SECTION I: INTRODUCTION... PAGE 1 SECTION II: TERMS AND DEFINITIONS... PAGE 3

TABLE OF CONTENTS SECTION I: INTRODUCTION... PAGE 1 SECTION II: TERMS AND DEFINITIONS... PAGE 3 SECTION III: HOW A CLAIM IS COMPLETED... PAGE 5 Sources of Data for the Claim... PAGE 5 Calculating the Claim... PAGE 7 SECTION IV: CLAIM SUBMISSION REQUIREMENTS... PAGE 9 Quarterly Claim Certification PAGE 10 Sample Time Study Calculation Detail....... PAGE 11 Sample Detailed Expenditure Report... PAGE 13 Sample Fringe Benefit Calculation... PAGE 15 Sample Claim Calculation Detail... PAGE 16 Sample Capital Calculation Detail... PAGE 20 Sample Quarterly Claim Summary... PAGE 21 SECTION V: TABLES AND CHARTS... PAGE 22

SECTION I: INTRODUCTION This manual is a guide to assist school districts in the Commonwealth of Virginia participating in the EPSDT Administrative Activity Claiming program. The objectives of the program are to identify administrative support costs associated with (1) the delivery of Medicaid-reimbursable health services provided by or through schools to the Medicaid-eligible student population, and (2) health-related activities performed by or through schools that facilitate the administration of the Medicaid program in the Commonwealth. Once these costs are identified on a quarterly basis, the state Medicaid agency, acting on behalf of school districts providing such administrative supports, files a claim for partial federal reimbursement of these expenditures. Federal reimbursement awarded for these expenditures is called federal financial participation (FFP). The basis for the FFP award is that the administrative support activities related to the provision of Medicaid health services in the schools help ensure the integrity and delivery of those services. Because schools are acting, both as health-care providers and as agents of the Medicaid agency, they must be enrolled as Medicaid providers to be able to participate in both the fee-for-service program (i.e., direct medical services provided to special education Medicaid-eligible students) and the EPSDT Administrative Activity Claiming Program, respectively. Enrollment requires that a school district execute a Medicaid provider agreement directly with Virginia s Medicaid agency- the Department of Medical Assistance Services (DMAS). In so doing, a school district agrees to comply with all state and federal Medicaid requirements related to the identification and claiming of Medicaid-reimbursable costs. This guide has been developed in consideration of the requirements to support administrative cost claiming and will facilitate an accurate accounting of appropriate costs by school districts. To capture a portion of the claimable administrative costs, all school direct service personnel and direct support personnel (refer to Page 22, Table I and Page 23, Table II, respectively) or a sample of such personnel must complete a quarterly time study three times per year for a period of five consecutive school days. The quarters are October- December, January-March, and April-June. The beginning day for an LEA s time study in any of the three quarters during which a time study will be conducted will be selected randomly for each LEA. An average of the time study data from the previous three quarters is applied for the fourth quarter, July-September. To capture the balance of claimable administrative costs, the time study data is then combined with (1) expenditure information provided by the school district (salary, fringe benefit, transportation, capital and indirect costs) and (2) the penetration of Medicaid eligible students among the total student population of a district (the Medicaid Eligibility Factor, so called), to calculate the total quarterly administrative expenditure claim. Medicaid program requirements mandate that DMAS periodically review, audit and monitor claims filed by local school districts for reimbursement of administrative costs. Such reviews necessitate that schools maintain all relevant information in a readily 1

reviewable format. DMAS will contact a school district well in advance of any scheduled desk audit or any other formal review. In addition, in order to ensure that the time study is statistically valid (for example, at the 95 percent or higher confidence level for a 5 percent error level), DMAS will also monitor the compliance of the school districts with the requirements of the sampling methodology. If you have any questions regarding the EPSDT Administrative Activity Claiming program, DMAS encourages you to contact the personnel listed below: Chris Owens Maternal and Child Health Coordinator Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 804-786-0342 (voice) 804-225-4393 (fax) cowens@dmas.state.va.us Amy Edwards Medicaid Specialist Virginia Department of Education PO Box 2120 Richmond, VA 23218-2120 804-692-0150 (voice) 804-371-8796 (fax) aedwards@mail.vak12ed.edu Susan Fischer University of Massachusetts Medical School 100 Century Drive Worcester, MA 01606 508-856-7640 (voice) 508-856-7643 (fax) Susan.Fischer@umassmed.edu 2

SECTION II: TERMS AND DEFINITIONS 1. EPSDT Administrative Claiming - The school setting offers unique advantages and opportunities to reach children and families to inform and encourage them to enroll in the Medicaid program as well as to provide assistance to students in accessing medical services. The Center for Medicaid State Operations (CMSO), the federal agency responsible for administration of the Medicaid program, recognizes that certain members of a school staff may spend a significant amount of time on such activities for its students. When administrative activities are found necessary for the proper and efficient administration of the State plan and the students are Medicaid-eligible or potentially eligible for Medicaid (if the activity is Medicaid eligibility outreach), Federal Financial Participation (FFP) may be available. 2. Capital Costs Major movable, building, and equipment costs having a useful life of more than one year. These costs are subject to a use allowance. 3. Direct Personnel - Direct health care providers who are eligible to participate in the time study (refer to Page 22, Table I). 4. Direct Support Personnel - Non-Direct health care providers who are eligible to participate in the time study (refer to Page 23, Table II). 5. DMAS The Commonwealth of Virginia s Department of Medical Assistance Services. 6. DOE - The Commonwealth of Virginia s Department of Education. 7. FFP or Federal Financial Participation- Federal reimbursement that is available for the identification of claimable EPSDT administrative costs. 8. Fringe Benefits - The cost of actual staff benefits (including health and life insurance, unemployment compensation, Medicare and pension contributions, Workers Compensation/injury payments and other benefits) funded from state/local revenues. 9. Gross Claim - The summation of claimable salaries or contractual agreements, fringe benefits, materials/supplies, transportation, indirect, and capital costs. 10. Indirect Cost Rate - The indirect cost rate that is provided by the Commonwealth of Virginia for use by the participating school district or Local Education Agency (LEA). This non-restricted indirect cost rate is based on the Office of Management and Budget Circular A-87/95 indirect cost allocation principles. The methodology used to determine the Non-restricted indirect cost rate specific to each LEA is to be approved by the Federal Cognizant Agency. 3

11. Job Position Grouping Categories of personnel that have been combined into groupings for the purpose of completing the time study. Referred to as job positions 01, 02, 03 and 04. 12. LEA - Local Education Agency. 13. Material and Supply Costs - The cost of actual materials and supplies funded by state/local revenue which are used to assist in the performance of allowable Medicaid administrative activities. 14. Medicaid Eligibility Factor - The ratio of Medicaid eligible students to the number of total students registered in the school district served in the participating Local Education Agency. 15. Net Claim - The product of the gross claim amount multiplied by the appropriate FFP rate. 16. OMB Circular A-87 - Office of Management and Budget Circular A-87, Cost Principles for State, Local, and Indian Tribal Governments. This circular establishes principles and standards for determining costs for Federal awards carried out through grants, cost reimbursement contracts, and other agreements with State and local governments and federally-recognized Indian tribal governments (governmental units). 17. Salary - That portion of the actual salary or contractual agreement funded by state/local revenues that is eligible for claiming during the quarter for which the claim is being submitted. 18. Time Study - The primary mechanism for identifying and categorizing activities performed by direct service personnel and direct support health care providers in a school district. It enables the determination of costs associated with administrative activities so that they may be properly claimed in the EPSDT Administrative Claiming Program. 19. UMMS- The University of Massachusetts Medical School through its Center for Health Care Financing. 4

SECTION III: HOW A CLAIM IS COMPLETED There are two key functions that must be performed by school district personnel in order to facilitate the development of a district s quarterly administrative claim. First, designated school personnel must complete a time study. Second, the district must transmit raw expenditure data to UMMS. Once those functions have been completed, UMMS then (1) performs a quality control screening of the time study data; (2) performs a quality control screening of the raw expenditure data; (3) manipulates the time study information and raw expenditure data to sort out claimable activities and the time spent on those activities; and, (4) applies the Medicaid Eligibility Factor for a district to arrive at a final quarterly claim calculation. The calculation made is of a district s gross expenditures; the federal government will award FFP based on the district s gross expenditures. Prior to filing a district s quarterly gross expenditure calculation for federal reimbursement, UMMS reports the gross expenditure amount back to each district; an authorized district official certifies the claim calculation amount by signing the Administrative Activity Claim Quarterly Claim Certification. (See Page 10) Below is a listing of all the cost components involved in the completion of a claim. Section I: Sources of Data for Claims, provides a listing of the tasks related to the two functions (time study completion and raw expenditure data compilation) that a district must participate in. For each of those tasks, there is a parenthetical notation of whether the task is to be performed by the school district, by UMMS, jointly by the school district and UMMS, or by another party). UMMS will provide technical assistance to school districts to help them perform both the time study function and the expenditure compilation tasks. Section II: Calculating the Claim, describes the steps of the final claim calculation process that UMMS performs for school districts. Section I. Sources of Data for Claim A. Identify Personnel Eligible for Time Study (District and UMMS) B. Time Study Data (including Sampling and Summarizing): i. Sampling - The time study sampling selected for each job position grouping should be both random and at the 95% confidence level, with plus or minus 5% precision. (UMMS) ii. Gathering - Gather all completed bubble-sheets from direct service and direct support personnel and separate them into groups by job position. (District) iii. Summarizing - For each job position grouping calculate the percentage of time spent on each administrative activity (Codes A- Q) in relationship to the total worked time. (Refer to Page 11, Sample Time Study Calculation Detail). (UMMS) 5

C. Cost Pool Data i. Gather actual expenses incurred during the quarter for Direct Service Personnel (refer to Page 22, Table I) from the school district s accounting system. The claimable expense categories are as follows: (District) 1. Salaries or contractual agreements 2. Fringe Benefits 3. Materials and Supplies ii. Gather actual expenses incurred during the quarter for Direct Support Personnel (refer to Page 23, Table II) from the school district s accounting system. The claimable expense categories are as follows: (District) 1. Salaries or contractual agreements 2. Fringe Benefits 3. Materials and Supplies iii. Restricted federal funding should be deducted from the actual expenses, such that only state/local funding sources are included in the expenditure data. (UMMS based on questions to District) D. Medicaid Eligibility Factor i. Gather school district enrollment information including, but not limited to name and date of birth. (District) ii. Gather Medicaid eligibility information from the Department of Medical Assistance Services. (DMAS) iii. Complete a data match to calculate the percentage of Medicaid eligible students per school district. (UMMS or Other TBD) E. Capital i. Identify the acquisition cost of the school district s building and fixed assets. Multiply this result by 2%. (District and UMMS) ii. Identify the acquisition cost of the school district s major movable equipment. Multiply this amount by 6.67%. (District and UMMS) 1. Building, fixed and major movable valuation shall be based on the acquisition cost of the assets involved. Where actual cost records have not been maintained, a reasonable estimate of the original acquisition cost may be used. The asset valuation shall exclude: a. The cost of land. b. Any portion of the cost of school buildings and equipment in satisfaction of a federal matching requirement. c. The annual use allowance calculation for buildings and fixed equipment will be computed at an annual 6

rate not exceeding 2% of the acquisition cost. The annual use allowance calculation for major movable equipment will be computed at an annual rate not to exceed 6.67% of the acquisition cost. d. Assets included in this calculation must be supported by adequate property records. Municipalities will manage equipment in accordance with state laws and procedures. Physical inventories must be taken at least once every two years (a statistical sampling approach is acceptable) to ensure that assets exist and are in use. (OMB Circular A-87) iii. Identify the school district s current interest expense associated with school building acquisition, construction, remodeling and equipment. (District and UMMS) 1. Allowable interest costs incurred as a result of school building acquisition, construction, remodeling and equipment must meet the following conditions: a. The financing is provided by a bona fide third party external to the municipality or school district b. The assets are used in support of the Medicaid Program. c. Earnings on debt service reserve funds are used to offset the current period s internal costs. iv. Add the calculated amounts for building and fixed assets, major movable equipment and interest expense. This amount is the school district s gross claim amount for capital. (UMMS) v. Calculate the capital percentage rate using the ratio of gross capital costs to district wide salaries plus fringe benefits. (Refer to Page 20, Sample Capital Calculation Detail) (UMMS) vi. Apply this percentage rate to the Medicaid administrative direct costs on the quarterly claim summary. (Refer to Page 21, Sample Quarterly Claim Summary). (UMMS) E. Indirect Costs i. Identify the school district s most recent non-restricted indirect cost rate for federal grants by contacting the Virginia Department of Education. (District or DOE) ii. Apply the school district s indirect cost rate for federal grants to the total of Medicaid administrative direct and capital costs in order to calculate the quarterly indirect costs. (Refer to Page 21, Sample Quarterly Claim Summary). (UMMS) Section II. Calculating the Claim (Refer to Sample Claim Calculation Detail) (All tasks in this section are performed by UMMS) a. Calculate percentage of time study per job position grouping. 7

b. Quarterly actual expenses by job position grouping should be allocated to each activity code A-Q, (Refer to Pages 16-19, Sample Claim Calculation Detail) based upon the results of the quarterly time study. c. The Medicaid Eligibility Factor for the district is applied only to actual expenses for Transportation Related Activities in Support of Medicaid Covered Services (activity code H), Translation Related Medicaid Services (activity code J), Program Planning, Policy Development, and Interagency Coordination Related to Medical Services (activity code L), Medicaid Specific Training (activity code N), Referral, Coordination, and Monitoring of Medicaid Services (activity code P). d. Actual expenses allocated to General Administration (activity code Q) should be multiplied by the general administrative overhead factor. If no allowable administrative activities are performed, no time associated with the administrative overhead factor should be included. e. Completing the steps indicated above produces the gross claim amount per administrative activity. f. Multiply the total gross claim amounts by the indirect cost rate to produce the grand total gross claim amount. g. The gross claim amount for each activity code (A-Q) should be multiplied by the FFP rate to produce the net claim amount. The FFP rate for all administrative expense categories is 50%. h. Add the net claim amount for each activity code (A-Q) to produce a total net claim amount. Capital expenses should also be multiplied by the 50% FFP rate. i. No FFP rate is applicable to actual expenses in Non-Medicaid Outreach (Code A), Facilitating Application for Non-Medicaid Programs (Code C), School Related and Educational Activities (Code E), Direct Medical Services (Code F), Transportation for Non-Medicaid Services (Code G), Non-Medicaid Translation Services (Code I), Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services (Code K), Non-Medicaid Training (Code M), and Referral, Coordination, and Monitoring of Non-Medicaid Services (Code O). 8

SECTION IV: CLAIM SUBMISSION REQUIREMENTS 1. Accuracy of the submitted quarterly claim must be certified by the superintendent or chief financial officer of the participating LEA and documented on a Quarterly Claim Certification (See to Page 10). 2. When submitting a school district s quarterly claim, the following items will be included: Quarterly Claim Certification Quarterly Claim Summary Claim Calculation Detail Capital Calculation Detail Fringe Benefit Calculation Detailed Expenditure Report 3. Quarterly claims will be submitted to the Virginia Department of Medical Assistance Services 30 days after end of the quarter. 4. Detailed claim documentation will be maintained for audit or reference purposes. 5. Quarterly Claim Submission Deadlines: July 1- September 30 Due date- October 30 October 1- December 31 Due date- January 30 January 1- March 31 Due date- April 30 April 1- June 30 Due date- July 30 6. Quarterly claims will be submitted to: XXX XXX Administrator Virginia Department of Medical Assistance Services XXXX XXXX (XXX) XXX-XXXX 9

ADMINISTRATIVE ACTIVITY CLAIM QUARTERLY CLAIM CERTIFICATION I certify that to the best of my knowledge, the EPSDT Administrative Claim for the quarter represents actual expenses accumulated under the provider agreement with the Virginia Department of Medical Assistance Services. The claim amount is solely related to our EPSDT Administrative Claim Agreement with the Virginia Department of Medical Assistance Services and does not duplicate any Federal claims for reimbursement. Grand Total Claim Gross $ Grand Total Claim Net $ Signature/Title Typed Name Date *The Quarterly Claim Certification must be submitted to DMAS on school district letterhead. 10

SAMPLE TIME STUDY CALCULATION DETAIL Virginia School-Based Administrative Claim Total Number of Total minutes Total number of minutes Percentage of time people per job spent per worked per week per spent per position number activity code job position number activity code A 7 278 2780 10.00% B 7 22 2780 0.79% C 7 98 2780 3.53% D 7 65 2780 2.34% E 7 450 2780 16.19% F 7 389 2780 13.99% G 7 277 2780 9.96% H 7 0 2780 0.00% I 7 0 2780 0.00% J 7 83 2780 2.99% K 7 65 2780 2.34% L 7 20 2780 0.72% M 7 156 2780 5.61% N 7 56 2780 2.01% O 7 253 2780 9.10% P 7 99 2780 3.56% Q 7 469 2780 16.87% Total Time 7 2780 2780 100% 11

SAMPLE TIME STUDY RESULTS Virginia School-Based Administrative Claim Job Position 01 Job Position 02 Job Position 03 Job Position 04 Occupational Therapist, Asst., or Aide Psychologist or Intern Case Manager Direct Support Personnel Physical Therapist, Asst., or Aide Physician Social Worker School RN/LPN or Aide, Audiologist Psychiatrist Guidance Counselor Hearing Impaired, Vision Specialist Adjustment Counselor Speech/Language Therapist, asst. aide A 0.00% 2.10% 1.13% 2.30% B 1.60% 6.03% 5.64% 3.13% C 0.98% 3.05% 0.66% 5.60% D 2.62% 5.25% 3.87% 2.77% E 2.25% 0.00% 1.73% 0.00% F 50.59% 47.03% 0.00% 0.00% G 6.61% 0.00% 7.76% 7.52% H 2.28% 11.87% 11.15% 9.11% I 0.00% 1.01% 12.36% 2.30% J 7.32% 6.06% 15.89% 0.30% K 0.00% 0.00% 7.65% 2.89% L 6.21% 2.78% 5.43% 2.09% M 2.07% 1.36% 2.54% 22.39% N 1.63% 8.31% 3.68% 18.43% O 8.00% 0.65% 1.02% 2.30% P 2.56% 2.01% 6.13% 5.52% Q 5.28% 2.49% 13.36% 13.35% Total Time 100.00% 100.00% 100.00% 100.00% 12

SAMPLE DETAILED EXPENDITURE REPORT Virginia School-Based Administrative Claim Staff Last Name Staff First Category Job Pos. Salary Fringe Total Name Code Benefits Adams Susan Occupational Therapist 01 $5,642 $1,382 $7,024 Baker Shirley School RN 01 $6,879 $1,685 $8,564 Desmond June Audiologist 01 $4,573 $1,120 $5,693 Hammel Margorie School RN 01 $8,995 $2,204 $11,199 Kean Erica Speech Therapist 01 $5,874 $1,439 $7,313 Parks Jessica Vision Specialist 01 $7,020 $1,720 $8,740 Smith Amy Physical Therapist 01 $4,566 $1,119 $5,685 Total Salaried $43,549 $10,670 $54,219 Smith Bob Occupational Therapist Asst. 01 $12,859 $12,859 White Peter Audiologist 01 $9,968 $9,968 Jones Tony Physical Therapist Asst. 01 $10,136 $10,136 Total Contracted $32,963 $0 $32,963 Materials $4,982 Subtotal $37,945 Total Group 01 $76,512 $10,670 $92,164 Belle Jane School Psychiatrist 02 $8,729 $2,139 $10,868 Herman John School Psychologist 02 $12,957 $3,175 $16,132 Jensen Frank School Psychologist 02 $8,450 $2,070 $10,520 Marks Cindy School Psychologist 02 $9,251 $2,267 $11,518 Total Salaried $39,387 $9,650 $49,037 Pratt Maria Physician 02 $8,452 $8,452 Sacco Helen Physician 02 $9,681 $9,681 Total Contracted $18,133 $0 $18,133 Materials $6,870 Subtotal $25,003 Total Group 02 $57,520 $9,650 $74,040 13

SAMPLE DETAILED EXPENDITURE REPORT (CONT) Virginia School-Based Administrative Claim Staff Last Name Staff First Category Job Pos. Salary Fringe Total Name Code Benefits Ackerman Sarah School Adjustment Counselor 03 $4,991 $1,223 $6,214 Fisher Michael School Social Worker 03 $6,784 $1,662 $8,446 Nelson Monica Guidance Counselor 03 $5,296 $1,298 $6,594 Richards Allison Case Manager 03 $9,852 $2,414 $12,266 Smith Doris Social Worker 03 $8,321 $2,039 $10,360 Walsh Anthony School Adjustment Counselor 03 $8,069 $1,977 $10,046 Wilson Diane Social Worker 03 $7,565 $1,854 $9,419 Materials $568 Total Group 03 $50,878 $12,466 $63,912 Adams Amy Asst. Director Special 04 $4,593 $1,125 $5,718 Education Jones Donna Special Education Clerk 04 $5,239 $1,284 $6,523 Toney Beth Special Education Clerk 04 $6,657 $1,631 $8,288 Thompson Katherine Special Education Director 04 $22,657 $5,551 $28,208 Patterson John Director of Pupil Personnel 04 $11,078 $2,714 $13,792 Cleary Jeff Educational Team Leader 04 $10,129 $2,482 $12,611 Stevens Scott Director of Nursing 04 $17,259 $4,229 $21,488 Materials $568 Total Group 04 $77,612 $19,016 $97,196 14

SAMPLE FRINGE BENEFIT CALCULATION Virginia School-Based Administrative Claim Benefit Description Annual Amount Annual Salaries Fringe Benefit Percentage Unemployment Compensation $158,957 $8,356,642 1.90% Health & Life Insurance $1,128,967 $8,356,642 13.51% Medicare Contribution $36,827 $8,356,642 0.44% Workers Comp\Injury Payments $64,000 $8,356,642 0.77% Pension Contributions $648,742 $8,356,642 7.76% Other $10,000 $8,356,642 0.12% Total $2,047,493 $8,356,642 24.50% 15

SAMPLE CLAIM CALCULATION DETAIL Virginia School-Based Administrative Claim JOB POSITION NUMBER 01 ACTIVITY COST MEDICAID GROSS ELIG. CLAIM FFP NET CLAIM % POOL or OVERHEAD FACTOR AMOUNT RATE AMOUNT A Non-Medicaid Outreach 0.00% 92,164 N/A $0 0% $0 B Medicaid Outreach 1.60% 92,164 N/A $1,475 50% $737 C Facilitating Application for Non-Medicaid Programs 0.98% 92,164 N/A $903 0% $0 D Facilitating Application for Medicaid Programs 2.62% 92,164 N/A $2,415 50% $1,207 E School Related and Educational Activities 2.25% 92,164 N/A $2,074 0% $0 F Direct Medical Service 50.59% 92,164 N/A $46,626 0% $0 G Transportation for Non Medicaid Services 6.61% 92,164 N/A $6,092 0% $0 H Transportation Related Activities in Support of Medicaid Services 2.28% 92,164 25.67% $539 50% $270 I Non Medicaid Translation 0.00% 92,164 N/A $0 0% $0 J Translation Related to Medicaid Services 7.32% 92,164 25.67% $1,732 50% $866 K Program Planning, Policy Development and Interagency Coordination Related to Non Medical Services 0.00% 92,164 N/A $0 0% $0 L Program Planning, Policy Development and Interagency Coordination Related To Medical Services 6.21% 92,164 25.67% $1,469 50% $735 M Non Medicaid Training 2.07% 92,164 N/A $1,908 0% $0 N Medicaid Specific Training 1.63% 92,164 25.67% $386 50% $193 O Referral, Coordination, and Monitoring of Non Medicaid Services 8.00% 92,164 N/A $7,373 0% $0 P Referral, Coordination, and Monitoring of Medicaid Services 2.56% 92,164 25.67% $606 50% $303 Q General Administration 5.28% 92,164 9.88% $481 50% $240 Total 100.00% $74,078 $4,551 16

SAMPLE CLAIM CALCULATION DETAIL (cont.) Virginia School-Based Administrative Claim JOB POSITION NUMBER 02 ACTIVITY COST MEDICAID ELIG. GROSS CLAIM FFP NET CLAIM % POOL or AMOUNT RATE AMOUNT OVERHEAD FACTOR A Non-Medicaid Outreach 2.10% $74,040 N/A $1,555 0% $0 B Medicaid Outreach 6.03% $74,040 N/A $4,465 50% $2,232 C Facilitating Application for Non-Medicaid Programs 3.05% $74,040 N/A $2,258 0% $0 D Facilitating Application for Medicaid Programs 5.25% $74,040 N/A $3,887 50% $1,944 E School Related and Educational Activities 0.00% $74,040 N/A $0 0% $0 F Direct Medical Service 47.03% $74,040 N/A $34,821 0% $0 G Transportation for Non Medicaid Services 0.00% $74,040 N/A $0 0% $0 H Transportation Related Activities in Support of Medicaid Services 11.87% $74,040 25.67% $2,256 50% $1,128 I Non Medicaid Translation 1.01% $74,040 N/A $748 0% $0 J Translation Related to Medicaid Services 6.06% $74,040 25.67% $1,152 50% $576 K Program Planning, Policy Development and Interagency Coordination 0.00% $74,040 N/A $0 0% $0 Related to Non Medical Services L Program Planning, Policy Development and Interagency Coordination 2.78% $74,040 25.67% $528 50% $264 Related To Medical Services M Non Medicaid Training 1.36% $74,040 N/A $1,007 0% $0 N Medicaid Specific Training 8.31% $74,040 25.67% $1,579 50% $790 O Referral, Coordination, and Monitoring of Non Medicaid Services 0.65% $74,040 N/A $481 0% $0 P Referral, Coordination, and Monitoring of Medicaid Services 2.01% $74,040 25.67% $382 50% $191 Q General Administration 2.49% $74,040 19.74% $364 50% $182 Total 100.00% $55,484 $7,307 17

SAMPLE CLAIM CALCULATION DETAIL (cont.) Virginia School-Based Administrative Claim JOB POSITION NUMBER 03 ACTIVITY COST MEDICAID ELIG. GROSS CLAIM FFP NET CLAIM % POOL or AMOUN RATE AMOUNT OVERHEAD FACTOR T A Non-Medicaid Outreach 1.13% $63,912 N/A $722 0% $0 B Medicaid Outreach 5.64% $63,912 N/A $3,605 50% $1,802 C Facilitating Application for Non-Medicaid Programs 0.66% $63,912 N/A $422 0% $0 D Facilitating Application for Medicaid Programs 3.87% $63,912 N/A $2,473 50% $1,237 E School Related and Educational Activities 1.73% $63,912 N/A $1,106 0% $0 F Direct Medical Service 0.00% $63,912 N/A $0 0% $0 G Transportation for Non Medicaid Services 7.76% $63,912 N/A $4,960 0% $0 H Transportation Related Activities in Support of Medicaid Services 11.15% $63,912 25.67% $1,829 50% $915 I Non Medicaid Translation 12.36% $63,912 N/A $7,900 0% $0 J Translation Related to Medicaid Services 15.89% $63,912 25.67% $2,607 50% $1,303 K Program Planning, Policy Development and Interagency Coordination 7.65% $63,912 N/A $4,889 0% $0 Related to Non Medical Services L Program Planning, Policy Development and Interagency Coordination 5.43% $63,912 25.67% $891 50% $445 Related To Medical Services M Non Medicaid Training 2.54% $63,912 N/A $1,623 0% $0 N Medicaid Specific Training 3.68% $63,912 25.67% $604 50% $302 O Referral, Coordination, and Monitoring of Non Medicaid Services 1.02% $63,912 N/A $652 0% $0 P Referral, Coordination, and Monitoring of Medicaid Services 6.13% $63,912 25.67% $1,006 50% $503 Q General Administration 13.36% $63,912 23.50% $2,007 50% $1,003 Total 100.00% $37,295 $7,511 18

SAMPLE CLAIM CALCULATION DETAIL (cont.) Virginia School-Based Administrative Claim JOB POSITION NUMBER 04 ACTIVITY COST MEDICAID ELIG. GROSS CLAIM FFP NET CLAIM % POOL or OVERHEAD FACTOR AMOUNT RATE AMOUNT A Non-Medicaid Outreach 2.30% $97,196 N/A $2,236 0% $0 B Medicaid Outreach 3.13% $97,196 N/A $3,042 50% $1,521 C Facilitating Application for Non-Medicaid Programs 5.60% $97,196 N/A $5,443 0% $0 D Facilitating Application for Medicaid Programs 2.77% $97,196 N/A $2,692 50% $1,346 E School Related and Educational Activities 0.00% $97,196 N/A $0 0% $0 F Direct Medical Service 0.00% $97,196 N/A $0 0% $0 G Transportation for Non Medicaid Services 7.52% $97,196 N/A $7,309 0% $0 H Transportation Related Activities in Support of Medicaid Services 9.11% $97,196 25.67% $2,273 50% $1,136 I Non Medicaid Translation 2.30% $97,196 N/A $2,236 0% $0 J Translation Related to Medicaid Services 0.30% $97,196 25.67% $75 50% $37 K Program Planning, Policy Development and Interagency Coordination 2.89% $97,196 N/A $2,809 0% $0 Related to Non Medical Services L Program Planning, Policy Development and Interagency Coordination 2.09% $97,196 25.67% $521 50% $261 Related To Medical Services M Non Medicaid Training 22.39% $97,196 N/A $21,762 0% $0 N Medicaid Specific Training 18.43% $97,196 25.67% $4,598 50% $2,299 O Referral, Coordination, and Monitoring of Non Medicaid Services 2.30% $97,196 N/A $2,236 0% $0 P Referral, Coordination, and Monitoring of Medicaid Services 5.52% $97,196 25.67% $1,377 50% $689 Q General Administration 13.35% $97,196 17.31% $2,246 50% $1,123 Total 100.00% $60,855 $8,413 19

SAMPLE CAPITAL CALCULATION DETAIL Virginia School-Based Administrative Claim SCHOOL BASED COST X USE ALLOWANCE = TOTAL BUILDING AND FIXED VALUATION (ALL SCHOOLS) X = $4,500,000 2% $90,000 MAJOR MOVEABLE VALUATION X = $1,200,000 6.67% $80,040 SCHOOL WIDE INTEREST EXPENSE = $500,000 $500,000 SUBTOTAL CAPITAL $670,040 TOTAL DISTRICT SALARY + FRINGE BENEFIT $10,404,135 SUBTOTAL CAPITAL/TOTAL DISTRICT SALARY + FRINGE 6.44% 20

SAMPLE QUARTERLY CLAIM SUMMARY VIRGINIA SCHOOL-BASED ADMINISTRATIVE CLAIM DESCRIPTION AMOUNTS DIRECT PERSONNEL-JOB POSITION 01 $9,102 DIRECT PERSONNEL-JOB POSITION 02 $14,613 DIRECT PERSONNEL-JOB POSITION 03 $15,021 DIRECT SUPPORT PERSONNEL -JOB POSITION 04 $16,826 SUBTOTAL JOB POSITIONS 01-04 $55,563 CAPITAL COSTS $3,578 SUBTOTAL- GROSS CLAIM AMOUNT $59,141 INDIRECT COSTS 22.65% $13,395 GRAND TOTAL CLAIM (GROSS) $72,536 GRAND TOTAL CLAIM (NET) $36,268 21

SECTION V: TABLES AND CHARTS TABLE I DIRECT PERSONNEL Job Position Position Number Occupational Therapist, Assistant or Aide 01 Physical Therapist, Assistant or Aide Speech/Language Therapist, Assistant or Aide RN/LPN or Aide or Assistant Audiologist/Hearing Impaired Specialist/ Vision Specialist Psychologist/Intern 02 Psychiatrist Physician Adjustment Counselor 03 Social Worker Guidance Counselor Case Manager * School personnel eligible to participate in this program are based on the actual functions that they perform, not on their job title. 22

SECTION V: TABLES AND CHARTS TABLE II DIRECT SUPPORT PERSONNEL Job Position Position Number Special Education: 04 Director, Administrators/Assistants Education Team Leaders/Chairperson Clerical and Technical Support Personnel Pupil Support Services: 04 Director, Administrators/Assistants Health Coordinators Clerical and Technical Support Personnel Nursing: 04 Director, Administrators/Assistants Clerical and Technical Support Personnel * School personnel eligible to participate in this program are based on the actual functions that they perform, not on their job title. 23