California Legislature—2013–14 Regular Session

Assembly Bill No. 1233

Introduced by Assembly Member Chesbro

February 22, 2013

An act to amend Section 14132.47 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

AB 1233, as introduced, Chesbro. Medi-Cal: Administrative Claiming process.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law establishes an Administrative Claiming process under which local governmental agencies and local educational consortia contract with the department for the purpose of obtaining federal matching funds to assist with the performance of administrative activities relating to the Medi-Cal program. Under existing law, a participating local governmental agency may include a Native American Indian tribe, a tribal organization, or a subgroup of a Native American Indian tribe or tribal organization.

This bill would authorize a Native American Indian tribe, a tribal organization, or a subgroup of a Native American Indian tribe or tribal organization to utilize the California Healthcare Eligibility, Enrollment, and Retention System software to submit applications for Medi-Cal coverage and to enroll applicants in the Medi-Cal program as part of the Administrative Claiming process.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

Section 14132.47 of the Welfare and Institutions
Code is amended to read:

14132.47.  

(a) It is the intent of the Legislature to provide local
governmental agencies the choice of participating in either or both
of the Targeted Case Management (TCM) and Administrative
Claiming process programs at their option, subject to the
requirements of this section and Section 14132.44.

(b) The department may contract with each participating local
governmental agency or each local educational consortium to assist
with the performance of administrative activities necessary for the
proper and efficient administration of the Medi-Cal program,
pursuant to begin delete Section 1396b(a) of Title 42 of the United States Code, end delete
Section 1903a of the federal Social Security Act begin insert (42 U.S.C. Sec.
1396b(a)) end insert , and this activity shall be known as the Administrative
Claiming process.

(c) (1) Subject to the requirements of paragraph (2) of
subdivision (f), as a condition for participation in the
Administrative Claiming process, each participating local
governmental agency or each local educational consortium shall,
for the purpose of claiming federal Medicaid reimbursement, enter
into a contract with the department and shall certify to the
department the total amount the local governmental agency or each
local educational consortium expended on the allowable
administrative activities.

(2) The department shall deny the claim if it determines that the
certification is not adequately supported, or does not otherwise
comply with federal requirements, for purposes of claiming federal
financial participation.

(d) Each participating local governmental agency or local
educational consortium may subcontract with private or public
entities to assist with the performance of administrative activities
necessary for the proper and efficient administration of the
Medi-Cal program under the conditions specified by the department
in regulations.

(e) Each Administrative Claiming process contract shall include
a requirement that each participating local governmental agency
or each local educational consortium submit a claiming plan in a
manner that shall be prescribed by the department in regulations,
developed in consultation with local governmental agencies.

(f) (1) The department shall require that each participating local
governmental agency or each local educational consortium certify
to the department both of the following:

(A)  The expenditure of 100 percent of the cost of performing
Administrative Claiming process activities. The funds expended
for this purpose shall be from the local governmental agency’s
general fund or the general funds of local educational agencies or
from any other funds allowed under federal law and regulation.

(B) In each fiscal year that its expenditures represent costs that
are eligible for federal financial participation for that fiscal year.
The department shall deny the claim if it determines that the
certification is not adequately supported for purposes of federal
financial participation.

(2) (A) (i) A city that is not a participating local governmental
agency, or any other local public entity, that contracts with a local
governmental agency pursuant to subdivision (d) and that is located
within a county that is a participating local governmental agency
pursuant to this section, may submit certification to the local
governmental agency of amounts expended for Administrative
Claiming services in accordance with Section 433.51 of Title 42
of the Code of Federal Regulations.

(ii) A city or other local public entity that submits certification
pursuant to this paragraph shall comply with the requirements of
paragraph (1), with other requirements applicable to local
governmental agencies that the department determines, in
regulations, to be applicable, and with all applicable federal
requirements.

(iii) The local governmental agency shall forward the city’s or
local public entity’s certification to the department for the purposes
of claiming federal financial participation.

(iv) As applicable, the local governmental agency shall obtain
and retain appropriate certifications from the expending city or
local public entity, together with documentation of the underlying
expenditures, as required by the department.

(B) A tribe or tribal organization, as defined in subdivision (n),
that is not participating in Administrative Claiming process
activities as a local governmental agency, may contract with, and
submit to a tribe or tribal organization that is contracting with, the
department pursuant to subdivision (b) amounts expended for
Administrative Claiming process activities that it is certifying in
accordance with Section 433.51 of Title 42 of the Code of Federal
Regulations and other applicable federal law and regulations. The
tribe or tribal organization receiving the certification shall forward
it to the department for purposes of claiming federal financial
participation. Such certification shall comply with all of the
requirements for certification set forth in subparagraph (A).

(g) (1) Notwithstanding any other provision of this section, the
state shall be held harmless, in accordance with paragraphs (2)
and (3), from any federal audit disallowance and interest resulting
from payments made to a participating local governmental agency
or local educational consortium pursuant to this section, for the
disallowed claim.

(2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which any participating local
governmental agency or local educational consortium has received
reimbursement for Administrative Claiming process activities, the
department shall recoup from the local governmental agency or
local educational consortium that submitted the disallowed claim,
through offsets or by a direct billing, amounts equal to the amount
of the disallowance and interest, in that fiscal year, for the
disallowed claim. All subsequent claims submitted to the
department applicable to any previously disallowed administrative
activity or claim, may be held in abeyance, with no payment made,
until the federal disallowance issue is resolved.

(3) Notwithstanding paragraph (2), to the extent that a federal
audit disallowance and interest results from a claim or claims for
which the participating local governmental agency or local
educational consortium has received reimbursement for
Administrative Claiming process activities performed by an entity
under contract with, and on behalf of, the participating local
governmental agency or local educational consortium, the
department shall be held harmless by that particular participating
local governmental agency or local educational consortium for
100 percent of the amount of the federal audit disallowance and
interest, for the disallowed claim.

(h) The use of local funds required by this section shall not
create, lead to, or expand the health care funding obligations or
service obligations for current or future years for any participating
local governmental agency or local educational consortium, except
as required by this section or as may be required by federal law.

(i) The department shall deny any claim from a participating
local governmental agency or local educational consortium if the
department determines that the claim is not adequately supported
in accordance with criteria established pursuant to this subdivision
and implementing regulations before it forwards the claim for
reimbursement to the federal Medicaid Program. In consultation
with local government agencies and local educational consortia,
the department shall adopt regulations that prescribe the
requirements for the submission and payment of claims for
administrative activities performed by each participating local
governmental agency and local educational consortium.

(j) Administrative activities shall be those determined by the
department to be necessary for the proper and efficient
administration of the state’s Medicaid plan and shall be defined
in regulation.

(k) If the department denies any claim submitted under this
section, the affected participating local governmental agency or
local educational consortium may, within 30 days after receipt of
written notice of the denial, request that the department reconsider
its action. The participating local governmental agency or local
educational consortium may request a meeting with the director
or his or her designee within 30 days to present its concerns to the
department after the request is filed. If the director or his or her
designee cannot meet, the department shall respond in writing
indicating the specific reasons for which the claim is out of
compliance to the participating local governmental agency or local
educational consortium in response to its appeal. Thereafter, the
decision of the director shall be final.

(l) To the extent consistent with federal law and regulations,
participating local governmental agencies or local educational
consortium may claim the actual costs of nonemergency,
nonmedical transportation of Medi-Cal eligibles to Medi-Cal
covered services, under guidelines established by the department,
to the extent that these costs are actually borne by the participating
local governmental agency or local educational consortium. A
local educational consortium may only claim for nonemergency,
nonmedical transportation of Medi-Cal eligibles for Medi-Cal
covered services, through the Medi-Cal administrative activities
program. Medi-Cal medical transportation services shall be claimed
under the local educational agency Medi-Cal billing option,
pursuant to Section 14132.06.

(m) As a condition of participation in the Administrative
Claiming process and in recognition of revenue generated to each
participating local governmental agency and each local educational
consortium in the Administrative Claiming process, each
participating local governmental agency and each local educational
consortium shall pay an annual participation fee through a
mechanism agreed to by the state and local governmental agencies
and local educational consortia, or, if no agreement is reached by
August 1 of each year, directly to the state. The participation fee
shall be used to cover the cost of administering the Administrative
Claiming process, including, but not limited to, claims processing,
technical assistance, and monitoring. The department shall
determine and report staffing requirements upon which projected
costs will be based. The amount of the participation fee shall be
based upon the anticipated salaries, benefits, and operating
expenses, to administer the Administrative Claiming process and
other costs related to that process.

(n)  begin insert (1) end insert begin insert   end insert For the purposes of this section, “participating local
governmental agency” means a county, chartered city, Native
American Indian tribe, tribal organization, or subgroup of a Native
American Indian tribe or tribal organization, under contract with
the department pursuant to subdivision (b).

begin insert

(2) Each participating Native American Indian tribe, tribal
organization, or subgroup of a Native American Indian tribe or
tribal organization may utilize the California Healthcare
Eligibility, Enrollment, and Retention System software to submit
applications for Medi-Cal coverage and may enroll applicants in
the Medi-Cal program as part of the Administrative Claiming
process.

end insert

(o) For purposes of this section, “local educational agency”
means a local educational agency, as defined in subdivision (h) of
Section 14132.06, that participates under the Administrative
Claiming process as a subcontractor to the local educational
consortium in its service region.

(p) (1) For purposes of this section, “local educational
consortium” means a local agency that is one of the service regions
of the California County Superintendent Educational Services
Association.

(2) Each local educational consortium shall contract with the
department pursuant to paragraph (1) of subdivision (c).

(q) (1) Each participating local educational consortium shall
be responsible for the local educational agencies in its service
region that participate in the Administrative Claiming process.
This responsibility includes, but is not limited to, the preparation
and submission of all administrative claiming plans, training of
local educational agency staff, overseeing the local educational
agency time survey process, and the submission of detailed
quarterly invoices on behalf of any participating local educational
agency.

(2) Each participating local educational consortium shall ensure
local educational agency compliance with all requirements of the
Administrative Claiming process established for local governmental
agencies.

(3) Ninety days prior to the initial participation in the
Administrative Claiming process, each local educational
consortium shall notify the department of its intent to participate
in the process, and shall identify each local educational agency
that will be participating as its subcontractor.

(r) (1) Each local educational agency that elects to participate
in the Administrative Claiming process shall submit claims through
its local educational consortium or through the local governmental
agency, but not both.

(2) Each local educational agency participating as a
subcontractor to a local educational consortium shall comply with
all requirements of the Administrative Claiming process established
for local governmental agencies.

(s) A participating local governmental agency or a local
educational consortium may charge an administrative fee to any
entity claiming Administrative Claiming through that agency.

(t) The department shall continue to administer the
Administrative Claiming process in conformity with federal
requirements.

(u) The department shall provide technical assistance to all
participating local governmental agencies and local educational
consortia in order to maximize federal financial participation in
the Administrative Claiming process.

(v) This section shall be applicable to Administrative Claiming
process activities performed, and to moneys paid to participating
local governmental agencies for those activities in the 1994-95
fiscal year and thereafter, and to local educational consortia in the
1998-99 fiscal year and thereafter.

(w) Nothing in this section or Section 14132.44 shall be
construed to prevent any state agency from participating in the
Administrative Claiming process or from contracting with others
to engage in these activities.