BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 276
---------------------------------------------------------------
|AUTHOR: |Wolk |
|---------------+-----------------------------------------------|
|VERSION: |March 26, 2015 |
---------------------------------------------------------------
---------------------------------------------------------------
|HEARING DATE: |April 15, 2015 | | |
---------------------------------------------------------------
---------------------------------------------------------------
|CONSULTANT: |Scott Bain |
---------------------------------------------------------------
SUBJECT : Medi-Cal: local educational agencies
SUMMARY : Requires the Department of Health Care Services to seek federal
financial participation for covered services that are provided
by a local education agency (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 third
parties.
Existing law:
1.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income persons receive health care benefits.
2.Requires that specified services provided by a LEA are covered
Medi-Cal benefits, to the extent federal financial
participation (FFP) is available, are subject to utilization
controls and standards adopted by DHCS, and are consistent
with Medi-Cal requirements for physician prescription, order,
and supervision.
3.Defines the scope of covered services that an LEA may provide,
which include targeted case management services (TCM) for
children with an individualized education plan (IEP) or an
individualized family service plan (IFSP).
4.Defines an LEA as 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
SB 276 (Wolk) Page 2 of ?
a University of California campus.
This bill:
1.Requires, subject to 2) below, DHCS to seek FFP for covered
services that are provided by a LEA 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; and,
b. Whether those same services are provided at no
charge to the beneficiary or to the community at
large.
2.Implements the requirement in 1) above if the LEA takes all
reasonable measures to ascertain and pursue claims for payment
of covered services against legally liable third parties
pursuant to a specified provision of federal Medicaid law that
requires that states take all reasonable measures to ascertain
and pursue claims for payment of health care items and
services against legally liable third parties.
3.Requires, if a legally liable third party denies a claim
submitted by a LEA pursuant to 2) above, the legally liable
third party to issue a notice of denial of non-coverage of
services or benefits.
4.Makes legislative findings and declarations regarding this
bill, including that:
a. LEAs must have an approved provider
participant agreement with DHCS through the federal
Centers for Medicare and Medicaid Services to be
eligible to provide services;
b. 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.
c. The providers and supervisors of staff for the
assessment and medically necessary health services are
school nurses;
d. The LEA billing option facilitates
reinvestment in health and social services for
SB 276 (Wolk) Page 3 of ?
students and their families so that schools can foster
access to and provide comprehensive health services to
eligible Medi-Cal students; and,
e. The funds are reimbursement for services
rendered and can be used as matching dollars to draw
down FFP, and the funds are restricted in their use as
they must supplement existing services, not supplant.
5.States legislative intent in enacting this bill 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 FFP are available, and the Legislature encourages
LEAs to utilize reimbursed funds to hire credentialed school
nurses to supplement, not supplant, existing LEA health
services personnel.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, this bill will
allow LEAs to receive reimbursement for qualified services
provided for all Medi-Cal eligible students regardless of
whether the student has an IEP or IFSP or whether similar
services are provided to regular education students at no
cost. This bill will allow schools to be reimbursed for all
services provided to all Medi-Cal eligible students. This
increased funding would enable schools to be more active in
managing the conditions affecting all students, may increase
the services they provide and may result in the hiring of more
school nurses. With school districts and county offices of
education having the ability to be reimbursed for all covered
services to Medi-Cal eligible students, FFP will increase.
2.LEA. The LEA Medi-Cal Billing Option Program was established
in 1993 and provides Medicaid FFP to LEAs for health-related
services provided by qualified medical practitioners.
Reimbursement is based upon a fee-for-service (FFS) model, and
school expenditures for qualified services rendered are
reimbursed at 50 percent of cost using federal Medicaid
matching funds. There is no state General Fund expense for the
program. Under the program, LEAs bill Medi-Cal for the direct
medical services they provide to Medi-Cal eligible students.
LEAs pay for the services and are reimbursed the FFP rate
relative to the cost of each individual service from federal
SB 276 (Wolk) Page 4 of ?
funds. Subject to specified conditions, LEA covered services
can include the following:
a. Health and mental health evaluations and health and
mental health education;
b. Medical transportation;
c. Nursing services;
d. Occupational therapy;
e. Physical therapy;
f. Physician services;
g. Mental health and counseling services;
h. School health aide services;
i. Speech pathology services;
j. Audiology services; and,
aa. Targeted case management services for children with
an IEP or an IFSP.
Under the state's Medicaid State Plan, LEA services are
limited to a maximum of 24 services per 12 month period for a
beneficiary without prior authorization, provided that
medical necessity criteria are met. LEAs may obtain
authorization for LEA services beyond 24 services per
12-month period from the beneficiary's:
a. IEP or IFSP developed for the special education
student;
b. California Childrens Services Program;
c. Short-Doyle Program;
d. Medi-Cal field office authorization (TAR); and,
e. Prepaid health plan authorization (including
Primary Care Case Management).
1.Recent federal guidance on Medicaid payment for "free care."
In December 2014, the federal Centers for Medicare & Medicaid
SB 276 (Wolk) Page 5 of ?
Services (CMS) issued a State Medicaid Director Letter
regarding Medicaid payment for services covered under a
state's Medicaid plan to an eligible Medicaid beneficiary that
are available without charge to the beneficiary, including
services that are available without charge to the community at
large, or "free care." Historically, CMS guidance on "free
care" was that Medicaid payment was generally not allowable
for services that were available without charge to the
beneficiary, with some statutory and some policy exceptions
(such as services provided as part of an IEP or IFSP.) The
free care policy as previously applied effectively prevented
the use of Medicaid funds to pay for covered services
furnished to Medicaid eligible beneficiaries when the provider
did not bill the beneficiary or any other individuals for the
services.
Under the new December 2014 guidance, Medicaid reimbursement
is available for covered services under the approved state
plan that are provided to Medicaid beneficiaries, regardless
of whether there is any charge for the service to the
beneficiary or the community at large. As a result, FFP is
available for Medicaid payments for care provided through
providers that do not charge individuals for the service, as
long as all other Medicaid requirements are met. As is the
case more generally, FFP for Medicaid payments is available
only when all of the following elements are satisfied:
a. The individual is a Medicaid beneficiary;
b. The service is a covered Medicaid service, provided
in accordance with the approved state plan methodologies,
including coverage under the Early and Periodic Screening
Diagnostic and Treatment (EPSDT) benefit provided to
children;
c. The provider is a Medicaid-participating provider
and meets all federal and/or state provider qualification
requirements;
d. The state plan contains a payment methodology for
determining rates that are consistent with efficiency,
economy and quality of care;
e. Third party liability (TPL) requirements are met;
f. Medicaid payment does not duplicate other specific
payments for the same service;
g. The state and provider maintain auditable
documentation to support claims for FFP;
h. The state conducts appropriate financial oversight
SB 276 (Wolk) Page 6 of ?
of provider billing practices; and,
i. All other program requirements (statutory,
regulatory, policy) for the service, payment, and
associated claiming are met.
CMS states the goal of its new guidance is to facilitate and
improve access to quality healthcare services and improve the
health of communities.
Prior to the CMS guidance in 2014, DHCS indicated there are
two exceptions to the free care rule: (a) Medicaid covered
services provided as part of an IEHP or IFSP; and (b) services
provided by Title V of the Social Security Act (the Maternal
Child Health Services Block Grant). DHCS indicates services
provided as part of an IEP/IFSP are exempt from the fee care
rule, they are not exempt from the TPL requirement. If any
student has Other Health Coverage, those third party insurers
must be billed prior to billing Medi-Cal for the service. The
TPL requirement is based on the basic premise under federal
Medicaid law and regulation that Medicaid is generally the
payor of last resort.
1.Prior legislation. AB 2608 (Bonilla), Chapter 755, Statutes of
2012, made permanent and expanded provisions relating to
program improvement activities in the Medi-Cal Local Billing
Option (LBO) program, through which LEAs can draw down federal
funding for health care services provided to Medi-Cal-eligible
students. AB 2608 also expanded the scope of transportation
services for which Medicaid reimbursements can receive
reimbursement.
SB 870 (Ducheny), Chapter 712, Statutes of 2010, (the 2010-11
Budget Bill) required DHCS to withhold one percent of LEA
reimbursements, not to exceed $650,000, for the purpose of
funding the work and related administrative costs associated
with the audit resources approved in a specified budget change
proposal to ensure fiscal accountability of the LEA Medi-Cal
LBO and to comply with the Medi-Cal State Plan.
AB 1540 (Committee on Health), Chapter 298, Statutes of 2009,
extended the LEA LBO program improvement provision sunset date
from January 1, 2010, to January 1, 2013.
AB 131 (Committee on Budget), Chapter 80, Statutes of 2005,
the 2005 health budget trailer bill, sunset the LEA program
SB 276 (Wolk) Page 7 of ?
improvement provisions January 1, 2010.
SB 231 (Ortiz), Chapter 655, Statutes of 2001, enacted the LEA
program improvement activities requirements, required DHCS to
obtain a state plan amendment to accomplish various goals to
enhance reimbursement for Medi-Cal services provided at school
sites and student access to those services, and sunset various
provisions of that bill January 1, 2006.
SB 256 (Maddy), Chapter 654, Statutes of 1993, established the
LEA LBO program by requiring that services provided by a LEA
are a Medi-Cal-covered benefit.
2.Support. This bill is sponsored by the California School
Nurses Organization (CSNO), which writes that schools nurses
provide direct health care services that are medically
necessary and ordered by the child's physician for all
children in the schools. CSNO states the provision of these
services allows the schools to meet the requirements under the
federal Individuals with Disabilities Education Act (IDEA) for
students who are in the special education category. With the
revised guidance from CMS in December 2014, LEAs are now able
to seek reimbursement for all health care provided to all
Medi-Cal eligible students in both regular and special
education. CSNO states it has been well documented that health
care delivered in the schools is an economic and efficacious
model. With this CMS change and the access to increased
reimbursement, CSNO anticipates that LEAs will improve the
coordination of students with chronic conditions some which
impact their ability to be successful in school. CSNO believes
this will be a value added, particularly to those schools with
students less likely to have access to comprehensive care, and
it believes the increased emphasis on prevention, early
intervention and chronic disease management. CSNO conclude
enhanced LEA billing will augment the current system while
providing care for children who require medical services to
function in the least restrictive environment.
3.Amendments.
a. The findings and declarations in this bill state the
providers and supervisors of staff for the assessment and
medically necessary health services are school nurses.
Staff recommends this language be broadened to include
other types of providers who provide health care services
in school who are not school nurses.
SB 276 (Wolk) Page 8 of ?
b. One of the existing problems an LEA experiences is
not receiving a response on a claims submission to a
third party. This bill requires, if a legally liable
entity denies a claim, that entity to issue a notice of
denial. A written denial could be used by the LEA as an
attempt to pursue claims for payment from legally liable
third parties. However, as drafted, if there is no
response from the legally liable third party, the
existing language does not solve this problem. Amendments
are needed to clarify this provision.
SUPPORT AND OPPOSITION :
Support: California School Nurses Organization (sponsor)
American Nurses Association California
California Black Health Network
California Chapter National Association of Social
Workers
California School Boards Association
Children Now
Lawndale Elementary School District
Manteca Unified School District
Nevada County Superintendent of Schools Holly
Hermansen
San Joaquin County Office of Education
Sulphur Springs School District
An individual
Oppose: None received
-- END --