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 claim, as a Medi-Cal Administrative Activity, facilitating Medi-Cal applications using the California Healthcare Eligibility, Enrollment, and Retention System.
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
P3 1(d) Each participating local governmental agency or local
2educational consortium may subcontract with private or public
3entities to assist with the performance of administrative activities
4necessary for the proper and efficient administration of the
5Medi-Cal program under the conditions specified by the department
7(e) Each Administrative Claiming process contract shall include
8a requirement that each participating local governmental agency
9or each local educational consortium submit a claiming plan in a
10manner that shall be prescribed by the department in regulations,
11developed in consultation with local governmental agencies.
12(f) (1) The department shall require that each
13governmental agency or each local educational consortium certify
14to the department both of the following:
15(A) The expenditure of 100 percent of the cost of performing
16Administrative Claiming process activities. The funds expended
17for this purpose shall be from the local governmental agency’s
18general fund or the general funds of local educational agencies or
19from any other funds allowed under federal law and regulation.
20(B) In each fiscal year that its expenditures represent costs that
21are eligible for federal financial participation for that fiscal year.
22The department shall deny the claim if it determines that the
23certification is not adequately supported for purposes of federal
25(2) (A) (i) A city that is not a participating local governmental
26agency, or any other local public entity, that contracts with a local
27 governmental agency pursuant to subdivision (d) and that is located
28within a county that is a participating local governmental agency
29pursuant to this section, may submit certification to the local
30governmental agency of amounts expended for Administrative
31Claiming services in accordance with Section 433.51 of Title 42
32of the Code of Federal Regulations.
33(ii) A city or other local public entity that submits certification
34pursuant to this paragraph shall comply with the requirements of
35paragraph (1), with other requirements applicable to local
36governmental agencies that the department determines, in
37regulations, to be applicable, and with all applicable federal
P4 1(iii) The local governmental agency shall forward the city’s or
2local public entity’s certification to the department for the purposes
3of claiming federal financial participation.
4(iv) As applicable, the local governmental agency shall obtain
5and retain appropriate certifications from the expending city or
6local public entity, together with documentation of the underlying
7expenditures, as required by the department.
8(B) A tribe or tribal organization, as defined in subdivision (n),
9that is not participating in Administrative Claiming process
10activities as a local governmental agency, may contract with, and
11submit to a tribe or tribal organization that is contracting with, the
12department pursuant to subdivision (b) amounts expended for
13Administrative Claiming process activities that it is certifying in
14accordance with Section 433.51 of Title 42 of the Code of Federal
15Regulations and other applicable federal law and regulations. The
16tribe or tribal organization receiving the certification shall forward
17it to the department for purposes of claiming federal financial
18participation. The certification shall comply with all of the
19requirements for certification set forth in subparagraph (A).
20(g) (1) Notwithstanding any other provision of this section, the
21state shall be held harmless, in accordance with paragraphs (2)
22and (3), from any federal audit disallowance and interest resulting
23from payments made to a participating local governmental agency
24or local educational consortium pursuant to this section, for the
26(2) To the extent that a federal audit disallowance and interest
27results from a claim or claims for which any participating local
28governmental agency or local educational consortium has received
29reimbursement for Administrative Claiming process activities, the
30department shall recoup from the local governmental agency or
31local educational consortium that submitted the disallowed claim,
32 through offsets or by a direct billing, amounts equal to the amount
33of the disallowance and interest, in that fiscal year, for the
34disallowed claim. All subsequent claims submitted to the
35department applicable to any previously disallowed administrative
36activity or claim, may be held in abeyance, with no payment made,
37until the federal disallowance issue is resolved.
38(3) Notwithstanding paragraph (2), to the extent that a federal
39audit disallowance and interest results from a claim or claims for
40which the participating local governmental agency or local
P5 1educational consortium has received reimbursement for
2Administrative Claiming process activities performed by an entity
3under contract with, and on behalf of, the participating local
4governmental agency or local educational consortium, the
5department shall be held harmless by that particular participating
6local governmental agency or local educational consortium for
7100 percent of the amount of the federal audit disallowance and
8interest, for the disallowed claim.
9(h) The use of local funds required by this section shall not
10create, lead to, or expand the health care funding obligations or
11service obligations for current or future years for any participating
12local governmental agency or local educational consortium, except
13as required by this section or as may be required by federal law.
14(i) The department shall deny any claim from a participating
15local governmental agency or local educational consortium if the
16department determines that the claim is not adequately supported
17in accordance with criteria established pursuant to this subdivision
18and implementing regulations before it forwards the claim for
19reimbursement to the federal Medicaid Program. In consultation
20with local governmental agencies and local educational consortia,
21the department shall adopt regulations that prescribe the
22requirements for the submission and payment of claims for
23administrative activities performed by each participating local
24governmental agency and local educational consortium.
25(j) Administrative activities shall be those determined by the
26department to be necessary for the proper and efficient
27administration of the state’s Medicaid plan and shall be defined
29(k) If the department denies any claim submitted under this
30section, the affected participating local governmental agency or
31local educational consortium may, within 30 days after receipt of
32written notice of the denial, request that the department reconsider
33its action. The participating local governmental agency or local
34educational consortium may request a meeting with the director
35or his or her designee within 30 days to present its concerns to the
36department after the request is filed. If the director or his or her
37designee cannot meet, the department shall respond in writing
38indicating the specific reasons for which the claim is out of
39compliance to the participating local governmental agency or local
P6 1educational consortium in response to its appeal. Thereafter, the
2decision of the director shall be final.
3(l) To the extent consistent with federal law and regulations,
4participating local governmental agencies or local educational
5consortium may claim the actual costs of nonemergency,
6nonmedical transportation of Medi-Cal eligibles to Medi-Cal
7covered services, under guidelines established by the department,
8to the extent that these costs are actually borne by the participating
9local governmental agency or local educational consortium. A
10local educational consortium may only claim for nonemergency,
11nonmedical transportation of Medi-Cal eligibles for Medi-Cal
12covered services, through the Medi-Cal administrative activities
13program. Medi-Cal medical transportation services shall be claimed
14under the local educational agency Medi-Cal billing option,
15pursuant to Section 14132.06.
16(m) As a condition of participation in the Administrative
17Claiming process and in recognition of revenue generated to each
18participating local governmental agency and each local educational
19consortium in the Administrative Claiming process, each
20participating local governmental agency and each local educational
21consortium shall pay an annual participation fee through a
22mechanism agreed to by the state and local governmental agencies
23and local educational consortia, or, if no agreement is reached by
24August 1 of each year, directly to the state. The participation fee
25shall be used to cover the cost of administering the Administrative
26Claiming process, including, but not limited to, claims processing,
27technical assistance, and monitoring. The department shall
28determine and report staffing requirements upon which projected
29costs will be based. The amount of the participation fee shall be
30based upon the anticipated salaries, benefits, and operating
31expenses, to administer the Administrative Claiming process and
32other costs related to that process.
33(n) (1) For the purposes of this
section, “participating local
34governmental agency” means a county, chartered city, Native
35American Indian tribe, tribal organization, or subgroup of a Native
36American Indian tribe or tribal organization, under contract with
37the department pursuant to subdivision (b).
38(2) Each participating Native American Indian tribe, tribal
39organization, or subgroup of a Native American Indian tribe or
40tribal organization may claim, as a Medi-Cal Administrative
P7 1Activity, facilitating Medi-Cal applications using the California Healthcare Eligibility,
3Enrollment, and Retention System.
4(o) For purposes of this section, “local educational agency”
5means a local educational agency, as defined in subdivision (h) of
6Section 14132.06, that participates under the Administrative
7 Claiming process as a subcontractor to the local educational
8consortium in its service region.
9(p) (1) For purposes of this section, “local educational
10consortium” means a local agency that is one of the service regions
11of the California County Superintendent Educational Services
13(2) Each local educational consortium shall contract with the
14department pursuant to paragraph (1) of subdivision (c).
15(q) (1) Each participating local educational consortium shall
16be responsible for the local educational agencies in its service
17region that participate in the Administrative Claiming process.
18This responsibility includes, but is not limited to, the preparation
19and submission of all administrative claiming plans, training of
20local educational agency staff, overseeing the local educational
21agency time survey process, and the submission of detailed
22quarterly invoices on behalf of any participating local educational
24(2) Each participating local educational consortium shall ensure
25local educational agency compliance with all requirements of the
26Administrative Claiming process established for local governmental
28(3) Ninety days prior to the initial participation in the
29Administrative Claiming process, each local educational
30consortium shall notify the department of its intent to participate
31in the process, and shall identify each local educational agency
32that will be participating as its subcontractor.
33(r) (1) Each local educational agency that elects to participate
34in the Administrative Claiming process shall submit claims through
35its local educational consortium or through the local governmental
36agency, but not both.
37(2) Each local educational agency participating as a
38subcontractor to a local educational consortium shall comply with
39all requirements of the Administrative Claiming process established
40for 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.
This act is an urgency statute necessary for the
21immediate preservation of the public peace, health, or safety within
22the meaning of Article IV of the Constitution and shall go into
23immediate effect. The facts constituting the necessity are:
24In order to facilitate implementation of the federal Patient
25Protection and Affordable Care Act (Public Law 111-148), as
26amended by the federal Health Care and Education Reconciliation
27Act of 2010 (Public Law 111-152) at the earliest possible time, it
28is necessary that this act take effect immediately.