Health Center Regulatory Issues, Health Center State Policy

Leveraging Medicaid Administrative Claiming for Health Centers

Guest post contributed by Lisa Chan-Sawin, MHA, and Gretchen Schroeder, MPH, Transform Health

Due to the COVID-19 outbreak, critical safety net providers such as Community Health Centers are experiencing significant drops in patient revenue as a result of stay-at-home orders across the nation. During this global public health crisis it is critical to explore innovative strategies to draw down additional dollars to support health centers while ensuring the continuity and livelihood of community-based health care services remains in place in rural and urban areas across the country. One such strategy, Medicaid Administrative Claiming (MAC), can be a useful tool in a health center’s portfolio to leverage federal Medicaid funding through Federal Financial Participation (FFP).

What is Medicaid Administrative Claiming?

Medicaid Administrative Claiming is a federal claiming mechanism used to cover activities that contribute to the efficient and effective administration of the Medicaid program.[1]  Through this mechanism, health centers and other eligible entities are able to defray part of the costs of some crucial services that support and ensure effective administration of Medicaid programs locally. 

How does it work?

Typically, an organization such as a health center will work with their state Medicaid office to participate in MAC, which is a reimbursement program where a portion of incurred costs are reimbursed to the claiming organization. The MAC FFP rates vary depending upon the MAC activity being claimed, but reimbursement is generally around 50%.  Health centers will need to pay 100% of the initial cost of services upfront and then seek the federal reimbursement. The federal government will cover typically around 50% of the cost of those certified activities, disbursing the money through the respective state Medicaid agency back to the original organization that conducted those activities. The MAC claiming process and receipt of the federal reimbursement can take several months and, in some states over one year, so it is critical to begin a relationship with your Medicaid agency on MAC to engage in this claiming process now.[2]

What types of services can be funded?

Examples of how MAC can be used for activities range from eligibility determinations to care coordination.

In response to COVID-19 specifically, health centers can utilize MAC to:

1)      Mobilize Community Health Workers (CHWs) to coordinate telehealth appointments.

2)      Assist clients in setting up mail-order prescriptions that they can no longer obtain in person.

There are a variety of different activities for which MAC can be used to reimburse health centers as they work to combat the COVID-19 crisis, some which will still be necessary post-pandemic, and it is important to explore these services now with your state Medicaid agency to develop this pipeline. In addition to claiming through MAC, other non-clinical services, including coordinating food deliveries for clients, could also be claimed through Targeted Case Management (TCM), another Medicaid program.[3]

How do I find out more?

The Centers for Medicare & Medicaid Services (CMS) issued guidance to states relaxing federal regulations in reimbursing activities related to the provision of care during COVID-19.  The CMS Disaster Response Toolkit, which provides information on how this guidance can assist health centers in drawing down Medicaid funding, can be found here. To learn more about what activities your health center can engage in and be partially reimbursed by MAC, check with your state Medicaid agency to see which activities are covered during non-emergency periods, as well activities that are COVID-19 specific that may not typically be reimbursed and are now.

To learn more about MAC or work with Transform Health, please contact Heather Bates, MSW, at heather@transformhc.com

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement number U30CS16089, Technical Assistance to Community and Migrant Health Centers and Homeless for $6,375,000.00 with 0% of the total NCA project financed with non-federal sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.


[1] Center for Medicare & Medicaid Services, Medicaid Administrative Claiming, 2020

[2] Center for Medicare & Medicaid Services, “No Wrong Door System Reference Document for Medicaid Administrative Claiming”, 2020

[3] Congressional Research Service, Medicaid Targeted Case Management Benefits, 2008

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