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 facilitate Medi-Cal eligibility determinationsend delete using the California Healthcare Eligibility, Enrollment, and Retention System begin delete as a Medi-Cal Administrative Activities-specific activityend delete.
This bill would declare that it is to take effect immediately as an urgency statute.
Vote: 2⁄3. 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
P3 1entities to assist with the performance of administrative activities
2necessary for the proper and efficient administration of the
3Medi-Cal program under the conditions specified by the department
5(e) Each Administrative Claiming process contract shall include
6a requirement that each participating local governmental agency
7or each local educational consortium submit a claiming plan in a
8manner that shall be prescribed by the department in regulations,
9developed in consultation with local governmental agencies.
10(f) (1) The department shall require that
each participating local
11governmental agency or each local educational consortium certify
12to the department both of the following:
13(A) The expenditure of 100 percent of the cost of performing
14Administrative Claiming process activities. The funds expended
15for this purpose shall be from the local governmental agency’s
16general fund or the general funds of local educational agencies or
17from any other funds allowed under federal law and regulation.
18(B) In each fiscal year that its expenditures represent costs that
19are eligible for federal financial participation for that fiscal year.
20The department shall deny the claim if it determines that the
21certification is not adequately supported for purposes of federal
23(2) (A) (i) A city that is not a participating local governmental
24agency, or any other local public entity, that contracts with a local
25 governmental agency pursuant to subdivision (d) and that is located
26within a county that is a participating local governmental agency
27pursuant to this section, may submit certification to the local
28governmental agency of amounts expended for Administrative
29Claiming services in accordance with Section 433.51 of Title 42
30of the Code of Federal Regulations.
31(ii) A city or other local public entity that submits certification
32pursuant to this paragraph shall comply with the requirements of
33paragraph (1), with other requirements applicable to local
34governmental agencies that the department determines, in
35regulations, to be applicable, and with all applicable federal
37(iii) The local governmental agency shall forward the city’s or
38local public entity’s certification to the department for the purposes
39of claiming federal financial participation.
P4 1(iv) As applicable, the local governmental agency shall obtain
2and retain appropriate certifications from the expending city or
3local public entity, together with documentation of the underlying
4expenditures, as required by the department.
5(B) A tribe or tribal organization, as defined in subdivision (n),
6that is not participating in Administrative Claiming process
7activities as a local governmental agency, may contract with, and
8submit to a tribe or tribal organization that is contracting with, the
9department pursuant to subdivision (b) amounts expended for
10Administrative Claiming process activities that it is certifying in
11accordance with Section 433.51 of Title 42 of the Code of Federal
12Regulations and other applicable federal law and regulations. The
13tribe or tribal organization receiving the certification shall forward
14it to the department for purposes of claiming federal financial
15participation. The certification shall comply with all of the
16requirements for certification set forth in subparagraph (A).
17(g) (1) Notwithstanding any other provision of this section, the
18state shall be held harmless, in accordance with paragraphs (2)
19and (3), from any federal audit disallowance and interest resulting
20from payments made to a participating local governmental agency
21or local educational consortium pursuant to this section, for the
23(2) To the extent that a federal audit disallowance and interest
24results from a claim or claims for which any participating local
25governmental agency or local educational consortium has received
26reimbursement for Administrative Claiming process activities, the
27department shall recoup from the local governmental agency or
28local educational consortium that submitted the disallowed claim,
29 through offsets or by a direct billing, amounts equal to the amount
30of the disallowance and interest, in that fiscal year, for the
31disallowed claim. All subsequent claims submitted to the
32department applicable to any previously disallowed administrative
33activity or claim, may be held in abeyance, with no payment made,
34until the federal disallowance issue is resolved.
35(3) Notwithstanding paragraph (2), to the extent that a federal
36audit disallowance and interest results from a claim or claims for
37which the participating local governmental agency or local
38educational consortium has received reimbursement for
39Administrative Claiming process activities performed by an entity
40under contract with, and on behalf of, the participating local
P5 1governmental agency or local educational consortium, the
2department shall be held harmless by that particular participating
3local governmental agency or local educational consortium for
4100 percent of the amount of the federal audit disallowance and
5interest, for the disallowed claim.
6(h) The use of local funds required by this section shall not
7create, lead to, or expand the health care funding obligations or
8service obligations for current or future years for any participating
9local governmental agency or local educational consortium, except
10as required by this section or as may be required by federal law.
11(i) The department shall deny any claim from a participating
12local governmental agency or local educational consortium if the
13department determines that the claim is not adequately supported
14in accordance with criteria established pursuant to this subdivision
15and implementing regulations before it forwards the claim for
16reimbursement to the federal Medicaid Program. In consultation
begin delete governmentend delete agencies and local educational
18consortia, the department shall adopt regulations that prescribe the
19requirements for the submission and payment of claims for
20administrative activities performed by each participating local
21governmental agency and local educational consortium.
22(j) Administrative activities shall be those determined by the
23department to be necessary for the proper and efficient
24administration of the state’s Medicaid plan and shall be defined
26(k) If the department denies any claim submitted under this
27section, the affected participating local governmental agency or
28local educational consortium may, within 30 days after receipt of
29written notice of the denial, request that the department reconsider
30its action. The participating local governmental agency or local
31educational consortium may request a meeting with the director
32or his or her designee within 30 days to present its concerns to the
33department after the request is filed. If the director or his or her
34designee cannot meet, the department shall respond in writing
35indicating the specific reasons for which the claim is out of
36compliance to the participating local governmental agency or local
37educational consortium in response to its appeal. Thereafter, the
38decision of the director shall be final.
39(l) To the extent
consistent with federal law and regulations,
40participating local governmental agencies or local educational
P6 1consortium may claim the actual costs of nonemergency,
2nonmedical transportation of Medi-Cal eligibles to Medi-Cal
3covered services, under guidelines established by the department,
4to the extent that these costs are actually borne by the participating
5local governmental agency or local educational consortium. A
6local educational consortium may only claim for nonemergency,
7nonmedical transportation of Medi-Cal eligibles for Medi-Cal
8covered services, through the Medi-Cal administrative activities
9program. Medi-Cal medical transportation services shall be claimed
10under the local educational agency Medi-Cal billing option,
11pursuant to Section 14132.06.
12(m) As a condition of participation in the Administrative
13Claiming process and in recognition of revenue generated to each
14participating local governmental agency and each local educational
15consortium in the Administrative Claiming process, each
16participating local governmental agency and each local educational
17consortium shall pay an annual participation fee through a
18mechanism agreed to by the state and local governmental agencies
19and local educational consortia, or, if no agreement is reached by
20August 1 of each year, directly to the state. The participation fee
21shall be used to cover the cost of administering the Administrative
22Claiming process, including, but not limited to, claims processing,
23technical assistance, and monitoring. The department shall
24determine and report staffing requirements upon which projected
25costs will be based. The amount of the participation fee shall be
26based upon the anticipated salaries, benefits, and operating
27expenses, to administer the Administrative Claiming process and
28other costs related to that process.
29(n) (1) For the purposes of this section, “participating local
30governmental agency” means a county, chartered city, Native
31American Indian tribe, tribal organization, or subgroup of a Native
32American Indian tribe or tribal organization, under contract with
33the department pursuant to subdivision (b).
34(2) Each participating Native American Indian tribe, tribal
35organization, or subgroup of a Native American Indian tribe or
36tribal organization may
begin delete facilitate Medi-Cal eligibility using the California Healthcare
39Eligibility, Enrollment, and Retention System
begin delete as a Medi-Cal .
40Administrative Activities-specific activityend delete
P7 1(o) For purposes of this section, “local educational agency”
2means a local educational agency, as defined in subdivision (h) of
3Section 14132.06, that participates under the Administrative
4 Claiming process as a subcontractor to the local educational
5consortium in its service region.
6(p) (1) For purposes of this section, “local educational
7consortium” means a local agency that is one of the service regions
8of the California County Superintendent Educational Services
10(2) Each local educational consortium shall contract with the
11department pursuant to paragraph (1) of subdivision (c).
12(q) (1) Each participating local educational consortium shall
13be responsible for the local educational agencies in its service
14region that participate in the Administrative Claiming process.
15This responsibility includes, but is not limited to, the preparation
16and submission of all administrative claiming plans, training of
17local educational agency staff, overseeing the local educational
18agency time survey process, and the submission of detailed
19quarterly invoices on behalf of any participating local educational
21(2) Each participating local educational consortium shall ensure
22local educational agency compliance with all requirements of the
23Administrative Claiming process established for local governmental
25(3) Ninety days prior to the initial participation in the
26Administrative Claiming process, each local educational
27consortium shall notify the department of its intent to participate
28in the process, and shall identify each local educational agency
29that will be participating as its subcontractor.
30(r) (1) Each local educational agency that elects to participate
31in the Administrative Claiming process shall submit claims through
32its local educational consortium or through the local governmental
33agency, but not both.
34(2) Each local educational agency participating as a
35subcontractor to a local educational consortium shall comply with
36all requirements of the Administrative Claiming process established
37for local governmental agencies.
38(s) A participating local governmental agency or a local
39educational consortium may charge an administrative fee to any
40entity claiming Administrative Claiming through that agency.
P8 1(t) The department shall
continue to administer the
2Administrative Claiming process in conformity with federal
4(u) The department shall provide technical assistance to all
5participating local governmental agencies and local educational
6consortia in order to maximize federal financial participation in
7the Administrative Claiming process.
8(v) This section shall be applicable to Administrative Claiming
9process activities performed, and to moneys paid to participating
10local governmental agencies for those activities in the 1994-95
11fiscal year and thereafter, and to local educational consortia in the
121998-99 fiscal year and thereafter.
13(w) Nothing in this section or Section 14132.44 shall be
14construed to prevent any state agency from participating in the
15Administrative Claiming process or from contracting with others
16to engage in these activities.
This act is an urgency statute necessary for the
18immediate preservation of the public peace, health, or safety within
19the meaning of Article IV of the Constitution and shall go into
20immediate effect. The facts constituting the necessity are:
21In order to facilitate implementation of the federal Patient
22Protection and Affordable Care Act (Public Law 111-148), as
23amended by the federal Health Care and Education Reconciliation
24Act of 2010 (Public Law 111-152) at the earliest possible time, it
25is necessary that this act take effect immediately.