State, Local, and Tribal Government (CN Agency Staff, State Medicaid Agency Staff, Other State Agency Staff, and School District Staff)

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Overview

Activity Descriptions
Time Log
Salary information
ODC information
Indirect Cost information
Time Log - Optional Weekly Ver

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Sheet 1: Activity Descriptions

APPENDIX C.3b. MEDICAID STATE COST DATA TRACKING LOGS	OMB #: XXXX-XXXX EXPIRATION DATE: XX/XX/XXXX
State Medicaid eligibility agency activity	Activity description
Start-up activities (For States participating in the previous DCM demonstration, these are activities involved in converting from the previous demonstration to DCM-F/RP. For States new to DCM, these are activities involved in adding DCM-F/RP to existing direct certification procedures.)
Negotiate data-sharing agreements	Draft MOU/MOA with child nutrition agency; edit and execute the agreements; develop specifications for the data needed from the Medicaid eligibility files.
Enhance MIS or student database	Make enhancements to systems and databases to allow for entry of information related to DCM/F-RP.
Develop and test programs for extract	Develop and test programs for creating extract. The extract consists of school-age children on Medicaid with household incomes at or below the DCM-F/RP thresholds.
Provide test file to CN agency	Provide test file to child nutrition agency.
Revise based on feedback	Revise specifications and programming in response to feedback.
Pre-implementation meetings and coordination	Hold internal pre-implementation staff meetings or conference calls with specialists and programmers, FNS, or the child nutrition agency to coordinate and discuss progress. Draft any necessary memos or status reports.
Other pre-implementation activities (describe in Notes column)	Additional pre-implementation activities not described above; please specify.
Ongoing activities for DCM-F/RP (These are activities that occur on an ongoing basis, or each time a DCM-F/RP match is conducted.)
Create extract	Create extract of school-age children on Medicaid with household incomes at or below the DCM-F/RP thresholds.
Send file to CN agency	Send file securely to child nutrition agency.
Respond to questions	Respond to data questions from child nutrition agency.
Conduct USDA evaluation activities	Conduct activities related to the USDA DCM/F-RP evaluation. These include developing and executing MOUs with Mathematica, participating in interviews, and discussing the evaluation with the evaluation team.
Post-implementation meetings and coordination	Hold internal post-implementation staff meetings or conference calls with specialists and programmers, FNS, or the child nutrition agency to coordinate and discuss any ongoing issues. Draft any necessary memos or status reports.
Other post-implementation activities (describe in Notes column)	Additional post-implementation activities not described above; please specify.
Note: In the time log on the next worksheet, please include only time incurred to implement DCM-F/RP that is in addition to time already associated with other forms of direct certification for school meals (such as direct certification through SNAP, TANF, or other programs).
Glossary of Terms:
CN = Child Nutrition;
DCM-F/RP = Demonstrations of Direct Certification with Medicaid for free and reduced-price meals;
MIS = management information system;
MOU/MOA = Memorandum of understanding (or agreement);
SNAP = Supplemental Nutrition Assistance Program;
TANF = Temporary Assistance for Needy Families;
USDA = U.S. Department of Agriculture.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. The time required to complete this information collection is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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Sheet 2: Time Log

APPENDIX C.3b. MEDICAID STATE COST DATA TRACKING LOGS					OMB #: XXXX-XXXX EXPIRATION DATE: XX/XX/XXXX
DCM-F/RP
Time Tracking Log
[STATE NAME] Medicaid Eligibility Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Name of agency/division:
Staffing position	Activity (select from list)	Total hours spent during month			Notes
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Note: In this time log, please include only time incurred to implement DCM-F/RP that is in addition to time already associated with other forms of direct certification for school meals (such as direct certification through SNAP, TANF, or other programs).

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Sheet 3: Salary information

APPENDIX C.3b. MEDICAID STATE COST DATA TRACKING LOGS					OMB #: XXXX-XXXX EXPIRATION DATE: XX/XX/XXXX
DCM-F/RP
Salary Worksheet
[STATE NAME] Medicaid Eligibility Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Staffing position (include each staff position listed in time log)	Pay rate (dollars)	Basis paid (select from list)	Fringe benefit percentage /amount	Fringe benefits calculated as:	Notes
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Sheet 4: ODC information

APPENDIX C.3b. MEDICAID STATE COST DATA TRACKING LOGS		OMB #: XXXX-XXXX EXPIRATION DATE: XX/XX/XXXX
DCM-F/RP
Other Direct Costs (ODC) Worksheet
[STATE NAME] Medicaid Eligibility Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Type of other direct cost (such as printing and mailing costs, charges for conference calls, or amounts paid to outside contractors for work on the project. Please describe.)	Amount during this data collection period (dollars)	Notes
Note: If totals by month are easier to report, please record them in the Notes column.

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Sheet 5: Indirect Cost information

APPENDIX C.3b. MEDICAID STATE COST DATA TRACKING LOGS		OMB #: XXXX-XXXX EXPIRATION DATE: XX/XX/XXXX
DCM-F/RP
Indirect Costs Worksheet
[STATE NAME] Medicaid Eligibility Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Question	Response
1. Does your accounting system assign indirect costs to any of the direct labor and ODC costs listed above? (Yes or No)	CHECK ONE: ___YES ___NO
2. If yes, describe how applicable indirect costs are defined and measured. (Hypothetical example: indirect costs include management, human resources, accounting, IT services, and building maintenance. They are charged at the rates of 12% of labor costs and 2% of ODCs.)
3. If yes, what were the total indirect costs associated with DCM-F/RP in [first month] - [last month]? (in dollars)
Thank you for completing this form. Your responses will help us understand the costs you incur and the various types of activities you perform when conducting direct certification. We understand that this task requires the investment of your time and greatly appreciate your participation. Although we have tried to make these forms both flexible and straightforward, we will appreciate any suggestions for improvements. Please contact your liaison with the study team or Josh Leftin ([email protected]) with any questions.

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Sheet 6: Time Log - Optional Weekly Ver

APPENDIX C.3b. MEDICAID STATE COST DATA TRACKING LOGS

OMB #: XXXX-XXXX EXPIRATION DATE: XX/XX/XXXX

DCM-F/RP

Time Tracking Log

[STATE NAME] Medicaid Eligibility Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])

Name of agency/division:

Staffing position

Activity (select from list)

Total hours spent during week

Notes

Week 1

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Week 5

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Week 12

Week xx

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Note: In this time log, please include only time incurred to implement DCM-F/RP that is in addition to time already associated with other forms of direct certification for school meals (such as direct certification through SNAP, TANF, or other programs).