BILL ANALYSIS Ó
SB 276
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Date of Hearing: June 23, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
276 (Wolk) - As Amended April 20, 2015
SENATE VOTE: 40-0
SUBJECT: Medi-Cal: local educational agencies.
SUMMARY: Requires DHCS to seek federal financial participation
(FFP) for covered services that are provided by a local
education agency (LEA) to a Medi-Cal eligible child 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 child or to
the community at large, and authorizes 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 third party
within 45 days.
EXISTING LAW:
1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
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qualified low-income persons receive health care benefits.
2)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.
3)Requires that specified services provided by a LEA are covered
Medi-Cal benefits, to the extent FFP is available.
4)Requires that specified services be subject to utilization
controls and standards adopted by DHCS, and are consistent
with Medi-Cal requirements for physician prescription, order,
and supervision.
5)Defines the scope of covered services that an LEA may provide,
which include targeted case management services (TCM) for
children with an IEP or an IFSP.
FISCAL EFFECT: According to the Senate Appropriations
Committee, one-time administrative costs of about $250,000 to
develop a state plan amendment and make system changes by DHCS
and unknown additional federal funding to LEAs to pay for
services to Medi-Cal beneficiaries (federal funds).
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COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, this bill will
allow LEAs to receive reimbursement for services provided to
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. The author states that
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. The author concludes that 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)BACKGROUND.
a) 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% 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 funds.
Subject to specified conditions, LEA covered services can
include the following:
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i) Health and mental health evaluations and health and
mental health education;
ii) Medical transportation;
iii) Nursing services;
iv) Occupational therapy;
v) Physical therapy;
vi) Physician services;
vii) Mental health and counseling services;
viii) School health aide services;
ix) Speech pathology services;
x) Audiology services; and,
xi) 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
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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:
i) IEP or IFSP developed for the special education
student;
ii) California Childrens Services Program;
iii) Short-Doyle Program;
iv) Medi-Cal field office authorization (TAR); and,
v) Prepaid health plan authorization (including Primary
Care Case Management).
b) "Free Care Rule". Historically, the Centers for
Medicare and Medicaid Services (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.
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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:
i) The individual is a Medicaid beneficiary;
ii) 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;
iii) The provider is a Medicaid-participating provider
and meets all federal and/or state provider qualification
requirements;
iv) The state plan contains a payment methodology for
determining rates that are consistent with efficiency,
economy and quality of care;
v) Third party liability (TPL) requirements are met;
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vi) Medicaid payment does not duplicate other specific
payments for the same service;
vii) The state and provider maintain auditable
documentation to support claims for FFP;
viii) The state conducts appropriate financial oversight
of provider billing practices; and,
ix) All other program requirements (statutory,
regulatory, policy) for the service, payment, and
associated claiming are met.
c) IEPs. Pursuant to the federal Individuals with
Disabilities Education Act (IDEA), children with
disabilities are guaranteed the right to a free,
appropriate public education, including necessary services
for a child to benefit from his or her education. An IEP
is a legally binding document that determines what special
education services a child will receive and why. IEPs
include a child's classification, placement, specialized
services, academic and behavioral goals, a behavior plan if
needed, percentage of time in regular education, and
progress reports from teachers and therapists. A child may
require any related services in order to benefit from
special education, including (but not limited to):
speech-language pathology and audiology services, early
identification and assessment of disabilities in children,
medical services, physical and occupational therapy,
orientation and mobility services; and psychological
services.
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According to the California Department of Education (CDE),
over 700,000, or approximately 11% of, California students
received Special Education services in the 2013-14 academic
year.
3)SUPPORT. This bill is sponsored by the California School
Nurses Organization (CSNO), which states 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, 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 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.
4)RELATED LEGISLATION.
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a) SB 123 (Liu) requires the Legislative Analyst, in
consultation with CDE and DHCS, to make recommendations
relative to the administration and oversight of the SMAA
program. SB 123 is pending in the Assembly Health
Committee.
b) AB 1133 (Achadjian) makes technical changes to existing
law regarding grants to LEAs to pay the state share of
costs of providing school-based early mental health
intervention and prevention services to eligible students.
AB 1133 was held in the Assembly Appropriations Committee.
c) AB 1018 (Cooper) requires DHCS and CDE to convene a
joint task force to examine the delivery of mental health
services to children eligible for ESPDT services and for
services required by the federal Individuals with
Disabilities Education Act. AB 1018 is pending in the
Senate Education Committee.
5)PREVIOUS LEGISLATION.
a) 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.
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b) 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.
c) 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.
6)DOUBLE REFERRAL. This bill is double referred; upon passage in
this Committee, this bill will be referred to the Assembly
Education Committee.
REGISTERED SUPPORT / OPPOSITION:
Support
California School Nurses Organization (sponsor)
American Nurses Association California
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Association of California School Administrators
California Federation of Teachers
California School Boards Association
California School-Based Health Alliance
California School Employees Association
Children Now
Emery Unified School District
Lawndale Elementary School District
Magnolia School District
Manteca Unified School District
National Association of Social Workers, California Chapter
Nevada County Superintendent of Schools Holly Hermansen
Sulphur Springs School District
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Opposition
None on file.
Analysis Prepared by:Paula Villescaz / HEALTH / (916)
319-2097