Amended in Senate April 20, 2015

Amended in Senate March 26, 2015

Senate Bill No. 276

Introduced by Senator Wolk

February 19, 2015

An act to amend Section 14132.06 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 276, as amended, Wolk. Medi-Cal: local educational agencies.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides that specified services, including targeted case management services for children with an individual education plan (IEP) or an individualized family service plan (IFSP), provided by local educational agencies (LEAs) are covered Medi-Cal benefits, and authorizes an LEA to bill for those services. Existing law requires the department to perform various activities with respect to the billing option for services provided by LEAs.

This bill would require the department to seek federal financial participation for covered services that are provided by an LEA to a child who is an eligible Medi-Cal beneficiary regardless of whether the child has an individualized education plan or an individualized family service plan, or whether those same services are provided at no charge to the beneficiary or to the community at large, if the LEA takes all reasonable measures to ascertain and pursue claims for payment of covered services against legally liable 3rd parties. The bill would require a legally liable 3rd party to begin insert either reimburse the claim or end insert issue a notice of denial of noncoverage of services or benefits if the legally liable 3rd party begin delete denies end delete begin insert receives end insert a claim for payment of covered services submitted by an LEA. begin insert The bill would authorize an LEA to bill the Medi-Cal program if there is no response to a claim for payment of covered services submitted to a legally liable 3rd party within 45 days, and would require the LEA to retain a copy of the claim submitted to the legally liable 3rd party for a period of 3 years. end insert

This bill would also expand the authority of an LEA to provide targeted case management services.

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.  

The Legislature finds and declares all of the
following:

(a) Local educational agencies (LEA) must have an approved
provider participant agreement with the State Department of Health
Care Services through the federal Centers for Medicare and
Medicaid Services to be eligible to provide services. To participate
in the LEA Medi-Cal billing option program, LEAs must reinvest
the federal reimbursement they receive under this program in health
and social services for children and families, and develop and
maintain a collaborative committee to assist them in decisions
regarding the reinvestment of federal reimbursements. The
providers and supervisors of staff for the assessment and medically
necessary health services are begin delete school nurses. end delete begin insert those qualified medical
practitioners the LEA employs or contracts with to render certain
health services. end insert

(b) The LEA billing option facilitates reinvestment in health
and social services for students and their families so that schools
can foster access to and provide comprehensive health services to
eligible Medi-Cal students.

(c) The funds are reimbursement for services rendered and can
be used as matching dollars to draw down federal financial
participation. The funds are restricted in their use; they must
supplement existing services, not supplant.

(d) It is, therefore, the intent of the Legislature in enacting this
act to ensure that a school district or county office of education
that is authorized as an LEA Medi-Cal provider is assured that all
options for federal financial participation are available. The
Legislature encourages LEAs to utilize reimbursed funds to hire
credentialed school nurses to supplement, not supplant, existing
LEA health services personnel.

SEC. 2.  

Section 14132.06 of the Welfare and Institutions Code
is amended to read:

14132.06.  

(a) Services specified in this section that are
provided by a local educational agency are covered Medi-Cal
benefits, to the extent federal financial participation is available,
and subject to utilization controls and standards adopted by the
department, and consistent with Medi-Cal requirements for
physician prescription, order, and supervision.

(b) Any provider enrolled on or after January 1, 1993, to provide
services pursuant to this section may bill for those services
provided on or after January 1, 1993.

(c) Nothing in this section shall be interpreted to expand the
current category of professional health care practitioners permitted
to directly bill the Medi-Cal program.

(d) Nothing in this section is intended to increase the scope of
practice of any health professional providing services under this
section or Medi-Cal requirements for physician prescription, order,
and supervision.

(e) (1) For the purposes of this section, the local educational
agency, as a condition of enrollment to provide services under this
section, shall be considered the provider of services. A local
educational agency provider, as a condition of enrollment to
provide services under this section, shall enter into, and maintain,
a contract with the department in accordance with guidelines
contained in regulations adopted by the director and published in
Title 22 of the California Code of Regulations.

(2) Notwithstanding paragraph (1), a local educational agency
providing services pursuant to this section shall utilize current
safety net and traditional health care providers, when those
providers are accessible to specific schoolsites identified by the
local educational agency to participate in this program, rather than
adding duplicate capacity.

(f) For the purposes of this section, covered services may include
all of the following local educational agency services:

(1) Health and mental health evaluations and health and mental
health education.

(2) Medical transportation.

(A) The following provisions shall not apply to medical
transportation eligible to be billed under this section:

(i) Section 51323(a)(2)(A) of Title 22 of the California Code
of Regulations.

(ii) Section 51323(a)(3)(B) of Title 22 of the California Code
of Regulations.

(iii) For students whose medical or physical condition does not
require the use of a gurney, Section 51231.1(f) of Title 22 of the
California Code of Regulations.

(iv) For students whose medical or physical condition does not
require the use of a wheelchair, Section 51231.2(e) of Title 22 of
the California Code of Regulations.

(B) (i) Subparagraph (A) shall become inoperative on January
1, 2018, or on the date the director executes a declaration stating
that the regulations implementing subparagraph (A) and Section
14118.5 have been updated, whichever is later.

(ii) The department shall post the declaration executed under
clause (i) on its Internet Web site and transmit a copy of the
declaration to the Assembly Committee on Budget and the Senate
Committee on Budget and Fiscal Review and the LEA Ad Hoc
Workgroup.

(iii) If subparagraph (A) becomes inoperative on January 1,
2018, subparagraph (A) and this subparagraph shall be inoperative
on January 1, 2018, unless a later enacted statute enacted before
that date, deletes or extends that date.

(iv) If subparagraph (A) becomes inoperative on the date the
director executes a declaration as described in clause (i),
subparagraph (A) and this subparagraph shall be inoperative on
the January 1 immediately following the date subparagraph (A)
becomes inoperative, unless a later enacted statute enacted before
that date, deletes or extends that date.

(3) Nursing services.

(4) Occupational therapy.

(5) Physical therapy.

(6) Physician services.

(7) Mental health and counseling services.

(8) School health aide services.

(9) Speech pathology services. These services may be provided
by either of the following:

(A) A licensed speech pathologist.

(B) A credentialed speech-language pathologist, to the extent
authorized by Chapter 5.3 (commencing with Section 2530) of
Division 2 of the Business and Professions Code.

(10) Audiology services.

(11) Targeted case management services for children regardless
of whether the child has an individualized education plan (IEP) or
an individualized family service plan (IFSP).

(g) Local educational agencies may, but need not, provide any
or all of the services specified in subdivision (f).

(h) For the purposes of this section, “local educational agency”
means the governing body of any school district or community
college district, the county office of education, a state special
school, a California State University campus, or a University of
California campus.

(i) Notwithstanding any other law, a community college district,
a California State University campus, or a University of California
campus, consistent with the requirements of this section, may bill
for services provided to any student, regardless of age, who is a
Medi-Cal recipient.

(j) No later than July 1, 2013, and every year thereafter, the
department shall make publicly accessible an annual accounting
of all funds collected by the department from federal Medicaid
payments allocable to local educational agencies, including, but
not limited to, the funds withheld pursuant to subdivision (g) of
Section 14115.8. The accounting shall detail amounts withheld
from federal Medicaid payments to each participating local
educational agency for that year. One-time costs for the
development of this accounting shall not exceed two hundred fifty
thousand dollars ($250,000).

(k) (1) If the requirement in paragraph (2) is satisfied, the
department shall seek federal financial participation for covered
services that are provided by a local educational agency pursuant
to subdivision (a) to a child who is an eligible Medi-Cal
beneficiary, regardless of either of the following:

(A) Whether the child has an IEP or an IFSP.

(B) Whether those same services are provided at no charge to
the beneficiary or to the community at large.

(2) The local educational agency shall take all reasonable
measures to ascertain and pursue claims for payment of covered
services specified in this section against legally liable third parties
pursuant to Section 1902(a)(25) of the federal Social Security Act
(42 U.S.C. Sec. 1396a(a)(25)).

(3) If a legally liable third party begin delete denies end delete begin insert receives end insert a claim
submitted by a local educational agency pursuant to paragraph (2),
the legally liable third party shall begin insert either reimburse the claim or end insert
issue a notice of denial of noncoverage of services or benefits. begin insert If
there is no response to a claim submitted to a legally liable third
party by a local educational agency within 45 days, the local
educational agency may bill the Medi-Cal program pursuant to
subdivision (b). The local educational agency shall retain a copy
of the claim submitted to the legally liable third party for a period
of three years. end insert