BILL ANALYSIS Ó
SB 276
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Date of Hearing: August 19, 2015
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Jimmy Gomez, Chair
SB 276
(Wolk) - As Amended July 16, 2015
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Urgency: No State Mandated Local Program: NoReimbursable: No
SUMMARY:
This bill updates code relating to the local educational agency
(LEA) Medi-Cal billing program to conform to recent federal
guidance that expands the services for which LEAs can bill
Medi-Cal. Specifically, this bill:
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1)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.
2)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.
FISCAL EFFECT:
1)Unknown, significant ongoing increased expenditures in the
Medi-Cal program from non GF-sources (local and federal
funds). LEAs also reimburse DHCS's administrative costs.
Certain administrative cost reimbursements are subject to a
cap.
2)One-time costs of $250,000 (local/federal) for the fiscal
intermediary to adjust information technology systems.
3)The California Department of Justice notes an unquantifiable,
but potentially significant GF impact based on a potential for
lawsuits challenging whether DHCS adequately confirmed that
the LEA took reasonable measures to ascertain legally liable
third parties. These lawsuits would be related to audits by
the federal government regarding FFP grants.
COMMENTS:
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1)Purpose. 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 FFP will increase by
allowing school districts and county offices of education to
be reimbursed for all covered services to Medi-cal eligible
students.
2)Background. Historically, federal guidance on "free care"
stated Medicaid payment was not available for services
provided for free to the public, with some limited 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 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.
In addition, schools note another barrier to reimbursement
occurs when they seek private third-party reimbursement and
receive no response. This bill allows LEAs to receive
reimbursement based on documentation that they submitted
claims for reimbursement by third parties and did not receive
a response within 45 days.
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3)Comments. As noted, it is unknown to what extent this bill and
new federal guidance will expand school-based health care
services. Although likely beneficial overall, staff notes any
significant expansion of the LEA billing option program poses
some concern about public dollars paying twice for services.
School-based services reimbursed through LEA billing are
generally services provided in a fee-for-service environment,
outside the "management" of managed care. From a school's
perspective, it may seem an obvious way to receive more in
federal dollars. However, it begs the question of why a
school is in a position of providing needed health care
services to students, on whose behalf the state is already
paying a monthly rate to Medi-Cal managed care plans to
comprehensively manage their health care needs. School-based
health care has obvious advantages, and perhaps some services
are appropriately provided on a population basis at a school
site. However, ideally, school-based care should be
integrated with the care provided and paid for through managed
care plans to prevent duplication of services and payment.
Consider the case of immunization. It may make sense and be
convenient for families for schools to offer immunizations to
students. However, to do this in an effective way, schools
need also to have the ability to communicate with the state's
immunization registry and/or providers at a student's medical
home, to ensure vaccination status is recorded and to ensure
vaccinations are not provided to a student who has already
received them. For managed care plans, vaccination status of
their enrollees needs to be documented in order for plans to
receive quality ratings. One way to ensure no duplication is
for managed care plans to contract with schools or
school-based providers outside of the LEA billing process,
something that has, according to schools, been slow to occur.
Perhaps this bill is not the place for a wholesale
reexamination of the relationship between school-based care
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and managed care. However, if school-based care grows
significantly, some additional oversight seems warranted to
assess the level of coordination or potential duplication of
services and payment.
Finally, DHCS notes certain administrative reimbursements are
subject to a cap, specifically audit and contract staff
functions. Because the fiscal impact is unknown and this
change could result in significantly more utilization of the
LEA billing option, reexamination of these caps seem
appropriate to ensure the caps can be adjusted based on
program growth.
Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081