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 facilitate Medi-Cal eligibility determinations using the California Healthcare Eligibility, Enrollment, and Retention System as a Medi-Cal Administrative Activities-specific activity.
begin deletemajority end delete.
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
P3 1Medi-Cal program under the conditions specified by the department
3(e) Each Administrative Claiming process contract shall include
4a requirement that each participating local governmental agency
5or each local educational consortium submit a claiming plan in a
6manner that shall be prescribed by the department in regulations,
7developed in consultation with local governmental agencies.
8(f) (1) The department shall require that
each participating local
9governmental agency or each local educational consortium certify
10to the department both of the following:
11(A) The expenditure of 100 percent of the cost of performing
12Administrative Claiming process activities. The funds expended
13for this purpose shall be from the local governmental agency’s
14general fund or the general funds of local educational agencies or
15from any other funds allowed under federal law and regulation.
16(B) In each fiscal year that its expenditures represent costs that
17are eligible for federal financial participation for that fiscal year.
18The department shall deny the claim if it determines that the
19certification is not adequately supported for purposes of federal
21(2) (A) (i) A city that is not a participating local governmental
22agency, or any other local public entity, that contracts with a local
23 governmental agency pursuant to subdivision (d) and that is located
24within a county that is a participating local governmental agency
25pursuant to this section, may submit certification to the local
26governmental agency of amounts expended for Administrative
27Claiming services in accordance with Section 433.51 of Title 42
28of the Code of Federal Regulations.
29(ii) A city or other local public entity that submits certification
30pursuant to this paragraph shall comply with the requirements of
31paragraph (1), with other requirements applicable to local
32governmental agencies that the department determines, in
33regulations, to be applicable, and with all applicable federal
35(iii) The local governmental agency shall forward the city’s or
36local public entity’s certification to the department for the purposes
37of claiming federal financial participation.
38(iv) As applicable, the local governmental agency shall obtain
39and retain appropriate certifications from the expending city or
P4 1local public entity, together with documentation of the underlying
2expenditures, as required by the department.
3(B) A tribe or tribal organization, as defined in subdivision (n),
4that is not participating in Administrative Claiming process
5activities as a local governmental agency, may contract with, and
6submit to a tribe or tribal organization that is contracting with, the
7department pursuant to subdivision (b) amounts expended for
8Administrative Claiming process activities that it is certifying in
9accordance with Section 433.51 of Title 42 of the Code of Federal
10Regulations and other applicable federal law and regulations. The
11tribe or tribal organization receiving the certification shall forward
12 it to the department for purposes of claiming federal financial
begin delete Suchend delete certification shall comply with all of the
14requirements for certification set forth in subparagraph (A).
15(g) (1) Notwithstanding any other provision of this section, the
16state shall be held harmless, in accordance with paragraphs (2)
17and (3), from any federal audit disallowance and interest resulting
18from payments made to a participating local governmental agency
19or local educational consortium pursuant to this section, for the
21(2) To the extent that a federal audit disallowance and interest
22results from a claim or claims for which any participating local
23governmental agency or local educational consortium has received
24reimbursement for Administrative Claiming process activities, the
25department shall recoup from the local governmental agency or
26local educational consortium that submitted the disallowed claim,
27 through offsets or by a direct billing, amounts equal to the amount
28of the disallowance and interest, in that fiscal year, for the
29disallowed claim. All subsequent claims submitted to the
30department applicable to any previously disallowed administrative
31activity or claim, may be held in abeyance, with no payment made,
32until the federal disallowance issue is resolved.
33(3) Notwithstanding paragraph (2), to the extent that a federal
34audit disallowance and interest results from a claim or claims for
35which the participating local governmental agency or local
36educational consortium has received reimbursement for
37Administrative Claiming process activities performed by an entity
38under contract with, and on behalf of, the participating local
39governmental agency or local educational consortium, the
40department shall be held harmless by that particular participating
P5 1local governmental agency or local educational consortium for
2100 percent of the amount of the federal audit disallowance and
3interest, for the disallowed claim.
4(h) The use of local funds required by this section shall not
5create, lead to, or expand the health care funding obligations or
6service obligations for current or future years for any participating
7local governmental agency or local educational consortium, except
8as required by this section or as may be required by federal law.
9(i) The department shall deny any claim from a participating
10local governmental agency or local educational consortium if the
11department determines that the claim is not adequately supported
12in accordance with criteria established pursuant to this subdivision
13and implementing regulations before it forwards the claim for
14reimbursement to the federal Medicaid Program. In consultation
15with local government agencies and local educational consortia,
16the department shall adopt regulations that prescribe the
17requirements for the submission and payment of claims for
18administrative activities performed by each participating local
19governmental agency and local educational consortium.
20(j) Administrative activities shall be those determined by the
21department to be necessary for the proper and efficient
22administration of the state’s Medicaid plan and shall be defined
24(k) If the department denies any claim submitted under this
25section, the affected participating local governmental agency or
26local educational consortium may, within 30 days after receipt of
27written notice of the denial, request that the department reconsider
28its action. The participating local governmental agency or local
29educational consortium may request a meeting with the director
30or his or her designee within 30 days to present its concerns to the
31department after the request is filed. If the director or his or her
32designee cannot meet, the department shall respond in writing
33indicating the specific reasons for which the claim is out of
34compliance to the participating local governmental agency or local
35educational consortium in response to its appeal. Thereafter, the
36decision of the director shall be final.
37(l) To the extent consistent with federal law and regulations,
38participating local governmental agencies or local educational
39consortium may claim the actual costs of nonemergency,
40nonmedical transportation of Medi-Cal eligibles to Medi-Cal
P6 1covered services, under guidelines established by the department,
2to the extent that these costs are actually borne by the participating
3local governmental agency or local educational consortium. A
4local educational consortium may only claim for nonemergency,
5nonmedical transportation of Medi-Cal eligibles for Medi-Cal
6covered services, through the Medi-Cal administrative activities
7program. Medi-Cal medical transportation services shall be claimed
8under the local educational agency Medi-Cal billing option,
9pursuant to Section 14132.06.
10(m) As a condition of participation in the Administrative
11Claiming process and in recognition of revenue generated to each
12participating local governmental agency and each local educational
13consortium in the Administrative Claiming process, each
14participating local governmental agency and each local educational
15consortium shall pay an annual participation fee through a
16mechanism agreed to by the state and local governmental agencies
17and local educational consortia, or, if no agreement is reached by
18August 1 of each year, directly to the state. The participation fee
19shall be used to cover the cost of administering the Administrative
20Claiming process, including, but not limited to, claims processing,
21technical assistance, and monitoring. The department shall
22determine and report staffing requirements upon which projected
23costs will be based. The amount of the participation fee shall be
24based upon the anticipated salaries, benefits, and operating
25expenses, to administer the Administrative Claiming process and
26other costs related to that process.
27(n) (1) For the purposes of this
section, “participating local
28governmental agency” means a county, chartered city, Native
29American Indian tribe, tribal organization, or subgroup of a Native
30American Indian tribe or tribal organization, under contract with
31the department pursuant to subdivision (b).
32(2) Each participating Native American Indian tribe, tribal
33organization, or subgroup of a Native American Indian tribe or
34tribal organization may facilitate Medi-Cal eligibility
35determinations using the California Healthcare Eligibility,
36Enrollment, and Retention System as a Medi-Cal Administrative
38(o) For purposes of this section, “local educational agency”
39means a local educational agency, as defined in subdivision (h) of
40Section 14132.06, that participates under the Administrative
P7 1 Claiming process as a subcontractor to the local educational
2consortium in its service region.
3(p) (1) For purposes of this section, “local educational
4consortium” means a local agency that is one of the service regions
5of the California County Superintendent Educational Services
7(2) Each local educational consortium shall contract with the
8department pursuant to paragraph (1) of subdivision (c).
9(q) (1) Each participating local educational consortium shall
10be responsible for the local educational agencies in its service
11region that participate in the Administrative Claiming process.
12This responsibility includes, but is not limited to, the preparation
13and submission of all administrative claiming plans, training of
14local educational agency staff, overseeing the local educational
15agency time survey process, and the submission of detailed
16quarterly invoices on behalf of any participating local educational
18(2) Each participating local educational consortium shall ensure
19local educational agency compliance with all requirements of the
20Administrative Claiming process established for local governmental
22(3) Ninety days prior to the initial participation in the
23Administrative Claiming process, each local educational
24consortium shall notify the department of its intent to participate
25in the process, and shall identify each local educational agency
26that will be participating as its subcontractor.
27(r) (1) Each local educational agency that elects to participate
28in the Administrative Claiming process shall submit claims through
29its local educational consortium or through the local governmental
30agency, but not both.
31(2) Each local educational agency participating as a
32subcontractor to a local educational consortium shall comply with
33all requirements of the Administrative Claiming process established
34for local governmental agencies.
35(s) A participating local governmental agency or a local
36educational consortium may charge an administrative fee to any
37entity claiming Administrative Claiming through that agency.
38(t) The department
shall continue to administer the
39Administrative Claiming process in conformity with federal
P8 1(u) The department shall provide technical assistance to all
2participating local governmental agencies and local educational
3consortia in order to maximize federal financial participation in
4the Administrative Claiming process.
5(v) This section shall be applicable to Administrative Claiming
6process activities performed, and to moneys paid to participating
7local governmental agencies for those activities in the 1994-95
8fiscal year and thereafter, and to local educational consortia in the
91998-99 fiscal year and thereafter.
10(w) Nothing in this section or Section 14132.44 shall be
11construed to prevent any state agency from participating in the
12Administrative Claiming process or from contracting with others
13to engage in these activities.