals with disabilities and developing strategies to improve the delivery and coordination of these services for those individuals.
LTCO programs also conduct many activities for older Americans for which Medicaid administrative funding would not be available. For example, allowable Medicaid administrative activities do not include gaining access to or coordinating non-Medicaid social, educational, vocational, legal, advocacy, safety, welfare and or other non-Medicaid health services. Also, LTCO programs authorized by the Older Americans Act (Public Law 89–73) are required by law to operate independently, without interference or influence so there should be mechanisms in place to avoid possible conflicts of interest between operation of the LTCO program and the Medicaid program. In addition, such programs must minimize conflicts with state survey and certification responsibilities.