BILL NUMBER: SB 123 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 30, 2016
AMENDED IN ASSEMBLY JUNE 16, 2016
AMENDED IN ASSEMBLY MAY 16, 2016
AMENDED IN SENATE MAY 12, 2015
AMENDED IN SENATE APRIL 6, 2015
INTRODUCED BY Senator Liu
(Principal coauthor: Assembly Member Santiago)
( Coauthor: Assembly Member
Thurmond )
JANUARY 15, 2015
An act to amend Section 14115.8 of, to amend, repeal, and add
Section 14132.47 of, and to add Sections 14005.272, 14005.273,
14132.471, and 14132.472 to, the Welfare and Institutions Code,
relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
SB 123, as amended, Liu. Medi-Cal: school-based administrative
activities.
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 by, and funded pursuant
to, federal Medicaid program provisions. Existing law establishes an
administrative claiming process under which the department is
authorized to contract with local governmental agencies and local
educational consortia for the purpose of obtaining federal matching
funds to assist with the performance of administrative activities
relating to the Medi-Cal program. Existing law defines a local
educational agency for these purposes as a local educational agency
that participates under the process as a subcontractor to the local
educational consortium in its service region.
Existing law provides that specified services provided by local
educational agencies (LEAs) are covered Medi-Cal benefits and
requires the department to perform various activities with respect to
the billing option for services provided by LEAs, including
amendment of the Medicaid state plan to ensure that schools shall be
reimbursed for all eligible services they provide. Existing law
requires the department to regularly consult with the State
Department of Education, school district representatives, county
offices of education, the local educational consortium, and local
educational agencies to assist in formulating those state plan
amendments.
This bill would additionally authorize
require the department to contract directly with a local
educational agency agency, if the local
educational agency chooses, to perform school-based
administrative activities necessary for the proper and efficient
administration of the Medi-Cal program, as specified, and
specified. The bill would designate
this activity the contracting between the department
and participating local educational agencies, local educational
consortia, and local governmental agencies to perform
those school-based administrative activities as the
School-Based Administrative Claiming process program. The bill
would require the department to administer or oversee the
administration of a single statewide random moment time survey for
the purposes of the program. The bill would make related legislative
findings and declarations.
This bill would require the department to prepare and file an
annual report with the Legislature for the School-Based
Administrative Claiming process program, which would include
specified information relating to the operation, components, and
rates of school-based Medicaid systems. The bill would require the
department to prepare and post on its Internet Web site an annual
report of the costs of administering the School-Based Administrative
Claiming process program and the LEA billing option and list local
educational agency participation in each.
This bill would require the department to enter into an
interagency agreement or memorandum of understanding (MOU) with the
State Department of Education to coordinate the efforts of both
departments with respect to the LEA billing option and the
School-Based Administrative Claiming process program. The bill would
require the department and the State Department of Education to
develop an appeals process, as specified, to contest an action of the
department or the State Department of Education. Any savings
available to the department from the restructuring of the
Administrative Claiming process made by the bill would be directed
toward the implementation of the interagency agreement or MOU
described in the bill, including, but not limited to, providing
necessary State Department of Education staff and support to county
offices of education.
This bill would require the department and the State
Department of Education to establish and jointly
administer and chair a School-Based Health Program and Policy
Workgroup, as specified, in order to assist the department in
formulating state plan amendments required to implement the LEA
billing option described above and for the purpose of advising the
department on issues related to the delivery of school-based Medi-Cal
services to students in the state. state, as
specified. The bill would require the department to consult
with the advisory group in connection with developing the interagency
agreement or MOU described above.
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. (a) The Legislature finds and declares all of the
following:
(1) Effective cross-agency collaboration is vital to deliver
high-quality school-based health services to California students.
(2) Existing federal directives require the chief executive
officer of a state or designee of that officer to ensure that an
interagency agreement or other mechanism for interagency coordination
is in effect between each noneducational public agency (health) and
the state education agency to ensure that a Free Appropriate Public
Education (FAPE) is provided for students. California does not
currently have the required interagency agreement.
(3)
(2) The United States Department of Education and the
United States Department of Health and Human Services, in a key
January 2016 policy letter, recognize the critical role that health
care coverage and health services play in ensuring all students are
ready and able to learn, and recommend action steps to better
coordinate health and education services to build strong and
sustainable partnerships and commitments between health and education
agencies at the local, state, and federal levels.
(4)
(3) The student success strategic priority in State
Superintendent of Public Instruction Tom Torlakson's 2015 Blueprint
2.0 includes Section 3.13, which prioritizes the development of
infrastructure at the State Department of Education to improve
cross-agency collaboration in support of student health.
(5)
(4) In Report 2014-130 issued on August 20, 2015, the
State Auditor recommended that the State Department of Health Care
Services institute significant structural changes to school-based
Medi-Cal programs in order to improve administration and oversight,
increase federal funding, and cut costs.
(6)
(5) Building an effective, transparent infrastructure
and accountability system to fully utilize all available federal
Medicaid funds is a critical component of developing the capacity to
deliver school-based health and mental health programs.
(7)
(6) These vital programs must be operated at a level
that meets the benchmark of national best practices in order to meet
the needs of California's most vulnerable children.
(b) It is the intent of the Legislature to ensure effective
coordination between health and education agencies at the state,
county, and local levels to address the achievement gap in our
schools and health and education equity issues in California.
SEC. 2. Section 14005.272 is added to the Welfare and Institutions
Code, to read:
14005.272. (a) The department, in consultation with
department and the State Department of
Education, Education shall establish and
jointly administer and chair a School-Based Health Program and
Policy Workgroup in order to assist the department in formulating the
state plan amendments required by subdivisions (a) and (b) of
Section 14115.8, and for the purpose of advising the department on
issues related to the delivery of school-based Medi-Cal services to
students in the state. The scope of the workgroup shall include, but
not be limited to, improving the operation of and participation in
all of the following school-based health programs:
(1) The School-Based Administrative Claiming process program
described in Section 14132.471.
(2) The local educational agency (LEA) Medi-Cal billing option
described in Section 14132.06.
(3) The Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) Program described in Section 14700.
(4)
(3) Other school-based health and mental health
programs, including including, but not
limited to, the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Program described in Section 14700 and
school-based health centers which may receive Medi-Cal funding.
(b) The workgroup shall, on a regular basis, provide input to the
department and the State Department of Education on the degree to
which the process and implementation of the School-Based
Administrative Claiming process program described in Section
14132.471 and the local educational agency
LEA Medi-Cal billing option program described in Section
14132.06 is are meeting the needs of
LEAs with respect to cost-effectiveness, program structure, and
operational effectiveness, including the process of appeals and
balancing withheld funds and actual expenses. The workgroup
shall also advise the department and the State Department of
Education on cr eating consistency across local
educational consortia (LECs), local governmental agencies (LGAs), and
the department with respect to contracts and processes and on
expanding options for an LEA to contract with LECs and LGAs described
in Section 14132.471 outside of the LEA's region, and make
recommendations to facilitate that option, including the impact on
the quarterly random moment time survey for the LEAs, LECs, and LGAs
participating in the School-Based Administrative Claiming
process program described in Section 14132.471.
(c) The workgroup shall also provide input to the department and
the State Department of Education on the development and continuing
operations of an office of school-based health programs
within the State Department of Education. the
interagency agreement or memorandum of understanding described in
Section 14132.472.
(d) The workgroup shall be representative of the diversity of
California local educational agencies LEAs
with respect to size, type, and geographic diversity and shall
include representatives from county offices of education and
education, urban, suburban, and rural
local educational agencies. and rural LEAs, and LECs
and LGAs described in S ection 14132.471 and from Region
IX of the federal Centers for Medicare and Medicaid Services.
The workgroup shall also include the LEA Ad Hoc Workgroup described
in Section 14132.06 and members with expertise in the school-based
health programs described in paragraphs (1) to (4), inclusive, of
subdivision (a).
(e) The workgroup may form technical advisory subcommittees as
necessary that shall report back to the workgroup on the development
of plans and timelines to implement the changes and expanded options
described in this section.
SEC. 3. Section 14005.273 is added to the Welfare and Institutions
Code, to read:
14005.273. Commencing with the 2017-18 state fiscal year, and
annually for each year thereafter, the department shall publish the
following information together in a single annual school-based
Medi-Cal report on a section of its Internet Web site:
(a) An annual A report that details
the costs of operating the School-Based Administrative Claiming
process program described in Section 14132.471, including the
costs and fees being charged to local educational agencies by local
educational consortia and local governmental agencies and any
vendor fees. The report shall also list each participating local
educational agency. The initial report
prepared and posted pursuant to this subdivision shall also
report on cost savings realized from the restructuring of
the Administrative Claiming process program through implementation of
the School-Based Administrative Claiming process program described
in Section 14132.471. recommendations of the workgroup
described in Section 14005.272. The report shall also
include elements similar to those in the annual report the department
is required to file for the local educational agency Medi-Cal
billing option program pursuant to Section 14115.8.
(b) An annual A report that details
the costs of operating the local educational agency (LEA) Medi-Cal
billing option program described in Section 14132.06. The report
shall also list each local educational agency participating in the
LEA Medi-Cal billing option program.
(c) An annual A report
regarding the rate of participation of
listing the local educational agencies participating
in the Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) Program described in Section 14700.
SEC. 4. Section 14115.8 of the Welfare and Institutions Code is
amended to read:
14115.8. (a) (1) The department shall amend the Medicaid state
plan with respect to the billing option for services by local
educational agencies (LEAs), to ensure that schools shall be
reimbursed for all eligible services that they provide that are not
precluded by federal requirements.
(2) The department shall examine methodologies for increasing
school participation in the Medi-Cal billing option for LEAs so that
schools can meet the health care needs of their students.
(3) The department, to the extent possible, shall simplify
claiming processes for LEA billing.
(4) The department shall eliminate and modify state plan and
regulatory requirements that exceed federal requirements when they
are unnecessary.
(b) If a rate study for the LEA Medi-Cal billing option is
completed pursuant to Section 52 of Chapter 171 of the Statutes of
2001, the department, in consultation with the entities named in
subdivision (c), (d) of Section 14005.272,
shall implement the recommendations from the study, to the
extent feasible and appropriate.
(c) Notwithstanding any other law, or any other contrary state
requirement, the department shall take whatever action is necessary
to ensure that, to the extent there is capacity in its certified
match, an LEA shall be reimbursed retroactively for the maximum
period allowed by the federal government for any department change
that results in an increase in reimbursement to local educational
agency providers.
(d) The department may undertake all necessary activities to
recoup matching funds from the federal government for reimbursable
services that have already been provided in the state's public
schools. The department shall prepare and take whatever action is
necessary to implement all regulations, policies, state plan
amendments, and other requirements necessary to achieve this purpose.
(e) The department shall file an annual report with the
Legislature that shall include at least all of the following:
(1) A copy of the annual comparison required by subdivision
(i). (h).
(2) A state-by-state comparison of school-based Medicaid total and
per eligible child claims and federal revenues. The comparison shall
include a review of the most recent two years for which completed
data is available.
(3) A summary of department activities and an explanation of how
each activity contributed toward narrowing the gap between California'
s per eligible student federal fund recovery and the per student
recovery of the top three states.
(4) A listing of all school-based services, activities, and
providers approved for reimbursement by the federal Centers for
Medicare and Medicaid Services in other state plans that are not yet
approved for reimbursement in California's state plan and the service
unit rates approved for reimbursement.
(5) The official recommendations made to the department by the
entities named in subdivision (c) and the action taken by the
department regarding each recommendation.
(6) A one-year timetable for state plan amendments and other
actions necessary to obtain reimbursement for those items listed in
paragraph (4).
(7) Identification of any barriers to local educational agency
reimbursement, including those specified by the entities named in
subdivision (c), (d) of Section 14005.272,
that are not imposed by federal requirements, and a description
of the actions that have been, and will be, taken to eliminate them.
(f) (1) These activities shall be funded and staffed by
proportionately reducing federal Medicaid payments allocable to LEAs
for the provision of benefits funded by the federal Medicaid program
under the billing option for services by LEAs specified in this
section. Moneys collected as a result of the reduction in federal
Medicaid payments allocable to LEAs shall be deposited into the Local
Educational Agency Medi-Cal Recovery Fund, which is hereby
established in the Special Deposit Fund established pursuant to
Section 16370 of the Government Code. These funds shall be used, upon
appropriation by the Legislature, only to support the department to
meet all the requirements of this section. If at any time this
section is repealed, it is the intent of the Legislature that all
funds in the Local Educational Agency Medi-Cal Recovery Fund be
returned proportionally to all LEAs whose federal Medicaid funds were
used to create this fund. The annual amount funded pursuant to this
paragraph shall not exceed one million five hundred thousand dollars
($1,500,000).
(2) Moneys collected under paragraph (1) shall be proportionately
reduced from federal Medicaid payments to all participating LEAs so
that no one LEA loses a disproportionate share of its federal
Medicaid payments.
(g) (1) The department may enter into a sole source contract to
comply with the requirements of this section.
(2) The level of additional staff to comply with the requirements
of this section, including, but not limited to, staff for which the
department has contracted for pursuant to paragraph (1), shall be
limited to that level that can be funded with revenues derived
pursuant to subdivision (g).
(h) The activities of the department shall include all of the
following:
(1) An annual comparison of the school-based Medicaid systems in
comparable states.
(2) Efforts to improve communications with the federal government,
the State Department of Education, and local educational agencies.
(3) The development and updating of written guidelines to local
educational agencies regarding best practices to avoid audit
exceptions, as needed.
(4) The establishment and maintenance of a local educational
agency user-friendly, interactive Internet Web site.
(5) Collaboration with the State Department of Education to help
ensure LEA compliance with state and federal Medicaid requirements
and to help improve LEA participation in the Medi-Cal billing option
for LEAs.
SEC. 5. 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 Section 1903a of the federal Social Security Act (42 U.S.C. Sec.
1396b(a)), 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.
regulations.
(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. The 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 governmental 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) (1) 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).
(2) Each participating Native American Indian tribe, tribal
organization, or subgroup of a Native American Indian tribe or tribal
organization may claim, as a Medi-Cal Administrative Activity,
facilitating Medi-Cal applications, which includes, but is not
limited to, using the California Healthcare Eligibility, Enrollment,
and Retention System.
(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 (1) Subject
to paragraph (2), 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.
(2) This section shall not be applicable to Administrative
Claiming process activities performed in the 2017-18 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.
(x) This section shall remain in effect only until January 1,
2018, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2018, deletes or extends
that date.
SEC. 6. Section 14132.47 is added to the
Welfare and Institutions Code , to read:
14132.47. (a) It is the intent of the Legislature to provide
local governmental agencies the choice of participating in the
Targeted Case Management (TCM) or the Administrative Claiming process
program, or both, 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 to assist with the performance of nonschool-based
administrative activities necessary for the proper and efficient
administration of the Medi-Cal program, pursuant to Section 1903a of
the federal Social Security Act (42 U.S.C. Sec. 1396b(a)), 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 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 expended on the allowable administrative
activities.
(2) The department shall deny the claim if the department
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 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 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 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 from any other funds allowed under federal law and
regulations.
(B) That the agency's expenditures represent costs that are
eligible for federal financial participation for each fiscal year.
The department shall deny the claim if the department 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, or
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 the certification to the department for purposes of claiming
federal financial participation. The 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, 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 has received reimbursement for Administrative
Claiming process activities, the department shall recoup from the
local governmental agency 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 has received
reimbursement for Administrative Claiming process activities
performed by an entity under contract with, and on behalf of, the
participating local governmental agency, the department shall be held
harmless by that particular participating local governmental agency
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, 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 if the department determines that the claim is
not adequately supported in accordance with criteria established
pursuant to this subdivision and implementing regulations before the
department forwards the claim for reimbursement to the federal
Medicaid program. In consultation with local governmental agencies,
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.
(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 may,
within 30 days after receipt of written notice of the denial, request
that the department reconsider its action. The participating local
governmental agency may request a meeting with the director or his or
her designee within 30 days to present the agency's 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 to the
participating local governmental agency in response to its appeal,
indicating the specific reasons for which the claim is out of
compliance. The decision of the director shall be final.
(l) To the extent consistent with federal law and regulations,
participating local governmental agencies 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.
(m) As a condition of participation in the Administrative Claiming
process and in recognition of revenue generated to each
participating local governmental agency in the Administrative
Claiming process, each participating local governmental agency shall
pay an annual participation fee through a mechanism agreed to by the
state and local governmental agencies, 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) (1) For the purposes of this section, "participating local
governmental agency" means a county, charter 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). A participating local
governmental agency for the purposes of this section does not include
a local educational agency or an agency under contract with the
department for the purpose of claiming reimbursement for school-based
administrative activities related to the Medi-Cal program.
(2) Each participating Native American Indian tribe, tribal
organization, or subgroup of a Native American Indian tribe or tribal
organization may claim, as a Medi-Cal Administrative Activity,
facilitating Medi-Cal applications, which includes, but is not
limited to, using the California Healthcare Eligibility, Enrollment,
and Retention System.
(o) A participating local governmental agency may charge an
administrative fee to any entity claiming Administrative Claiming
through that agency.
(p) The department shall continue to administer the Administrative
Claiming process in conformity with federal requirements.
(q) The department shall provide technical assistance to all
participating local governmental agencies in order to maximize
federal financial participation in the Administrative Claiming
process.
(r) 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.
(s) 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.
(t) This section shall become operative on January 1, 2018.
SEC. 5. SEC. 7. Section 14132.471 is
added to the Welfare and Institutions Code, to read:
14132.471. (a) It is the intent of the Legislature to provide
local governmental agencies with the option to participate in the
Targeted Case Management (TCM) program and to provide local
educational agencies with the option to participate in the
Administrative Claiming process program, subject to the requirements
of this section and Section 14132.44.
(b) (1) Beginning no later than the 2017-18 state fiscal year the
department shall administer, or oversee the administration of, a
single statewide quarterly random moment time survey for the
School-Based Administrative Claiming process program.
(2) The statewide quarterly random moment time survey described in
paragraph (1) shall not apply to the Los Angeles Unified School
District (LAUSD), which shall conduct its own random moment time
survey. Data from the random moment time survey conducted by LAUSD
shall not be included in the statewide random moment time survey
described in paragraph (1).
(b)
(c) (1) The department may
contract with a participating local educational consortium or
local governmental agency, and shall, if a local
educational agency chooses, contract with a local educational
agency to perform school-based administrative activities
necessary for the proper and efficient administration of the Medi-Cal
program, pursuant to Section 1903a of the federal Social Security
Act (42 U.S.C. Sec. 1396b(a)), and this activity shall be known as
the School-Based Administrative Claiming process.
(c)
(2) A local educational agency that contracts with the department
pursuant to paragraph (1) may contract with a participating local
educational consortium or local governmental agency to perform some
or all of the duties imposed on a participant by this section.
(3) For purposes of this section, "participating local educational
agency, local educational consortium, or local governmental agency"
or "participant" means a local educational agency, local educational
consortium, or local government agency that contracts with the
department pursuant to paragraph (1).
(d) (1) As a condition of participation in the
School-Based Administrative Claiming process program, each
participating local educational agency, local educational
consortium, or local governmental agency shall, for the
purpose of claiming federal Medicaid reimbursement, shall
enter into a contract with the department and shall certify
to the department, pursuant to subdivision (f), the total amount the
local educational agency expended on the allowable administrative
activities. A local educational agency may certify the amount
expended on allowable administrative activities either directly to
the department or through a local educational consortium or local
governmental agency.
(2) The department shall deny the claim if the department
determines that the certification is not adequately supported, or
otherwise does not comply with federal requirements, for purposes of
claiming federal financial participation.
(d)
(e) Each School-Based Administrative Claiming process
contract shall include a requirement for each participating local
educational agency agency, local educational
consortium, or local governmental agency to submit a claiming
plan in a manner that shall be prescribed by the department in
regulations developed in consultation with local educational
agencies. agencies, local educational consortia, and
local governmental agencies.
(e)
(f) (1) The department shall require each participating
local educational agency agency, local
educational consortium, or local governmental agency to certify
to the department both of the following:
(A) That the local educational agency
participant claiming federal Medicaid reimbursement expended
funds from its general fund or from any other fund allowed under
federal law and regulation regulations
to pay for 100 percent of the cost of performing School-Based
Administrative Claiming process program activities.
(B) For each fiscal year, that the local educational
agency's expenditures of the participant claiming
federal Medicaid reimbursement represent costs that are
eligible for federal financial participation for that fiscal year.
(2) A tribe or tribal organization, as described in subdivision
(n), may contract with, or submit to a tribe or tribal organization
that is contracting with, the department pursuant to subdivision (b)
amounts expended for School-Based 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 the certification to the
department for purposes of claiming federal financial participation.
The certification shall comply with all of the requirements for
certification set forth in subparagraph (A) of paragraph (1).
(f)
(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
educational agency agency, local
educational consortium, or local governmental agency
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 a participating local
educational agency agency, local
educational consortium, or local governmental agency has
received reimbursement for School-Based Administrative Claiming
process activities, the department shall recoup from the
local educational agency participant 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 a
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 educational agency
agency, local educational consortium, or local
governmental agency has received reimbursement for School-Based
Administrative Claiming process activities performed by an entity
under contract with, and on behalf of, the participating
local educational agency, participant, the
department shall be held harmless by that particular
participating local educational agency participant
for 100 percent of the amount of the federal audit disallowance
and interest for the disallowed claim.
(g)
(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 a
participating local educational agency, local
educational consortium, or local governmental agency except as
required by this section or as may be required by federal law.
(h)
(i) (1) The department shall, in consultation with
participating local educational agencies,
agency, local educational consortium, or local governmental agency,
adopt regulations that prescribe the requirements for the
submission and payment of claims for administrative activities
performed by each participating local educational agency.
participant.
(2) The department shall deny a claim from a participating local
educational agency agency, local educational
consortium, or local governmental agency if the department
determines that the claim is not adequately supported in accordance
with criteria established pursuant to this subdivision and
implementing regulations before the department forwards the claim for
reimbursement to the federal Medicaid program.
(i)
(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.
(j)
(k) If the department denies a claim submitted under
this section, the affected participating local educational agency,
local educational consortium, or local governmental agency,
within 30 days after receipt of written notice of the denial,
may request that the department reconsider its action. The
participating local educational agency participant
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 to the
participating local educational agency participant
in response to its request for reconsideration, indicating the
specific reasons for which the claim is out of compliance. The
local educational agency participant
may appeal the decision of the director pursuant to the appeals
process established by the department and the State Department of
Education pursuant to paragraph (3) of subdivision (a) of Section
14132.471. 14132.473.
(k)
( l ) To the extent consistent
with federal law and regulations, participating local educational
agencies agencies, local educational
consortia, or local governmental agencies 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 educational agencies.
participants . A local educational
agency participant 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.
( l )
(m) As a condition of participation in the School-Based
Administrative Claiming process and in recognition of revenue
generated to a participating local educational agency
agency, local educational consortium, or local
governmental agency in the School-Based Administrative Claiming
process, each participating local educational agency
participant shall pay an annual participation
fee through a mechanism agreed to by the state and the
participating local
educational agencies. participant. The
participation fee shall be used to cover the cost of administering
the School-Based Administrative Claiming process. 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 School-Based Administrative Claiming process and
other costs related to that process.
(m)
(n) (1) For the purposes of this section,
"participating local educational agency" includes a 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 (c).
(2) Each participating Native American Indian tribe, tribal
organization, or subgroup of a Native American Indian tribe or tribal
organization may claim, as a Medi-Cal administrative activity,
facilitating Medi-Cal applications, including, but not limited to,
using the California Healthcare Eligibility, Enrollment, and
Retention System.
(n)
(o) (1) For purposes of this
section, "local educational agency" includes county offices of
education, special education local plan areas, Healthy Start
programs, and local educational agencies, as defined in subdivision
(h) of Section 14132.06, that participate in the School-Based
Administrative Claiming process program as a contractor with the
department.
(o)
(2) 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.
(p) (1) Each participating local educational
agency agency, local educational consortium, or local
governmental agency that contracts with the department pursuant to
paragraph (1) of subdivision (c) shall be responsible for the
preparation and submission of all administrative claiming plans,
training of local educational agency staff, and the submission of
detailed quarterly invoices.
(2) A participating local educational consortium shall be
responsible for a local educational agency in its service region that
participates in the School-Based Administrative Claiming process
program solely as a subcontractor to the local educational
consortium. 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, the submission of detailed
quarterly invoices on behalf of any participating local educational
agency, and ensuring that the local educational agency complies with
all requirements of the School-Based Administrative Claiming process
program.
(2)
(3) Each participating local educational
agency agency, local educational consortium, or local
governmental agency shall comply with all requirements of the
School-Based Administrative Claiming process program.
(3)
(4) Ninety days prior to the initial participation in
the School-Based Administrative Claiming process program, each local
educational agency agency, local educational
consortium, or local governmental agency shall notify the
department of its intent to participate in the program.
(p)
(q) Each local educational agency
consortium or local governmental agency that elects to
participate in the School-Based Administrative Claiming process
program shall submit claims directly to the department.
department. A local educational agency that elects to
participate in the School-Based Administrative Claiming process
program may submit claims directly to the department, or to a local
educational consortium or local governmental agency.
(q)
(r) The department shall continue to administer the
School-Based Administrative Claiming process program in conformity
with federal requirements.
(r)
(s) The department shall, by July 1, 2017, in
conjunction with the State Department of Education pursuant to the
interagency agreement or memorandum of understanding developed
pursuant to Section 14132.471, 14132.472,
provide technical assistance to all participating local
educational agencies agencies, local
educational consortia, and local governmental agencies in order
to maximize the allowable federal financial participation in the
School-Based Administrative Claiming process program.
(s)
(t) This section shall be applicable to School-Based
Administrative Claiming process program activities
performed in the 2017-18 fiscal year and thereafter.
(t)
The department shall prepare and file an annual report with the
Legislature for the School-Based Administrative Claiming process
program, similar to the annual report the department is required to
file for the local educational agency Medi-Cal billing option program
pursuant to Section 14115.8.
(u)
(u) This section and Section 14132.44 shall not be
construed to prevent a state agency from participating in the
School-Based Administrative Claiming process program or from
contracting with others to engage in these activities.
(v)
(v) This section shall not be construed to prohibit
county offices of education education, local
educational consortia, or local government
governmental agencies from providing services to local
educational agencies to facilitate participation in school-based
health programs on a fee-for-service basis.
basis; however, local governmental agencies and local educational
consortia shall only require local educational agencies to contract
for services that are actually provided and necessary for the
performance of oversight and monitoring responsibilities, including
training regarding random moment time surveys, random moment time
survey study tasks, roster updates, and financial review. This
section shall not be construed to prohibit a county office of
education or a local educational consortium providing services to a
local educational agency from contracting 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.
SEC. 6. SEC. 8. Section 14132.472 is
added to the Welfare and Institutions Code, to read:
14132.472. (a) By July 1, 2017, January
1, 2018, the department shall enter into an interagency
agreement or memorandum of understanding (MOU) with the State
Department of Education to coordinate the efforts of both departments
with respect to the School-Based Administrative Claiming process
program described in Section 14132.471 and the local educational
agency (LEA) Medi-Cal billing option (the LEA billing option)
described in Section 14132.06. The agreement or MOU shall focus on
the following:
(1) Maximizing the department's Medicaid program expertise.
(2) Coordinating functions and resources between the department
and the State Department of Education, and building personnel
capacity at the State Department of Education, to assist local
educational agencies in implementing and meeting the requirements of
the School-Based Administrative Claiming process program
and the LEA billing option at the local level.
level based on recommendations and input from the School-Based
Health Program and Policy Workgroup described in Section 14005.272.
That coordination shall include an agreement regarding the use
of funds withheld pursuant to Section 14132.473.
(3) Developing a process by which a local educational agency may
appeal an action of the department or the State Department of
Education with respect to the School-Based Administrative Claiming
process program or the LEA billing option. The appeals process shall
utilize the Office of Administrative Hearings, or another neutral
third party acceptable to the department and the State Department of
Education, as the appeals authority.
(b) In developing the interagency agreement or MOU described in
subdivision (a), the department shall do all of the following:
(1) Estimate the cost savings resulting from the
recommendations of the School-Based Health Program and Policy
Workgroup described in Section 14005.272 on restructuring of
the Administrative Claiming process program through implementation of
the School-Based Administrative Claiming process program described
in Section 14132.471. The department shall provide the estimate of
cost savings, data used to support the estimate, and a description of
the methodology used to calculate the estimate to the State
Department of Education.
(2) Consult with relevant nonprofit organizations involved in
facilitating information sharing among state Medicaid and education
agencies involved in the administration of Medicaid claiming for
school-based services to identify, and implement if feasible, best
practices that accomplish the coordination of efforts required by
subdivision (a).
(3) Consult with the School-Based Health Program and Policy
Workgroup established pursuant to Section 14005.272 regarding
the role of the State Department of Education on the impact of
the implementation of the School-Based Administrative Claiming
process program and the LEA billing option on operations at the local
level and any changes to the MOU that the workgroup recommends.
(4) Develop a schedule for the regular ongoing meetings of the
School-Based Health Program and Policy Workgroup to provide feedback
to the department and the State Department of Education.
(c) Any savings resulting from the restructuring of the
Administrative Claiming process program through implementation of the
School-Based Administrative Claiming process program and available
to the department shall on an ongoing basis be directed toward
implementation of the interagency agreement or MOU entered into
pursuant to this section, including, but not limited to, providing
necessary State Department of Education staff support and support to
county offices of education.