AB 1233, as amended, 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
begin delete utilizeend delete the California Healthcare Eligibility, Enrollment, and Retention System begin delete software to submit applications for Medi-Cal coverage and to enroll applicants in the Medi-Cal program as part of the Administrative Claiming processend delete.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 14132.47 of the Welfare and Institutions
2Code is amended to read:
(a) It is the intent of the Legislature to provide local
4governmental agencies the choice of participating in either or both
5of the Targeted Case Management (TCM) and Administrative
6Claiming process programs at their option, subject to the
7requirements of this section and Section 14132.44.
8(b) The department may contract with each participating local
9governmental agency or each local educational consortium to assist
10with the performance of administrative activities necessary for the
11proper and efficient administration of the Medi-Cal program,
12pursuant to Section 1903a of the federal Social Security Act (42
13U.S.C. Sec. 1396b(a)), and this activity shall be known as the
14Administrative Claiming process.
15(c) (1) Subject to the requirements of paragraph (2) of
16subdivision (f), as a condition for participation in the
17Administrative Claiming process, each participating local
18governmental agency or each local educational consortium shall,
19for the purpose of claiming federal Medicaid reimbursement, enter
20into a contract with the department and shall certify to the
21department the total amount the local governmental agency or each
22local educational consortium expended on the allowable
24(2) The department shall deny the claim if it determines that the
25certification is not adequately supported, or does not otherwise
26comply with federal requirements, for purposes of claiming federal
28(d) Each participating local governmental agency or local
29educational consortium may subcontract with private or public
30entities to assist with the performance of administrative activities
31necessary for the proper and efficient administration of the
32Medi-Cal program under the conditions specified by the department
P3 1(e) Each Administrative Claiming process contract shall include
2a requirement that each participating local governmental agency
3or each local educational consortium submit a claiming plan in a
4manner that shall be prescribed by the department in regulations,
5developed in consultation with local governmental agencies.
6(f) (1) The
department shall require that each participating local
7governmental agency or each local educational consortium certify
8to the department both of the following:
9(A) The expenditure of 100 percent of the cost of performing
10Administrative Claiming process activities. The funds expended
11for this purpose shall be from the local governmental agency’s
12general fund or the general funds of local educational agencies or
13from any other funds allowed under federal law and regulation.
14(B) In each fiscal year that its expenditures represent costs that
15are eligible for federal financial participation for that fiscal year.
16The department shall deny the claim if it determines that the
17certification is not adequately supported for purposes of federal
19(2) (A) (i) A city that is not a participating local governmental
20agency, or any other local public entity, that contracts with a local
21 governmental agency pursuant to subdivision (d) and that is located
22within a county that is a participating local governmental agency
23pursuant to this section, may submit certification to the local
24governmental agency of amounts expended for Administrative
25Claiming services in accordance with Section 433.51 of Title 42
26of the Code of Federal Regulations.
27(ii) A city or other local public entity that submits certification
28pursuant to this paragraph shall comply with the requirements of
29paragraph (1), with other requirements applicable to local
30governmental agencies that the department determines, in
31regulations, to be applicable, and with all applicable federal
33(iii) The local governmental agency shall forward the city’s or
34local public entity’s certification to the department for the purposes
35of claiming federal financial participation.
36(iv) As applicable, the local governmental agency shall obtain
37and retain appropriate certifications from the expending city or
38local public entity, together with documentation of the underlying
39expenditures, as required by the department.
P4 1(B) A tribe or tribal organization, as defined in subdivision (n),
2that is not participating in Administrative Claiming process
3activities as a local governmental agency, may contract with, and
4submit to a tribe or tribal organization that is contracting with, the
5department pursuant to subdivision (b) amounts expended for
6Administrative Claiming process activities that it is certifying in
7accordance with Section 433.51 of Title 42 of the Code of Federal
8Regulations and other applicable federal law and regulations. The
9tribe or tribal organization receiving the certification shall forward
10it to the department for purposes of claiming federal financial
11participation. Such certification shall comply with all of the
12requirements for certification set forth in subparagraph (A).
13(g) (1) Notwithstanding any other provision of this section, the
14state shall be held harmless, in accordance with paragraphs (2)
15and (3), from any federal audit disallowance and interest resulting
16from payments made to a participating local governmental agency
17or local educational consortium pursuant to this section, for the
19(2) To the extent that a federal audit disallowance and interest
20results from a claim or claims for which any participating local
21governmental agency or local educational consortium has received
22reimbursement for Administrative Claiming process activities, the
23department shall recoup from the local governmental agency or
24local educational consortium that submitted the disallowed claim,
25 through offsets or by a direct billing, amounts equal to the amount
26of the disallowance and interest, in that fiscal year, for the
27disallowed claim. All subsequent claims submitted to the
28department applicable to any previously disallowed administrative
29activity or claim, may be held in abeyance, with no payment made,
30until the federal disallowance issue is resolved.
31(3) Notwithstanding paragraph (2), to the extent that a federal
32audit disallowance and interest results from a claim or claims for
33which the participating local governmental agency or local
34educational consortium has received reimbursement for
35Administrative Claiming process activities performed by an entity
36under contract with, and on behalf of, the participating local
37governmental agency or local educational consortium, the
38department shall be held harmless by that particular participating
39local governmental agency or local educational consortium for
P5 1100 percent of the amount of the federal audit disallowance and
2interest, for the disallowed claim.
3(h) The use of local funds required by this section shall not
4create, lead to, or expand the health care funding obligations or
5service obligations for current or future years for any participating
6local governmental agency or local educational consortium, except
7as required by this section or as may be required by federal law.
8(i) The department shall deny any claim from a participating
9local governmental agency or local educational consortium if the
10department determines that the claim is not adequately supported
11in accordance with criteria established pursuant to this subdivision
12and implementing regulations before it forwards the claim for
13reimbursement to the federal Medicaid Program. In consultation
14with local government agencies and local educational consortia,
15the department shall adopt regulations that prescribe the
16requirements for the submission and payment of claims for
17administrative activities performed by each participating local
18governmental agency and local educational consortium.
19(j) Administrative activities shall be those determined by the
20department to be necessary for the proper and efficient
21administration of the state’s Medicaid plan and shall be defined
23(k) If the department denies any claim submitted under this
24section, the affected participating local governmental agency or
25local educational consortium may, within 30 days after receipt of
26written notice of the denial, request that the department reconsider
27its action. The participating local governmental agency or local
28educational consortium may request a meeting with the director
29or his or her designee within 30 days to present its concerns to the
30department after the request is filed. If the director or his or her
31designee cannot meet, the department shall respond in writing
32indicating the specific reasons for which the claim is out of
33compliance to the participating local governmental agency or local
34educational consortium in response to its appeal. Thereafter, the
35decision of the director shall be final.
36(l) To the extent consistent with federal law and regulations,
37participating local governmental agencies or local educational
38consortium may claim the actual costs of nonemergency,
39nonmedical transportation of Medi-Cal eligibles to Medi-Cal
40covered services, under guidelines established by the department,
P6 1to the extent that these costs are actually borne by the participating
2local governmental agency or local educational consortium. A
3local educational consortium may only claim for nonemergency,
4nonmedical transportation of Medi-Cal eligibles for Medi-Cal
5covered services, through the Medi-Cal administrative activities
6program. Medi-Cal medical transportation services shall be claimed
7under the local educational agency Medi-Cal billing option,
8pursuant to Section 14132.06.
9(m) As a condition of participation in the Administrative
10Claiming process and in recognition of revenue generated to each
11participating local governmental agency and each local educational
12consortium in the Administrative Claiming process, each
13participating local governmental agency and each local educational
14consortium shall pay an annual participation fee through a
15mechanism agreed to by the state and local governmental agencies
16and local educational consortia, or, if no agreement is reached by
17August 1 of each year, directly to the state. The participation fee
18shall be used to cover the cost of administering the Administrative
19Claiming process, including, but not limited to, claims processing,
20technical assistance, and monitoring. The department shall
21determine and report staffing requirements upon which projected
22costs will be based. The amount of the participation fee shall be
23based upon the anticipated salaries, benefits, and operating
24expenses, to administer the Administrative Claiming process and
25other costs related to that process.
26(n) (1) For the purposes of this
section, “participating local
27governmental agency” means a county, chartered city, Native
28American Indian tribe, tribal organization, or subgroup of a Native
29American Indian tribe or tribal organization, under contract with
30the department pursuant to subdivision (b).
31(2) Each participating
Native American Indian tribe, tribal
32organization, or subgroup of a Native American Indian tribe or
33tribal organization may utilize the California Healthcare Eligibility,
34Enrollment, and Retention System software to submit applications
35for Medi-Cal coverage and may enroll applicants in the Medi-Cal
36program as part of the Administrative Claiming process.
3(o) For purposes of this section, “local educational agency”
4means a local educational agency, as defined in subdivision (h) of
5Section 14132.06, that participates under the Administrative
6Claiming process as a subcontractor to the local educational
7consortium in its service region.
8(p) (1) For purposes of this section, “local educational
9consortium” means a local agency that is one of the service regions
10of the California County Superintendent Educational Services
12(2) Each local educational consortium shall contract with the
13department pursuant to paragraph (1) of subdivision (c).
14(q) (1) Each participating local educational consortium shall
15be responsible for the local educational agencies in its service
16region that participate in the Administrative Claiming process.
17This responsibility includes, but is not limited to, the preparation
18and submission of all administrative claiming plans, training of
19local educational agency staff, overseeing the local educational
20agency time survey process, and the submission of detailed
21quarterly invoices on behalf of any participating local educational
23(2) Each participating local educational consortium shall ensure
24local educational agency compliance with all requirements of the
25Administrative Claiming process established for local governmental
27(3) Ninety days prior to the initial participation in the
28Administrative Claiming process, each local educational
29consortium shall notify the department of its intent to participate
30in the process, and shall identify each local educational agency
31that will be participating as its subcontractor.
32(r) (1) Each local educational agency that elects to participate
33in the Administrative Claiming process shall submit claims through
34its local educational consortium or through the local governmental
35agency, but not both.
36(2) Each local educational agency participating as a
37subcontractor to a local educational consortium shall comply with
38all requirements of the Administrative Claiming process established
39for local governmental agencies.
P8 1(s) A participating local governmental agency or a local
2educational consortium may charge an administrative fee to any
3entity claiming Administrative Claiming through that agency.
4(t) The department shall continue to administer the
5Administrative Claiming process in conformity with federal
7(u) The department shall provide technical assistance to all
8participating local governmental agencies and local educational
9consortia in order to maximize federal financial participation in
10the Administrative Claiming process.
11(v) This section shall be applicable to Administrative Claiming
12process activities performed, and to moneys paid to participating
13local governmental agencies for those activities in the 1994-95
14fiscal year and thereafter, and to local educational consortia in the
151998-99 fiscal year and thereafter.
16(w) Nothing in this section or Section 14132.44 shall be
17construed to prevent any state agency from participating in the
18Administrative Claiming process or from contracting with others
19to engage in these activities.