Amended in Senate May 5, 2015

Amended in Senate April 6, 2015

Senate Bill No. 534

Introduced by Senator Pan

February 26, 2015

An act to amend Section 14105.94 of, and to add Section 14105.941 to, the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 534, as amended, Pan. Medi-Cal: ground emergency medical transportation services: supplemental reimbursement.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law authorizes certain ground emergency medical transportation providers to receive supplemental Medi-Cal reimbursement in addition to the rate of payment that the provider would otherwise receive for those services. Existing law provides that participation in the supplemental reimbursement program by an eligible provider is voluntary, and requires the nonfederal share of the supplemental reimbursement to be paid only with funds from specified governmental entities.

This bill would authorize the department to provide supplemental reimbursement under these provisions for the cost of paramedic services at a rate of payment equal to cost.

This bill would also require the department to design and implement an intergovernmental transfer (IGT) program in order to increase capitation payments to Medi-Cal managed care plans for covered ground emergency medical transportation services, as specified. The bill would require the department to implement the IGT program on begin delete January 1, end delete begin insert July 1, end insert 2016, or a later date if otherwise required pursuant to any necessary federal approvals obtained. The bill would provide that participation in the IGTs is voluntary on the part of the transferring entity and would require Medi-Cal managed care plans to pay 100% of any amount of increased capitation payments made to eligible providers for providing and making available ground emergency medical transportation begin delete services. end delete begin insert services, and would permit, to the extent federal approval is obtained, the increased capitation payments to commence for dates of services on or after January 1, 2016. end insert

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.  

Section 14105.94 of the Welfare and Institutions
Code is amended to read:

14105.94.  

(a) An eligible provider, as described in subdivision
(b), may, in addition to the rate of payment that the provider would
otherwise receive for Medi-Cal ground emergency medical
transportation services, receive supplemental Medi-Cal
reimbursement to the extent provided in this section.

(b) A provider shall be eligible for supplemental reimbursement
only if the provider has all of the following characteristics
continuously during a state fiscal year:

(1) Provides ground emergency medical transportation services
to Medi-Cal beneficiaries.

(2) Is a provider that is enrolled as a Medi-Cal provider for the
period being claimed.

(3) Is owned or operated by the state, a city, county, city and
county, fire protection district organized pursuant to Part 2.7
(commencing with Section 13800) of Division 12 of the Health
and Safety Code, special district organized pursuant to Chapter 1
(commencing with Section 58000) of Division 1 of Title 6 of the
Government Code, community services district organized pursuant
to Part 1 (commencing with Section 61000) of Division 3 of Title
6 of the Government Code, health care district organized pursuant
to Chapter 1 (commencing with Section 32000) of Division 23 of
the Health and Safety Code, or a federally recognized Indian tribe.

(c) An eligible provider’s supplemental reimbursement pursuant
to this section shall be calculated and paid as follows:

(1) The supplemental reimbursement to an eligible provider, as
described in subdivision (b), shall be equal to the amount of federal
financial participation received as a result of the claims submitted
pursuant to paragraph (2) of subdivision (f).

(2) In no instance shall the amount certified pursuant to
paragraph (1) of subdivision (e), when combined with the amount
received from all other sources of reimbursement from the
Medi-Cal program, exceed 100 percent of actual costs, as
determined pursuant to the Medi-Cal State Plan, for ground
emergency medical transportation services.

(3) The supplemental Medi-Cal reimbursement provided by this
section shall be distributed exclusively to eligible providers under
a payment methodology based on ground emergency medical
transportation services provided to Medi-Cal beneficiaries by
eligible providers on a per-transport basis or other federally
permissible basis. The department may, to the extent permitted
under federal law and regulations, provide supplemental
reimbursement for the cost of paramedic services at a rate of
payment equal to cost. The department shall obtain approval from
the federal Centers for Medicare and Medicaid Services for the
payment methodology to be utilized, and shall not make any
payment pursuant to this section prior to obtaining that approval.

(d) (1) It is the Legislature’s intent in enacting this section to
provide the supplemental reimbursement described in this section
without any expenditure from the General Fund. An eligible
provider, as a condition of receiving supplemental reimbursement
pursuant to this section, shall enter into, and maintain, an agreement
with the department for the purposes of implementing this section
and reimbursing the department for the costs of administering this
section.

(2) The nonfederal share of the supplemental reimbursement
submitted to the federal Centers for Medicare and Medicaid
Services for purposes of claiming federal financial participation
shall be paid only with funds from the governmental entities
described in paragraph (3) of subdivision (b) and certified to the
state as provided in subdivision (e).

(e) Participation in the program by an eligible provider described
in this section is voluntary. If an applicable governmental entity
elects to seek supplemental reimbursement pursuant to this section
on behalf of an eligible provider owned or operated by the entity,
as described in paragraph (3) of subdivision (b), the governmental
entity shall do all of the following:

(1) Certify, in conformity with the requirements of Section
433.51 of Title 42 of the Code of Federal Regulations, that the
claimed expenditures for the ground emergency medical
transportation services are eligible for federal financial
participation.

(2) Provide evidence supporting the certification as specified
by the department.

(3) Submit data as specified by the department to determine the
appropriate amounts to claim as expenditures qualifying for federal
financial participation.

(4) Keep, maintain, and have readily retrievable, any records
specified by the department to fully disclose reimbursement
amounts to which the eligible provider is entitled, and any other
records required by the federal Centers for Medicare and Medicaid
Services.

(f) (1) The department shall promptly seek any necessary federal
approvals for the implementation of this section. The department
may limit the program to those costs that are allowable
expenditures under Title XIX of the federal Social Security Act
(42 U.S.C. Sec. 1396 et seq.). If federal approval is not obtained
for implementation of this section, this section shall not be
implemented.

(2) The department shall submit claims for federal financial
participation for the expenditures for the services described in
subdivision (e) that are allowable expenditures under federal law.

(3) The department shall, on an annual basis, submit any
necessary materials to the federal government to provide assurances
that claims for federal financial participation will include only
those expenditures that are allowable under federal law.

(g) (1) If either a final judicial determination is made by any
court of appellate jurisdiction or a final determination is made by
the administrator of the federal Centers for Medicare and Medicaid
Services that the supplemental reimbursement provided for in this
section must be made to any provider not described in this section,
the director shall execute a declaration stating that the
determination has been made and on that date this section shall
become inoperative.

(2) The declaration executed pursuant to this subdivision shall
be retained by the director, provided to the fiscal and appropriate
policy committees of the Legislature, the Secretary of State, the
Secretary of the Senate, the Chief Clerk of the Assembly, and the
Legislative Counsel, and posted on the department’s Internet Web
site.

(h) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement and administer this section by
means of provider bulletins, or similar instructions, without taking
regulatory action.

SEC. 2.  

Section 14105.941 is added to the Welfare and
Institutions Code, immediately following Section 14105.94, to
read:

14105.941.  

(a) The department shall design and implement,
in consultation with eligible providers as described in subdivision
(b), an intergovernmental transfer program relating to Medi-Cal
managed care, ground emergency medical begin delete transport end delete begin insert transportation end insert
services in order to increase capitation payments for the purpose
of increasing reimbursement to eligible providers.

(b) A provider shall be eligible for increased reimbursement
pursuant to this section only if the provider meets both of the
following conditions in an applicable state fiscal year:

(1) Provides ground emergency medical begin delete transport end delete begin insert transportation end insert
services to Medi-Cal managed care enrollees pursuant to a contract
or other arrangement with a Medi-Cal managed care plan.

(2) Is owned or operated by the state, a city, county, city and
county, fire protection district organized pursuant to Part 2.7
(commencing with Section 13800) of Division 12 of the Health
and Safety Code, special district organized pursuant to Chapter 1
(commencing with Section 58000) of Division 1 of Title 6 of the
Government Code, community services district organized pursuant
to Part 1 (commencing with Section 61000) of Division 3 of Title
6 of the Government Code, health care district organized pursuant
to Chapter 1 (commencing with Section 32000) of Division 23 of
the Health and Safety Code, or a federally recognized Indian tribe.

(c) (1) To the extent intergovernmental transfers are voluntarily
made by, and accepted from, an eligible provider described in
subdivision (b), or a governmental entity affiliated with an eligible
provider, the department shall make increased capitation payments
to applicable Medi-Cal managed care plans for covered ground
emergency medical transportation services.

(2) The increased capitation payments made pursuant to this
section shall be in amounts actuarially equivalent to the
supplemental fee-for-service payments available for eligible
providers pursuant to Section 14105.94, to the extent permissible
under federal law.

(3) Except as provided in subdivision (f), all funds associated
with intergovernmental transfers made and accepted pursuant to
this section shall be used to fund additional payments to eligible
providers.

(4) Medi-Cal managed care plans shall pay 100 percent of any
amount of increased capitation payments made pursuant to this
section to eligible providers for providing and making available
ground emergency medical transportation services pursuant to a
contract or other arrangement with a Medi-Cal managed care plan.

(d) The intergovernmental transfer program developed pursuant
to this section shall be implemented on begin delete January 1, end delete begin insert July 1, end insert 2016,
or a later date if otherwise required pursuant to any necessary
federal approvals obtained, and only to the extent
intergovernmental transfers from the eligible provider, or the
governmental entity with which it is affiliated, are provided for
this purpose. To the extent permitted by federal law, the department
may implement the intergovernmental transfer program and
increased capitation payments pursuant to this section on a
retroactive basis as needed.

(e) Participation in the intergovernmental transfers under this
section is voluntary on the part of the transferring entities for
purposes of all applicable federal laws.

(f) This section shall be implemented without any additional
expenditure from the General Fund. As a condition of participation
under this section, each eligible provider as described in
subdivision (b), or the governmental entity affiliated with an
eligible provider, shall agree to reimburse the department for any
costs associated with implementing this section. Intergovernmental
transfers described in this section are not subject to the
administrative fee assessed under paragraph (1) of subdivision (d)
of Section 14301.4.

(g) As a condition of participation under this section, Medi-Cal
managed care plans, eligible providers as described in subdivision
(b), and governmental entities affiliated with eligible providers
shall agree to comply with any requests for information or similar
data requirements imposed by the department for purposes of
obtaining supporting documentation necessary to claim federal
funds or to obtain federal approvals.

(h) This section shall be implemented only if and to the extent
federal financial participation is available and is not otherwise
jeopardized, and any necessary federal approvals have been
obtained.

(i) To the extent that the director determines that the payments
made pursuant to this section do not comply with federal Medicaid
requirements, the director retains the discretion to return or not
accept an intergovernmental transfer, and may adjust payments
pursuant to this section as necessary to comply with federal
Medicaid requirements.

(j) To the extent federal approval is obtained, the increased
capitation payments under this section may commence for dates
of service on or after January 1, 2016.

(k) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
section by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions, without taking regulatory action.