BILL NUMBER: AB 754 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 14, 2009
INTRODUCED BY Assembly Member Chesbro
FEBRUARY 26, 2009
An act to amend Section 5777 and 5778 of the Welfare and
Institutions Code, relating to Medi-Cal mental health services.
LEGISLATIVE COUNSEL'S DIGEST
AB 754, as amended, Chesbro. Medi-Cal mental health managed care
contracts.
Existing law provides for provision of Mental
mental health services to Medi-Cal recipients, as part of,
the Early and Periodic Screening, Diagnosis, and Treatment Program
(EPSDT), which is administered by the State Department of Mental
Health (department) and the counties.
Existing law separately provides for the Medi-Cal program,
administered by the State Department of Health Care Services, under
which qualified low-income persons are provided with health care
services, including mental health services.
Under existing law, the department is required to implement
managed mental health care for Medi-Cal recipients through
fee-for-service or capitated contracts with counties, counties acting
jointly, qualified individuals or organizations, or nongovernmental
entities. The department is responsible for assuming specified
program oversight authority formerly provided by the State Department
of Health Care Services, including, but not limited to, oversight of
certain utilization controls.
Existing law requires a contract entered into pursuant to the
above provisions to include a provision that the county mental health
plan shall bear the financial risk for the cost of providing
medically necessary mental health services to Medi-Cal beneficiaries
irrespective of whether the cost of those services exceeds the
payment set forth in the contract.
This bill would provide that the contract need not include a
provision that the county mental health plan shall not bear the
financial risk for the cost of providing EPSDT services.
Under existing law, a change may be made during a contract term or
at the time of contract renewal, where there is a change in
obligations required by federal or state law or when required by a
change in the interpretation or implementation of any law or
regulation. Existing law provides, to the extent permitted by federal
law and except as provided, if any change in obligations occurs that
affects the cost to the county mental health plan of performing
under the terms of its contract, the department may reopen contracts,
as specified.
This bill would provide that either the department or the mental
health plan may reopen the contract.
Existing law requires the department to recover overpayments of
federal financial participation from mental health plans within the
timeframes required by federal law and regulation and to return those
funds to the State Department of Health Care Services for repayment
to the federal Centers for Medicare and Medicaid Services.
This bill would also require the department to reimburse
underpayment of federal financial participation to mental health
plans within the required timeframes and would make conforming
changes.
This bill would require mental health plan claims for federal
financial participation to be submitted to the federal Centers for
Medicare and Medicaid Services by the department and the State
Department of Health Care Services throughout the fiscal year as
claims are received. The bill would also require payments be made to
the mental health plans as soon as within 30
days after the federal payments have been received by the
state.
Existing law requires the department to allocate the amount of
payment set forth in the contract at the beginning of the contract
period to the mental health plan. Existing law requires the funds to
be considered to be funds of the plan that may be held by the
department.
This bill would require the department to allocate and distribute
the full amount of payment set forth in the contract at the beginning
of the contract period to the mental health plan and would make
conforming changes.
Under existing law, each fiscal year the state matching funds for
Medi-Cal specialty mental health services are required to be included
in the annual budget for the department. Existing law requires the
amount included to be based on historical cost, adjusted for changes
in the number of Medi-Cal beneficiaries and other relevant factors.
Existing law provides that the appropriation for funding the state
share of the costs for EPSDT specialty mental health services
provided under the Medi-Cal specialty mental health services waiver
shall be used only for reimbursement payments of claims for those
services.
This bill would require the funds appropriated for EPSDT specialty
mental health services provided under the Medi-Cal specialty mental
health services waiver for reimbursement payments of claims for those
services to be distributed annually to mental health plans based on
a formula that takes into account the mental health plan's historical
EPSDT claims and maintenance of effort obligations. The bill would
require the department to distribute 75% of the appropriated amount
to mental health plans each fiscal year once the state budget is
adopted and to distribute the remaining 25% to the mental health
plans for additional claims within 30 days of when the plan submits a
claim.
Existing law requires Medi-Cal state General Fund matching dollars
to be distributed to counties based on historic Medi-Cal acute
inpatient psychiatric costs for the county's beneficiaries and on the
number of persons eligible for Medi-Cal in that county.
This bill would, instead, specify that the matching dollars shall
to be distributed to counties each fiscal year once
within 30 days after the state budget is adopted
based on historic Medi-Cal acute inpatient psychiatric costs for the
county's beneficiaries and on the number of persons eligible for
Medi-Cal in that county.
Existing law requires the allocation method for the state funds
transferred for fiscal years following the 1994-95 fiscal year for
acute inpatient psychiatric and other specialty mental health
services to be determined by the department in consultation with a
statewide organization representing counties.
This bill would require the allocation method to be determined no
later than June 1 of the previous fiscal year.
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 5777 of the Welfare and Institutions Code is
amended to read:
5777. (a) (1) Except as otherwise specified in this part, a
contract entered into pursuant to this part shall include a provision
that the mental health plan contractor shall bear the financial risk
for the cost of providing medically necessary mental health
services, exclusive of Early Periodic Screening Diagnosis and
Treatment (EPSDT) services, to Medi-Cal beneficiaries irrespective of
whether the cost of those services exceeds the payment set forth in
the contract. If the expenditures for services do not exceed the
payment set forth in the contract, the mental health plan contractor
shall report the unexpended amount to the department, but shall not
be required to return the excess to the department.
(2) If the mental health plan is not the county's, the mental
health plan may not transfer the obligation for any mental health
services to Medi-Cal beneficiaries to the county. The mental health
plan may purchase services from the county. The mental health plan
shall establish mutually agreed-upon protocols with the county that
clearly establish conditions under which beneficiaries may obtain
non-Medi-Cal reimbursable services from the county. Additionally, the
plan shall establish mutually agreed-upon protocols with the county
for the conditions of transfer of beneficiaries who have lost
Medi-Cal eligibility to the county for care under Part 2 (commencing
with Section 5600), Part 3 (commencing with Section 5800), and Part 4
(commencing with Section 5850).
(3) The mental health plan shall be financially responsible for
ensuring access and a minimum required scope of benefits, consistent
with state and federal requirements, to the services to the Medi-Cal
beneficiaries of that county regardless of where the beneficiary
resides. The department shall require that the definition of medical
necessity used, and the minimum scope of benefits offered, by each
mental health contractor be the same, except to the extent that any
variations receive prior federal approval and are consistent with
state and federal statutes and regulations.
(b) Any contract entered into pursuant to this part may be renewed
if the plan continues to meet the requirements of this part,
regulations promulgated pursuant thereto, and the terms and
conditions of the contract. Failure to meet these requirements shall
be cause for nonrenewal of the contract. The department may base the
decision to renew on timely completion of a mutually agreed upon plan
of correction of any deficiencies, submissions of required
information in a timely manner, or other conditions of the contract.
At the discretion of the department, each contract may be renewed for
a period not to exceed three years.
(c) (1) The obligations of the mental health plan shall be changed
only by contract or contract amendment that has been agreed to by
all parties to the contract.
(2) A change may be made during a contract term or at the time of
contract renewal, where there is a change in obligations required by
federal or state law or when required by a change in the
interpretation or implementation of any law or regulation. To the
extent permitted by federal law and except as provided under
paragraph (10) of subdivision (c) of Section 5778, if any change in
obligations occurs that affects the cost to the mental health plan of
performing under the terms of its contract, the department or the
mental health plan may reopen contracts to negotiate the state
General Fund allocation to the mental health plan under Section 5778,
if the mental health plan is reimbursed through a fee-for-service
payment system, or the capitation rate to the mental health plan
under Section 5779, if the mental health plan is reimbursed through a
capitated rate payment system. During the time period required to
redetermine the allocation or rate, payment to the mental health plan
of the allocation or rate in effect at the time the change occurred
shall be considered interim payments and shall be subject to increase
or decrease, as the case may be, effective as of the date on which
the change is effective.
(3) To the extent permitted by federal law, either the department
or the mental health plan may request that contract negotiations be
reopened during the course of a contract due to substantial changes
in the cost of covered benefits that result from an unanticipated
event.
(d) The department shall immediately terminate a contract when the
director finds that there is an immediate threat to the health and
safety of Medi-Cal beneficiaries. Termination of the contract for
other reasons shall be subject to reasonable notice of the department'
s intent to take that action and notification of affected
beneficiaries. The plan may request a public hearing by the Office of
Administrative Hearings.
(e) A plan may terminate its contract in accordance with the
provisions in the contract. The plan shall provide written notice to
the department at least 180 days prior to the termination or
nonrenewal of the contract.
(f) Upon the request of the Director of Mental Health, the
Director of the Department of Managed Health Care may exempt a mental
health plan contractor or a capitated rate contract from the
Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code). These exemptions may be subject to conditions the director
deems appropriate. Nothing in this part shall be construed to impair
or diminish the authority of the Director of the Department of
Managed Health Care under the Knox-Keene Health Care Service Plan Act
of 1975, nor shall anything in this part be construed to reduce or
otherwise limit the obligation of a mental health plan contractor
licensed as a health care service plan to comply with the
requirements of the Knox-Keene Health Care Service Plan Act of 1975,
and the rules of the Director of the Department of Managed Health
Care promulgated thereunder. The Director of Mental Health, in
consultation with the Director of the Department of Managed Health
Care, shall analyze the appropriateness of licensure or application
of applicable standards of the Knox-Keene Health Care Service Plan
Act of 1975.
(g) (1) The department, pursuant to an agreement with the State
Department of Health Care Services, shall provide oversight to the
mental health plans to ensure quality, access, and cost efficiency.
At a minimum, the department shall, through a method independent of
any agency of the mental health plan contractor, monitor the level
and quality of services provided, expenditures pursuant to the
contract, and conformity with federal and state law.
(2) (A) Commencing July 1, 2008, county mental health plans, in
collaboration with the department, the federally required external
review organization, providers, and other stakeholders, shall
establish an advisory statewide performance improvement project (PIP)
to increase the coordination, quality, effectiveness, and efficiency
of service delivery to children who are either receiving at least
three thousand dollars ($3,000) per month in the EPSDT Program
services or children identified in the top 5 percent of the county
EPSDT cost, whichever is lowest. The statewide PIP shall replace one
of the two required PIPs that mental health plans must perform under
federal regulations outlined in the mental health plan contract.
(B) The federally required external quality review organization
shall provide independent oversight and reviews with recommendations
and findings or summaries of findings, as appropriate, from a
statewide perspective. This information shall be accessible to county
mental health plans, the department, county welfare directors,
providers, and other interested stakeholders in a manner that both
facilitates, and allows for, a comprehensive quality improvement
process for the EPSDT Program.
(C) Each July, the department, in consultation with the federally
required external quality review organization and the county mental
health plans, shall determine the average monthly cost threshold for
counties to use to identify children to be reviewed who are currently
receiving EPSDT services. The department shall consult with
representatives of county mental health directors, county welfare
directors, providers, and the federally required external quality
review organization in setting the annual average monthly cost
threshold and in implementing the statewide PIP. The department shall
provide an annual update to the Legislature on the results of this
statewide PIP by October 1 of each year for the prior fiscal year.
(D) It is the intent of the Legislature for the EPSDT PIP to
increase the coordination, quality, effectiveness, and efficiency of
service delivery to children receiving EPSDT services and to
facilitate evidence-based practices within the program, and other
high-quality practices consistent with the values of the public
mental health system within the program to ensure that children are
receiving appropriate mental health services for their mental health
wellness.
(E) This paragraph shall become inoperative on September 1, 2011.
(h) County employees implementing or administering a mental health
plan act in a discretionary capacity when they determine whether or
not to admit a person for care or to provide any level of care
pursuant to this part.
(i) If a county chooses to discontinue operations as the local
mental health plan, the new plan shall give reasonable consideration
to affiliation with nonprofit community mental health agencies that
were under contract with the county and that meet the mental health
plan's quality and cost efficiency standards.
(j) Nothing in this part shall be construed to modify, alter, or
increase the obligations of counties as otherwise limited and defined
in Chapter 3 (commencing with Section 5700) of Part 2. The county's
maximum obligation for services to persons not eligible for Medi-Cal
shall be no more than the amount of funds remaining in the mental
health subaccount pursuant to Sections 17600, 17601, 17604, 17605,
17606, and 17609 after fulfilling the Medi-Cal contract obligations.
SEC. 2. Section 5778 of the Welfare and Institutions Code is
amended to read:
5778. (a) This section shall be limited to specialty mental
health services reimbursed through a fee-for-service payment system.
(b) The following provisions shall apply to matters related to
specialty mental health services provided under the Medi-Cal
specialty mental health services waiver, including, but not limited
to, reimbursement and claiming procedures, reviews and oversight, and
appeal processes for mental health plans (MHPs) and MHP
subcontractors.
(1) During the initial phases of the implementation of this part,
as determined by the department, the MHP contractor and
subcontractors shall submit claims under the Medi-Cal program for
eligible services on a fee-for-service basis.
(2) A qualifying county may elect, with the approval of the
department, to operate under the requirements of a capitated,
integrated service system field test pursuant to Section 5719.5
rather than this part, in the event the requirements of the two
programs conflict. A county that elects to operate under that section
shall comply with all other provisions of this part that do not
conflict with that section.
(3) (A) No sooner than October 1, 1994, state matching funds for
Medi-Cal fee-for-service acute psychiatric inpatient services, and
associated administrative days, shall be transferred to the
department. No later than July 1, 1997, upon agreement between the
department and the State Department of Health Care Services, state
matching funds for the remaining Medi-Cal fee-for-service mental
health services and the state matching funds associated with field
test counties under Section 5719.5 shall be transferred to the
department.
(B) The department, in consultation with the State Department of
Health Care Services, a statewide organization representing counties,
and a statewide organization representing health maintenance
organizations shall develop a timeline for the transfer of funding
and responsibility for fee-for-service mental health services from
Medi-Cal managed care plans to MHPs. In developing the timeline, the
department shall develop screening, referral, and coordination
guidelines to be used by Medi-Cal managed care plans and MHPs.
(4) (A) (i) A MHP subcontractor providing specialty mental health
services shall be financially responsible for federal audit
exceptions or disallowances to the extent that these exceptions or
disallowances are based on the MHP subcontractor's conduct or
determinations.
(ii) The state shall be financially responsible for federal audit
exceptions or disallowances to the extent that these exceptions or
disallowances are based on the state's conduct or determinations. The
state shall not withhold payment from a MHP for exceptions or
disallowances that the state is financially responsible for pursuant
to this clause.
(iii) A MHP shall be financially responsible for state audit
exceptions or disallowances to the extent that these exceptions or
disallowances are based on the MHP's conduct or determinations. A MHP
shall not withhold payment from a MHP subcontractor for exceptions
or disallowances for which the MHP is financially responsible
pursuant to this clause.
(B) For purposes of subparagraph (A), a "determination" shall be
shown by a written document expressly stating the determination,
while "conduct" shall be shown by any credible, legally admissible
evidence.
(C) The department and the State Department of Health Care
Services shall work jointly with MHPs in initiating any necessary
appeals. The department may invoice or offset the amount of any
federal disallowance or audit exception against subsequent claims
from the MHP or MHP subcontractor. This offset may be done at any
time, after the audit exception or disallowance has been withheld
from the federal financial participation claim made by the State
Department of Health Care Services. The maximum amount that may be
withheld shall be 25 percent of each payment to the plan or
subcontractor.
(5) (A) Oversight by the department of the MHPs and MHP
subcontractors may include client record reviews of Early Periodic
Screening Diagnosis and Treatment (EPSDT) specialty mental health
services under the Medi-Cal specialty mental health services waiver
in addition to other audits or reviews that are conducted.
(B) The department may contract with an independent,
nongovernmental entity to conduct client record reviews. The contract
awarded in connection with this section shall be on a competitive
bid basis, pursuant to the Department of General Services contracting
requirements, and shall meet both of the following additional
requirements:
(i) Require the entity awarded the contract to comply with all
federal and state privacy laws, including, but not limited to, the
federal Health Insurance Portability and Accountability Act (HIPAA;
42 U.S.C. Sec. 1320d et seq.) and its implementing regulations, the
Confidentiality of Medical Information Act (Part 2.6 (commencing with
Section 56) of Division 1 of the Civil Code), and Section 1798.81.5
of the Civil Code. The entity shall be subject to existing penalties
for violation of these laws.
(ii) Prohibit the entity awarded the contract from using, selling,
or disclosing client records for a purpose other than the one for
which the record was given.
(C) For purposes of this paragraph, the following terms shall have
the following meanings:
(i) "Client record" means a medical record, chart, or similar
file, as well as other documents containing information regarding an
individual recipient of services, including, but not limited to,
clinical information, dates and times of services, and other
information relevant to the individual and services provided and that
evidences compliance with legal requirements for Medi-Cal
reimbursement.
(ii) "Client record review" means examination of the client record
for a selected individual recipient for the purpose of confirming
the existence of documents that verify compliance with legal
requirements for claims submitted for Medi-Cal reimbursement.
(D) The department shall recover overpayments of federal financial
participation from MHPs within the timeframes required by federal
law and regulation and return those funds owed by the MHPs to the
State Department of Health Care Services for repayment to the federal
Centers for Medicare and Medicaid Services. The department shall
also reimburse underpayments of federal financial participation to
MHPs within the timeframes required by federal law and regulation.
The department shall recover overpayments and reimburse underpayments
of General Fund moneys utilizing the recoupment methods and
timeframes required by the State Administrative Manual and timeframes
specified in the MHP contract.
(6) (A) The department, in consultation with mental health
stakeholders, the California Mental Health Directors Association, and
MHP subcontractor representatives, shall provide an appeals process
that specifies a progressive process for resolution of disputes about
claims or recoupments relating to specialty mental health services
under the Medi-Cal specialty mental health services waiver.
(B) The department shall provide MHPs and MHP subcontractors the
opportunity to directly appeal findings in accordance with procedures
that are similar to those described in Article 1.5 (commencing with
Section 51016) of Chapter 3 of Subdivision 1 of Division 3 of Title
22 of the California Code of Regulations, until new regulations for a
progressive appeals process are promulgated. When an MHP
subcontractor initiates an appeal, it shall give notice to the MHP.
The department shall propose a rulemaking package by no later than
the end of the 2008-09 fiscal year to amend the existing appeals
process. The reference in this subparagraph to the procedures
described in Article 1.5 (commencing with Section 51016) of Chapter 3
of Subdivision 1 of Division 3 of Title 22 of the California Code of
Regulations, shall only apply to those appeals addressed in this
subparagraph.
(C) The department shall develop regulations as necessary to
implement this paragraph.
(7) The department shall assume the applicable program oversight
authority formerly provided by the State Department of Health Care
Services, including, but not limited to, the oversight of utilization
controls as specified in Section 14133. The MHP shall include a
requirement in any subcontracts that all inpatient subcontractors
maintain necessary licensing and certification. MHPs shall require
that services delivered by licensed staff are within their scope of
practice. Nothing in this part shall prohibit the MHPs from
establishing standards that are in addition to the minimum federal
and state requirements, provided that these standards do not violate
federal and state Medi-Cal requirements and guidelines.
(8) Subject to federal approval and consistent with state
requirements, the MHP may negotiate rates with providers of mental
health services.
(9) Under the fee-for-service payment system, any excess in the
payment set forth in the contract over the expenditures for services
by the plan shall be spent for the provision of specialty mental
health services under the Medi-Cal specialty mental health service
waiver and related administrative costs.
(10) Nothing in this part shall limit the MHP from being
reimbursed appropriate federal financial participation for any
qualified services even if the total expenditures for service exceeds
the contract amount with the department. Matching nonfederal public
funds shall be provided by the plan for the federal financial
participation matching requirement. MHP claims for federal financial
participation shall be submitted to the federal Centers for Medicare
and Medicaid Services by the department and the State Department of
Health Care Services throughout the fiscal year as the claims are
received from MHPs. Payments shall be made to the MHP as
soon as within 30 days after the federal
payments have been received by the state.
(c) The provisions of this subdivision shall apply to managed
mental health care funding allocations and risk-sharing
determinations and arrangements.
(1) The department shall allocate and distribute the full
contracted amount at the beginning of the contract period to the MHP.
(2) Each fiscal year the state matching funds for Medi-Cal
specialty mental health services shall be included in the annual
budget for the department. The amount included shall be based on
historical cost, adjusted for changes in the number of Medi-Cal
beneficiaries and other relevant factors. The appropriation for
funding the state share of the costs for EPSDT specialty mental
health services provided under the Medi-Cal specialty mental health
services waiver shall only be used for reimbursement payments of
claims for those services and funds appropriated for that
purpose shall be distributed to MHPs annually based on a
formula that takes into account the MHPs' historical EPSDT claims and
maintenance of effort obligations. The department shall distribute
75 percent of the funds appropriated to the MHP each fiscal year once
the state budget is adopted. The MHP shall account for its
expenditure of the 75 percent distribution with its submission of
EPSDT claims. The department shall distribute the remaining 25
percent of the funds appropriated to the MHP for additional EPSDT
claims within 30 days of when the MHP submits a claim .
(3) Initially, the MHP shall use the fiscal intermediary of the
Medi-Cal program of the State Department of Health Care Services for
the processing of claims for inpatient psychiatric hospital services
and may be required to use that fiscal intermediary for the remaining
mental health services. The providers for other specialty mental
health Medi-Cal services shall not be initially required to use the
fiscal intermediary but may be required to do so on a date to be
determined by the department. The department and its MHPs shall be
responsible for the initial incremental increased matching costs of
the fiscal intermediary for claims processing and information
retrieval associated with the operation of the services funded by the
transferred funds.
(4) The MHPs shall have sufficient funds on deposit with the
department as the matching funds necessary for federal financial
participation to ensure timely payment of claims for acute
psychiatric inpatient services and associated administrative days.
The department and the State Department of Health Care Services, in
consultation with a statewide organization representing counties,
shall establish a mechanism to facilitate timely availability of
those funds. Any funds held by the state on behalf of a plan shall be
deposited in a mental health managed care deposit fund and shall
accrue interest to the plan. The department shall exercise any
necessary funding procedures pursuant to Section 12419.5 of the
Government Code and Sections 8776.6 and 8790.8 of the State
Administrative Manual regarding county claim submission and payment.
(5) The goal for funding of the future capitated system shall be
to develop statewide rates for beneficiary, by aid category and with
regional price differentiation, within a reasonable time period. The
formula for distributing the state matching funds transferred to the
department for acute inpatient psychiatric services to the
participating counties shall be based on the following principles:
(A) Medi-Cal state General Fund matching dollars shall be
distributed to counties each fiscal year once
within 30 days after the state budget is adopted based on
historic Medi-Cal acute inpatient psychiatric costs for the county's
beneficiaries and on the number of persons eligible for Medi-Cal in
that county.
(B) All counties shall receive a baseline based on historic and
projected expenditures up to October 1, 1994.
(C) Projected inpatient growth for the period October 1, 1994, to
June 30, 1995, inclusive, shall be distributed to counties below the
statewide average per eligible person on a proportional basis. The
average shall be determined by the relative standing of the aggregate
of each county's expenditures of mental health Medi-Cal dollars per
beneficiary. Total Medi-Cal dollars shall include both
fee-for-service Medi-Cal and Short-Doyle Medi-Cal dollars for both
acute inpatient psychiatric services, outpatient mental health
services, and psychiatric nursing facility services, both in
facilities that are not designated as institutions for mental disease
and for beneficiaries who are under 22 years of age and
beneficiaries who are over 64 years of age in facilities that are
designated as institutions for mental disease.
(D) There shall be funds set aside for a self-insurance risk pool
for small counties. The department may provide these funds directly
to the administering entity designated in writing by all counties
participating in the self-insurance risk pool. The small counties
shall assume all responsibility and liability for appropriate
administration of these funds. For purposes of this subdivision,
"small counties" means counties with less than 200,000 population.
Nothing in this paragraph shall in any way obligate the state or the
department to provide or make available any additional funds beyond
the amount initially appropriated and set aside for each particular
fiscal year, unless otherwise authorized in statute or regulations,
nor shall the state or the department be liable in any way for
mismanagement of loss of funds by the entity designated by the
counties under this paragraph.
(6) The allocation method for state funds transferred for acute
inpatient psychiatric services shall be as follows:
(A) For the 1994-95 fiscal year, an amount equal to 0.6965 percent
of the total shall be transferred to a fund established by small
counties. This fund shall be used to reimburse MHPs in small counties
for the cost of acute inpatient psychiatric services in excess of
the funding provided to the MHP for risk reinsurance, acute inpatient
psychiatric services and associated administrative days,
alternatives to hospital services as approved by participating small
counties, or for costs associated with the administration of these
moneys. The methodology for use of these moneys shall be determined
by the small counties, through a statewide organization representing
counties, in consultation with
the department.
(B) The balance of the transfer amount for the 1994-95 fiscal year
shall be allocated to counties based on the following formula:
County Percentage
Alameda.............................. 3.5991
Alpine............................... .0050
Amador............................... .0490
Butte................................ .8724
Calaveras............................ .0683
Colusa............................... .0294
Contra Costa......................... 1.5544
Del Norte............................ .1359
El Dorado............................ .2272
Fresno............................... 2.5612
Glenn................................ .0597
Humboldt............................. .1987
Imperial............................. .6269
Inyo................................. .0802
Kern................................. 2.6309
Kings................................ .4371
Lake................................. .2955
Lassen............................... .1236
Los Angeles.......................... 31.3239
Madera............................... .3882
Marin................................ 1.0290
Mariposa............................. .0501
Mendocino............................ .3038
Merced............................... .5077
Modoc................................ .0176
Mono................................. .0096
Monterey............................. .7351
Napa................................. .2909
Nevada............................... .1489
Orange............................... 8.0627
Placer............................... .2366
Plumas............................... .0491
Riverside............................ 4.4955
Sacramento........................... 3.3506
San Benito........................... .1171
San Bernardino....................... 6.4790
San Diego............................ 12.3128
San Francisco........................ 3.5473
San Joaquin.......................... 1.4813
San Luis Obispo...................... .2660
San Mateo............................ .0000
Santa Barbara........................ .0000
Santa Clara.......................... 1.9284
Santa Cruz........................... 1.7571
Shasta............................... .3997
Sierra............................... .0105
Siskiyou............................. .1695
Solano............................... .0000
Sonoma............................... .5766
Stanislaus........................... 1.7855
Sutter/Yuba.......................... .7980
Tehama............................... .1842
Trinity.............................. .0271
Tulare............................... 2.1314
Tuolumne............................. .2646
Ventura.............................. .8058
Yolo................................. .4043
(7) The allocation method for the state funds transferred for
subsequent years for acute inpatient psychiatric and other specialty
mental health services shall be determined by the department in
consultation with a statewide organization representing counties no
later than June 1 of the previous fiscal year.
(8) The allocation methodologies described in this section shall
only be in effect while federal financial participation is received
on a fee-for-service reimbursement basis. When federal funds are
capitated, the department, in consultation with a statewide
organization representing counties, shall determine the methodology
for capitation consistent with federal requirements. The share of
cost ratio arrangement for EPSDT specialty mental health services
provided under the Medi-Cal specialty mental health services waiver
between the state and the counties in existence during the 2007-08
fiscal year shall remain as the share of cost ratio arrangement for
these services unless changed by statute.
(9) The formula that specifies the amount of state matching funds
transferred for the remaining Medi-Cal fee-for-service mental health
services shall be determined by the department in consultation with a
statewide organization representing counties. This formula shall
only be in effect while federal financial participation is received
on a fee-for-service reimbursement basis.
(10) (A) For the managed mental health care program, exclusive of
EPSDT specialty mental health services provided under the Medi-Cal
specialty mental health services waiver, the department shall
establish, by regulation, a risk-sharing arrangement between the
department and counties that contract with the department as MHPs to
provide an increase in the state General Fund allocation, subject to
the availability of funds, to the MHP under this section, where there
is a change in the obligations of the MHP required by federal or
state law or regulation, or required by a change in the
interpretation or implementation of any such law or regulation which
significantly increases the cost to the MHP of performing under the
terms of its contract.
(B) During the time period required to redetermine the allocation,
payment to the MHP of the allocation in effect at the time the
change occurred shall be considered an interim payment, and shall be
subject to increase effective as of the date on which the change is
effective as determined in the MHP contract or contract amendment.
(C) In order to be eligible to participate in the risk-sharing
arrangement, the county shall demonstrate, to the satisfaction of the
department, its commitment or plan of commitment of all annual
funding identified in the total mental health resource base, from
whatever source, but not including county funds beyond the required
maintenance of effort, to be spent on specialty mental health
services. This determination of eligibility shall be made annually.
The department may limit the participation in a risk-sharing
arrangement of any county that transfers funds from the mental health
account to the social services account or the health services
account, in accordance with Section 17600.20 during the year to which
the transfers apply to MHP expenditures for the new obligation that
exceed the total mental health resource base, as measured before the
transfer of funds out of the mental health account and not including
county funds beyond the required maintenance of effort. The State
Department of Mental Health shall participate in a risk-sharing
arrangement only after a county has expended its total annual mental
health resource base.
(d) The following provisions govern the administrative
responsibilities of the department and the State Department of Health
Care Services:
(1) It is the intent of the Legislature that the department, the
State Department of Health Care Services, and the contracting MHPs
consult and collaborate closely regarding administrative functions
related to and supporting the managed mental health care program in
general, and the delivery and provision of EPSDT specialty mental
health services provided under the Medi-Cal specialty mental health
services waiver, in particular. To this end, the following provisions
shall apply:
(A) Commencing in the 2009-10 fiscal year, and each fiscal year
thereafter, the department shall consult with the State Department of
Health Care Services and amend the interagency agreement between the
two departments as necessary to include improvements or updates to
procedures for the accurate and timely processing of Medi-Cal claims
for specialty mental health services provided under the Medi-Cal
specialty mental health services waiver. The interagency agreement
shall ensure that there are consistent and adequate time limits,
consistent with federal and state law, for claims submitted and the
need to correct errors.
(B) Commencing in the 2009-10 fiscal year, and each fiscal year
thereafter, upon a determination by the department and the State
Department of Health Care Services that it is necessary to amend the
interagency agreement, the department and the State Department of
Health Care Services shall process the interagency agreement to
ensure final approval by January 1, for the following fiscal year,
and as adjusted by the budgetary process.
(C) The interagency agreement shall include, at a minimum, all of
the following:
(i) A process for ensuring the completeness, validity, and timely
processing of Medi-Cal claims as mandated by the federal Centers for
Medicare and Medicaid Services.
(ii) Procedures and timeframes by which the department shall
submit complete, valid, and timely invoices to the State Department
of Health Care Services, which shall notify the department of
inconsistencies in invoices that may delay payments.
(iii) Procedures and timeframes by which the department shall
notify MHPs of inconsistencies that may delay payment.
(2) (A) The department shall consult with the State Department of
Health Care Services and the California Mental Health Directors
Association in February and September of each year to review the
methodology used to forecast future trends in the provision of EPSDT
specialty mental health services provided under the Medi-Cal
specialty mental health services waiver, to estimate these yearly
EPSDT specialty mental health services related costs, and to estimate
the annual amount of funding required for reimbursements for EPSDT
specialty mental health services to ensure relevant factors are
incorporated in the methodology. The estimates of costs and
reimbursements shall include both federal financial participation
amounts and any state General Fund amounts for EPSDT specialty mental
health services provided under the State Medi-Cal specialty mental
health services waiver. The department shall provide the State
Department of Health Care Services the estimate adjusted to a cash
basis.
(B) The estimate of annual funding described in subparagraph (A)
shall, include, but not be limited to, the following factors:
(i) The impacts of interactions among caseload, type of services,
amount or number of services provided, and billing unit cost of
services provided.
(ii) A systematic review of federal and state policies, trends
over time, and other causes of change.
(C) The forecasting and estimates performed under this paragraph
are primarily for the purpose of providing the Legislature and the
Department of Finance with projections that are as accurate as
possible for the state budget process, but will also be informative
and useful for other purposes. Therefore, it is the intent of the
Legislature that the information produced under this paragraph shall
be taken into consideration under paragraph (10) of subdivision (c).