BILL ANALYSIS Ó
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | SB 276|
|Office of Senate Floor Analyses | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
THIRD READING
Bill No: SB 276
Author: Wolk (D)
Amended: 4/20/15
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 4/15/15
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Pan, Roth,
Wolk
NO VOTE RECORDED: Nielsen
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
SUBJECT: Medi-Cal: local educational agencies
SOURCE: California School Nurses Organization
DIGEST: This bill requires the Department of Health Care
Services (DHCS) to seek federal financial participation for
covered services that are provided by a local educational agency
(LEA) to a child who is an eligible Medi-Cal beneficiary,
regardless of whether the child has an individualized education
plan (IEP) or an individualized family service plan (IFSP), 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.
ANALYSIS:
SB 276
Page 2
Existing law:
1)Establishes the Medi-Cal program, administered by DHCS, under
which qualified low-income persons receive health care
benefits.
2)Requires that specified services provided by an 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 for children
with an IEP or an 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
a University of California campus.
This bill:
1)Requires, subject to 2) below, DHCS to seek FFP for covered
services that are provided by an 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
SB 276
Page 3
services against legally liable third parties.
3)Requires, if a legally liable third party receives a claim
submitted by an LEA pursuant to 2) above, the legally liable
third party to either reimburse the claim or issue a notice of
denial of non-coverage of services or benefits.
4)Permits the LEA, if there is no response to a claim submitted
to a legally liable third party by an LEA within 45 days, to
bill the Medi-Cal program. Requires the LEA to retain a copy
of the claim submitted to the legally liable third party for a
period of three years.
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.
Comments
1)Author's statement. According to the author, "[T]his 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 model, and
school expenditures for qualified services rendered are
reimbursed at 50 percent of cost using federal Medicaid
SB 276
Page 4
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
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 Children's Services Program;
c) Short-Doyle Program;
d) Medi-Cal field office authorization; and,
e) Prepaid health plan authorization (including Primary
Care Case Management).
1)Recent federal guidance on Medicaid payments for "free care."
In December 2014, the federal Centers for Medicare & Medicaid
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
SB 276
Page 5
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.
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 IEP 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 third-party liability (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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
1)One-time administrative costs of about $250,000 to develop a
state plan amendment and make system changes by DHCS (General
Fund and federal funds).
SB 276
Page 6
2)No additional General Fund costs for administering the
program. Under current practice, DHCS retains a small portion
of the available federal matching funds to pay for state
administrative costs.
3)Unknown additional federal funding to LEAs to pay for services
to Medi-Cal beneficiaries (federal funds). Recent federal
guidance expands the availability of federal matching funds
for health care services provided by LEAs. This bill amends
state law to allow LEAs to draw down additional federal
funding. Under current law, the non-federal share of costs is
provided by LEAs. There is no General Fund contribution to the
program.
SUPPORT: (Verified5/26/15)
California School Nurses Organization (source)
American Nurses Association California
California Black Health Network
California Chapter National Association of Social Workers
California Federation of Teachers
California School-Based Health Alliance
California School Boards Association
Children Now
Emery Unified School District
Hayward Unified School District
Lawndale Elementary School District
Manteca Unified School District
Nevada County Superintendent of Schools Holly Hermansen
Nevada Joint Union High School District
Ripon Unified School District
San Joaquin County Office of Education
Sulphur Springs Unified School District
One individual
OPPOSITION: (Verified05/26/15)
None received
SB 276
Page 7
ARGUMENTS IN 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 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 concludes enhanced LEA billing will augment the
current system while providing care for children who require
medical services to function in the least restrictive
environment.
Prepared by:Scott Bain / HEALTH /
5/30/15 17:49:34
**** END ****